Show:
Charting
Intake & Output
Fluid Restriction
Activity
Weights
100
The patient ate 100% of his lunch. Where is this charted?
I & O band/Lunch
100
How often do I record I & O?
Meal trays should be charted as soon as they are picked up. I & O must be recorded at the end of shift/every 8 hours- 0600, 1400, 2200.
100
How can I determine how much fluid my patient can have per shift and per tray?
Hang a fluid restriction sign on the door.
100
T or F. My patient is too tired to get up to the chair, so it is alright for him to lay in bed today.
False. Encourage the patient to have meals in chair. The longer the patient lays in bed, the more deconditioned he becomes making his recovery harder.
100
How often do I weigh my patient
Daily- before eating and after voiding and upon admission
200
The patient weighs 67 kg on the standing scale. Where do I chart this?
Adult Quick View/Height and weight
200
Do I only need to chart I & O at end of shift?
No. Record I & O every time you empty or refill a hat or pitcher.
200
Why does my patient need to limit their fluid intake?
The heart cannot pump off excess fluid, so the more fluid they consume the harder their heart works and fluid backs up into the lungs and other areas.
200
T or F. Patients do not need to ambulate.
False. Ambulation helps promote strength and helps improve respiratory effort.
200
Where do I chart my weight on admission
Cerner and on the white board
300
My patient is NPO. How should I document this?
Zero is recorded under the meal intake section
300
What should I do if I notice my patient has not voided during my shift (8 hours)?
Ask the patient if they are saving their urine, if not then explain the importance of measuring urine output. If the patient voids, but doesn't save then chart void count and add a comment patient didn't save. If the patient didn't void mark zero and notify the nurse asap.
300
What should I do if the patient goes over their fluid restriction?
Notify the nurse and encourage them to limit their fluids.
300
T or F. My patient has swelling in her feet. I should elevate them on pillows.
True! This will help decrease the swelling and improve circulation.
300
T or F. It is okay to use the bed scale if my patient is sleeping.
False. The patient should be weighed on the standing scale unless they cannot bear weight or they refuse.
400
My patient forgot to save his urine . Is it okay to chart void count?
Remind the patient to save his urine. Do not chart void count unless patient forgot or refuses to it. Always document a reason if you chart void count.
400
Is it okay for me to chart my I & O at the end of my 12 hour shift?
No. I & O must be recorded every 8 hours.
400
Should I completely fill the water pitcher every shift?
No. Mark in permanent marker on the pitcher the amount that the patient can have every shift.
400
How often should a patient ambulate?
BID at a minimum. Check with the nurse to see what is ordered. It may be every shift.
400
Why are daily weights important?
To help determine a patient's progress and course of treatment.
500
T or F. Charting is optional and I should only do it if I have time. Why?
False!! Documentation is extremely important in the treatment and management of heart failure patients. The physicians and other staff rely on our documentation in order to determine the course of treatment.
500
How does documenting I & O impact the patient's treatment?
The physician will look at output and determine if treatment is effective.
500
T or F. Is it okay to get your patient salt out of the galley? Is jello considered a fluid?
False! Yes!
500
What do you do if your patient becomes dyspnic during ambulation? Do you need to notify the RN?
Check oxygen saturation and encourage frequent rest breaks. Heart failure patients will experience dyspnea if retaining fluid or overexerting themselves. Yes!
500
What do I do if my patient weighs > 2.2 kg from the day before? What does this mean?
Reweigh the patient using the same type of scale. If the weight is the same then notify the RN. The patient is retaining fluid and the nurse needs to be notified.