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 (not applicable) in the daily education box
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?
- a communication tool
- "Tells a Story"
- brief summary of progress notes
- in conjunction with verbal report
What is the End of Shift report?
- frequent refusals
- 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?
Nurse: "I sent a signed MD order for Amoxicillin to the office.
Dad: "We already picked up Jr.'s prescription."
Nurse: "Let me follow up. In the meantime, Dad if you can give Jr. his amoxicillin, that will be great! I have to confirm with ACCS before I can give it."
What is the correct response to handling a physician's order?
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 required to follow the plan of treatment
- Able to give or refuse 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.
- Clean G tube site daily/prn.
- 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 s/s of kidney stones OR a UTI?
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
What are components of the POT?
- Client name/DOB
- Medication name/dose/frequency/route/diagnosis
- Order type (verbal, written, clarification)
- Provider's signature/Nurse's signature/Date
What is needed to change a medication or treatment?