Podcast
Questions and Answers
What indicates a patient is at high risk for developing a VTE according to the scoring system?
What indicates a patient is at high risk for developing a VTE according to the scoring system?
All anti-inflammatory drugs can be used for VTE prevention.
All anti-inflammatory drugs can be used for VTE prevention.
False
Name one type of medication that is included under cytotoxic drugs.
Name one type of medication that is included under cytotoxic drugs.
Chemotherapy agents
A patient at risk for VTE must be assessed based on their _____ and _____ data.
A patient at risk for VTE must be assessed based on their _____ and _____ data.
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Match the following medications with their categories:
Match the following medications with their categories:
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Which of the following is NOT a non-pharmacological prevention strategy for VTE?
Which of the following is NOT a non-pharmacological prevention strategy for VTE?
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A patient must be monitored for 48 hours after major surgery.
A patient must be monitored for 48 hours after major surgery.
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What constitutes a very high-risk score for VTE?
What constitutes a very high-risk score for VTE?
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Which of the following is a risk factor for VTE?
Which of the following is a risk factor for VTE?
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Congestive heart failure does not contribute to the risk of developing VTE.
Congestive heart failure does not contribute to the risk of developing VTE.
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What is the significance of assessing for swollen legs or varicose veins during the examination?
What is the significance of assessing for swollen legs or varicose veins during the examination?
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Surgery lasting longer than ______ minutes is considered major surgery.
Surgery lasting longer than ______ minutes is considered major surgery.
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Match the patient conditions to their related VTE risk:
Match the patient conditions to their related VTE risk:
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Which of the following describes a pharmacological prevention method for VTE?
Which of the following describes a pharmacological prevention method for VTE?
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All patients under the age of 41 are at no risk for developing VTE.
All patients under the age of 41 are at no risk for developing VTE.
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What is the role of central venous access in relation to VTE risk?
What is the role of central venous access in relation to VTE risk?
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Which of the following is NOT a risk factor for the development of deep vein thrombosis (DVT)?
Which of the following is NOT a risk factor for the development of deep vein thrombosis (DVT)?
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Clotting disorders include thrombophilia and haemophilia.
Clotting disorders include thrombophilia and haemophilia.
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What should a nurse do after calculating a patient's venous thromboembolism (VTE) score?
What should a nurse do after calculating a patient's venous thromboembolism (VTE) score?
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The formation of an intravascular clot is known as _________.
The formation of an intravascular clot is known as _________.
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Match the following conditions with their corresponding potential risk factors for VTE:
Match the following conditions with their corresponding potential risk factors for VTE:
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Which statement is true regarding non-pharmacological prevention of VTE?
Which statement is true regarding non-pharmacological prevention of VTE?
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A patient who has had a stillborn child may be at risk for clotting disorders.
A patient who has had a stillborn child may be at risk for clotting disorders.
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What is the purpose of circling the patient's risk result on the VTE sticker?
What is the purpose of circling the patient's risk result on the VTE sticker?
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Study Notes
Guidelines to Completion of Patient Documentation
- This document guides users in completing adult patient nursing and clinical records.
- Accurate and comprehensive recording of patient conditions, treatment plans, interventions and patient responses is crucial.
- It ensures effective communication among patient care teams.
- The document supports investigations, legal inquiries and complaints.
- It informs medical aid authorizations.
- The records are used to bill patient admissions and treatments, for statistics, funding, and strategic decision-making
- The document applies to all nursing practitioners and users who record information for adult patients.
- All nursing practitioners and employees must comply with legal requirements for clinical records
- Patient records should accurately reflect the nursing care rendered.
- Patient reactions to nursing care and treatment should be included.
- Nurse-patient communication with multi-disciplinary team members must be recorded.
- All nursing interventions and events must be recorded by the respective nurses.
- Only pre-approved Mediclinic patient records can be used.
- Abnormalities should be circled in assessment documents and indicated on the flow records. Repetition of information is unnecessary, except for abnormalities.
- All patient documentation must reflect a complete, valid picture of all hospitalizations, from admission to discharge.
- All diagnoses, conditions, and comorbidities should be documented.
- All complications (medical and surgical) must be documented.
- The documentation should reflect the nurses' work (including patient education and psychosocial support).
- The documentation must reflect the objective clinical judgment of the nurse.
- All documentation must maintain logical and sequential order.
Critical Elements in Documentation
- Legible: All handwriting must be neat and clear to read. Only approved Mediclinic stationery is acceptable.
- Accurate: Only accurate facts and details should be recorded.
- Concise: Recording must be clear and concise.
- Credible: The recorded data must be demonstrably truthful.
- Chronological: Entries must reflect the order and time of occurrences. Late entries must be clearly referenced.
- Permanent: Use permanent ink (black).
- Free of Erasures: Errors should be lined out with an initial, and not corrected with correction fluid.
- Differentiable: Entries by different nurses should be distinguishable, with each entry on a new line.
- Identifiable: Each record must be identified with a patient sticker, initials, surname, hospital number and date of birth, and the treating physician/ nurse. Each entry must be signed and the nurse's rank indicated.
Completion: General Assessment Record (N0953)
- The document is designed for patients admitted to admission centers or directly admitted to nursing units.
- Record the patient's condition, treatment plan, care interventions, and patient reactions to care.
- Fill in extra information in applicable open spaces, beside details.
- Each record will be identified with a single patient sticker on the front page.
- The assessment must be completed as soon as possible after admission.
- If interpreters are needed, arrange them prior to patient admission.
Completion: Waterlow Pressure Sore Risk Assessment (N3297)
- This assessment determines patient risk for pressure sores during the hospital stay.
- Record the date and time of assessment in the provided blocks.
- Categorize, and note any associated data about patient characteristics or conditions, such as BMI.
Completion: Venous Thromboembolism (VTE) Risk Assessment (N3297)
- This assessment evaluates the risk of thrombosis (blood clots).
- Record the date and time of each assessment.
- Use patient history (subjective data) with physical exams to determine score.
Completion: Signature Sheet (N3373)
- This sheet is completed by all members of the multidisciplinary team involved in the patient documentation (during the patient's hospital stay).
Completion: Adult Early Warning Observation Record (N3182)
- This record helps identify patients at risk of deterioration.
- It guides nurse practitioners in providing appropriate interventions.
- The record uses three coloured zones to indicate observation readings: white, orange, and red.
Completion: Patient Care Plan Basic Needs (N0909)
- Each "basic needs" care plan is activated in the morning.
- Nursing practitioners must review and update the plan.
- The active status of the plan (or a change in status) needs to be indicated by a √ mark.
Completion: Specific Patient Care Plan (N1012)
- Nursing prescriptions must be specific, measurable, attainable, realistic, and time-bound (SMART).
- The plan should be based on the nursing diagnosis, and each prescription should state the expected outcome.
Completion: Fluid Balance Record (N0949)
- This record tracks fluid intake and output.
- Includes both intravenous (IV) and oral/tube feedings.
- Documents the actual time of each recording.
Completion: Peri-Operative Record (N0997)
- Records information about patient consent for procedures, allergies, and risk factors.
- Includes documentation of patient consent including the type of procedure.
Completion: Post-Operative Patient Care Plan (N1000)
- Documents the patient's post-operative care plan, including vital signs, fluid balance , and pain management.
Completion: Implementation Record (N1009)
- Documents all nursing activities and observations, in chronological order.
- Includes specific details for each nursing action, frequency, and any associated issues or problems.
Completion: Prescription Chart (P1002)
- Used to capture medication details, including allergies, weight, height, and medical diagnosis.
Completion: Pharmacy Order Form
- This form is used for ordering medications
- It records the date, time of any medication prescribed, as well as the quantity.
Completion: Prescription Booklet (P3246)
- Used to record medical prescriptions from patients.
- Medical diagnosis must be recorded on the page, as well as weights, heights and allergies.
Completion: Clinical Evaluation: General Patients (CL3187)
- This document is used to share patient information with case managers.
- Includes details such as vitals (e.g., blood pressure, pulse rate, temperature), body mass index, oxygen use, and further information about comorbidities
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