Unit 3 (CHAPTERS 9, 11, 20)

Question 1

What is a medical record?

Answer 1

A collection of information about a persons health, the care provided by health care workers, and the clients process.

Question 2

What is the medical record used for?

Answer 2

Share information for health care providers, thus ensuring client safety and countinity of care.

Question 3

Who has access to the medical record?

Answer 3

All personal involved in a persons health care, including the person

Question 4

Narrative charting

Answer 4

The cycle of documentation generally used in source orianted records. WRITTING INFORMATION IN CHRONOLOGICAL ORDER.

Question 5

Computerized Charting

Answer 5

Documenting client information via the computer.

Question 6

How do we protect health information?

Answer 6

HIPPA

Question 7

Can nurses use abbreviations?

Answer 7

ONLY abberviations on agency approved list.

Question 8

Change of Shift Reports

Answer 8

• A discussion between a nursing spokeperson from the shift thats ending and arriving.
• Summary of each Pts conditions and current status of care.

Question 9

What do we say when we answer the phone?

Answer 9

• Answer promptly
• Speak in a normal tone
• Identify yourself by name, title, and unit
• Obtain the reson for call
• Discretely identify the client
• converse in a courteous and buisness like manner
• repeat information to make sure its correct

Question 10

Pain

Answer 10

Unpleasent sensation usually associated with a diease or injury
5th vital sign

Question 11

Process of pain

Time To Prepare Mentally

Answer 11

Transduction
Transmission
Pereception
Modulation

Question 12

Transduction

Answer 12

Chemical information at the cellular level into eletrical impulses the move toward the spinal cord.

Question 13

Transmission

Answer 13

Stimuli move from the perpheral nervous system toward the brain.

Question 14

Perception

Answer 14

The concious exeprience of discomfort

Question 15

Pain Threshold

Answer 15

• The point at which sufficient pain transmitting stimuli reach the brain
• each person’s threshold is the same

Question 16

Pain Tolerance

Answer 16

• The amount of pain a person handle.

- Diffrent for everbody

Question 17

Modulation

Answer 17

Last phase of impulse transmission during which the brain with spinal nerves in downward fashion to subsquently after the pain.

Question 18

Pain Theories

Answer 18

Specificity theory
Pattern Theory
Gate Control Theory
Nueroma Trix Theory
Endogenous Opioid Theory

Question 19

Types of Pain

Answer 19

Cutaneous
Ursceral
Neuropathic
Acute
Chronic

Question 20

Visceral Pain

Answer 20

Discomfort arising from Internal Organ

Question 21

Neuopathic Pain

Answer 21

Pain w/ atypical characteristics

Happens up to days months or weeks after sourse of pain is resolved leg amputation

Question 22

ACUTE pain

Answer 22

discomfort for short duration

Question 23

CHRONIC pain

Answer 23

Discomfort that last longer than 6 months

Question 24

What should be included in the pain assessment

Answer 24

Onset
Quality
Intensity
Location
Duration

Question 25

What are the tools you can use to assess pain?

Answer 25

Nemeric Scale Word Scale Linear Scale Visual Analogy

Question 26

Patient Controlled Analgesia

Answer 26

Intervention that allows client to self administrate opioid pain medication through use of an infusion device

Question 27

What are some Nonpharmacologic ways to control pain

Answer 27

``` Education Imagery Distraction Relaxation Tech. Apply hot or cold Meditation Transcutaneous Eletrical Nerve Stimulation (TENS) Acupuncture Percutaneous Electrial Nerve Stin (PENS) Bio feedback Hypnosis ```

Question 28

What is a placebo

Answer 28

Imitation of a drug

Question 29

Admission

Answer 29

``` Physicians admit patients to facility. Billing information through admission department Medical history and physical Medical orders Scheduled Admission Emergency Admission Patient I.D. Bracelet ```

Question 30

Nursing Admission

Answer 30

``` Prepare room Welcome patient Orient patient Location of nurses station Bathroom Personal storage How to call nurse How to adjust bed Lights Telephone TV Daily routine- meal times When the MD makes rounds Scheduled tests/surgery ```

Question 31

Common Response to Admission

Answer 31

Anxiety Loneliness Decreased privacy Loss of identity

Question 32

``` what is this considered? Safeguarding Valuables and clothing Helping the patient undress Compiling the data base Medical admission responsibilities Common responses to admission ```

Answer 32

Admission

Question 33

Discharge Process

Answer 33

Termination of care from a health care facility. Discharge begins at admission Written orders for discharge Give discharge instructions Notify business office Write a summary of condition at discharge Request room to be cleaned

Question 34

Leaving Against Medical Advice

Answer 34

``` Patient leaves before MD discharges When the patient is unhappy Try to negotiate Have patient sign AMA form Document ```

Question 35

Discharge Planning

Answer 35

Improves client outcomes Post discharge needs Coordinating community resources Special considerations

Question 36

Discharge Instructions

Answer 36

Teaching (METHOD) page 170 Prescriptions Appointments Summary of discharge orders

Question 37

``` Gathering belongings Arranging Transportation Escorting the Client Writing a discharge summary Terminal cleaning .........This is a process of ```

Answer 37

Discharging the patient

Question 38

Transferring

Answer 38

``` Transfer activities Extended Care Facilities Skilled Nursing Facilities Intermediate Care Facilities Basic Care Facilities Nursing Homes Referrals Home health care ```

Question 39

METHOD

Answer 39

``` Medacation Envioroment Treatments Health Teaching Outpatient Referal Diet ```

Question 40

Gate control theory

Answer 40

1 message at a time

Question 41

Endogenous opioids

Answer 41

Natural like morphine, its substances that your body produces.

Question 42

What are the natural things your body produces that act like morphine

Answer 42

Endorphins Dynorphins Enkepalins

Question 43

Cutaneous Pain

Answer 43

Orginates at the skin

Question 44

Dermis Level

Answer 44

Pain localized

Question 45

Subcanteous Level

Answer 45

Tissiue injuries, produces aching pain

Question 46

Somatic Pain

Answer 46

Discomfort generated from deeper connective tissue

Question 47

Reffered Pain

Answer 47

Poorly localized: discomfort in a general area

Question 48

When do you assess pain?

Answer 48

When pt is addmited When taking vital signs at res/ during activity b4 and after treatmet ( 20 min after)

Question 49

JACHO

Answer 49

requires evidence that psin of termanially ill is being proprly treated

Question 50

Opioid

Answer 50

Morphine Codeine Meperdine Funtanyl

Question 51

Non opioid

Answer 51

Tylenol, Motrin, Advil

Question 52

Adjuvant Drugs

Answer 52

drugs that assist in accomplishing the desired effect of a primary drug

Question 53

Rhizotomy

Answer 53

Surgical Sectioning of a nerve route close to spinal cord

Question 54

Cordotomy

Answer 54

Intruption of pain pathway in spinal cord