Assessment
after 30 mins - 1 hour
When should pain be reassessed?
Assessment (page 1)
Narrative (page 2)
What is a nursing progress note?
N/A
What is an unacceptable answer for education?
Listed on the POT, these are a set of practices to prevent the spread of disease.
What are precautions?
A document completed by the nurse requesting a change in medication or treatment that must be signed and dated by the doctor.
What is a physician's order?
A reassessment and new vitals
What is documented beyond an 8-hr shift?
Requires 2 witness signatures
unmet daily goals
side effects of a new medication
non-compliance with POT
What are educational opportunities?
A POT that has not been signed by the provider and is permissible to make changes to
What is an "In Progress" POT?
Patient's home binder
Where do the yellow copies get stored?
The FLACC scale
What assessment uses face, legs, activity, crying and consolability to identify pain?
24/7 Drop box
M-F 8am-5pm
Encrypted email
What are the ways to get Originals (white copies) to the office?
Nurse to patient, patient to nurse, nurse to nurse, nurse to family, family to nurse
What are education pathways?
Not governed by the plan of treatment; able to execute or decline meds or treatments.
Who are the family/caregivers/clients?
By taking blank order forms to appointments
What is the quickest way to get an order signed?
Suctioned--x4
Chest PT-- x2
What are the number of times the nurse completed the tasks?
A resource found in the patient's binder that assists with documentation compliance.
What is a Task Summary?
To prevent breakdown, we are required to turn and reposition every 2 hours.
What is an intervention to maintain skin-integrity?
Provide incontinence care every 2 hours.
Bathe and provide oral care daily.
Clean all medical equipment weekly.
What are orders on a POT?
Examples:
decreasing from 25 mg to 12.5 mg tabs
applying hand lotion to dry skin
using a new piece of DME
What are instances in which a physician's order is needed?
Blood-tinged urine, back or stomach pain, change in urine frequency, fever, n/v
What are signs/symptoms of kidney stones?
Addendum
What is the term for updating a note after the shift is complete and the note has been submitted?
We are required by this agency to educate every client, every shift.
Who are DMAS? (Dept Medical Assistance Serv)
Medications, Allergies, Diagnoses, DME, Code status, Nutrition, Goals, Providers, etc.
What are 5 components of the POT?
Client name, DOB
Medication name, dose, frequency, route, diagnosis
Type of order (verbal, written, clarification)
Medical provider's signature, Nurse's signature, Date
What is needed to change a medication?