Basic Care - Clinical Nursing

What is Medicare?

is the federal health insurance program for: People who are 65 or older. Certain younger people with disabilities. People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)

How does Medicare work?

1) must be over 65

2) receiving benefits

4 plans are available

PART A: Hospital no premium

PART B: Physiciants/Outpatient (beneficiaries must enroll) has premium

If a patient has medicare, YOU MUST BILL MEDICARE, it is illegal if you don't

CANNOT BILL FOR MAINTENANCE

Need to fill out ABN Form before treatment process occurs

What is Medicaid?

A health insurance assistance program for some low income people (especially children and pregnant women) sponsored by federal and state governments

How does Medicaid work?

Medicaid does not pay benefits to individuals directly; Medicaid sends benefit payments to health care providers. In some states Medicaid beneficiaries are required to pay a small fee (co-payment) for medical services. ... The federal government pays on average 57 percent of Medicaid expenses.

What are Advanced Directives?

-legal documents to make medical decision for patients when they are unable

-all hospitals must provide patients with information about this right to declare their personal wishes about treatment and give them opportunity to make a decision. (living will, health care proxy or power of attorney, health care surrogate)

What is a Bill of Patients Rights?

A patient's bill of rights is a list of guarantees for those receiving medical care. It may take the form of a law or a non-binding declaration. Typically a patient's bill of rights guarantees patients information, fair treatment, and autonomy over medical decisions, among other rights.

What is Client-Centered Care?

Care based on the patient's needs, values, and preferences

What is the Client-Centered Determination Act?

is to inform patients of their rights regarding decisions toward their own medical care, and ensure that these rights are communicated by the health care provider.

What is Discharge Planning?

Coordinating, planning, and arranging for the transition from one health care setting to another

How do you Discharge a patient?

●Teach the patient and family about the patient's illness and its effect on his or her lifestyle. - document - give out supplies

●Provide instructions for home care.

●Communicate dietary or activity instructions.

●Explain the purpose, adverse effects, and scheduling of medication treatment.

●Planning can include arranging transportation.

●Follow-up care may be necessary.

●Coordinate outpatient or home care services.

SBAR Documentation

Situation

Background

Assessment

Recommendation

What is SBAR used for?

a technique that can be used to facilitate prompt and appropriate communication. This communication model has gained popularity in healthcare settings, especially among professionals such as nursing staff.

How does SBAR improve patient safety?

SBAR communication has demonstrated that it enhances efficient communication that promotes effective collaboration, improves patient outcomes, and increases patient satisfaction with care. SBAR is an evidence-based best practice communication technique.

Why is SABR important?

a technique that can be used to facilitate prompt and appropriate communication. ... It is a way for health care professionals to communicate effectively with one another, and also allows for important information to be transferred accurately.

What is the SOAP format?

the universally preferred schema of organization and documentation of case histories; required by many insurance companies and you shouldn't go to court without it

What is the SOAP format?

subjective, objective, assessment, plan

What is the SGA evaluation?

The Subjective Global Assessment (SGA) is a type of clinical tool doctors use to determine a person's overall state of health. It is most often used when assessing nutritional status in patients with kidney problems like end-stage renal disease or chronic renal insufficiency.

How do you Assess Pain?

1) determine location (localized, diffused)

2) eval intensity

a. pain intensity scale 0-10

b. id time of day pain is most intense

3) determine onset/duration of pain (gradual, sudden and length of time)

4) description of pain (sharp, throb, tender, etc)

5) functional assessment of pain

a. McGill Pain Questionnaire

b. Pain Disability Index

c. Functional Interference Estimate

What is the McGill Pain Questionnaire?

20 groups of words from which the patient picks one word per group to describe his/her pain; usually performed once every 2-4 weeks

What is Pain Disability Index?

a simple and rapid instrument for measuring the impact that pain has on the ability of a person to participate in essential life activities.

What is the Functional Interference Estimate?

The Functional Interference Estimate (FIE) is a brief, 5-item self-report measure that assesses the degree to which pain interferes with daily functioning.

What is the Low Fowler's Position?

Supine with the head of the bed elevated 15-30 degrees

Why are patients put in the Low Fowler's Position?

This position is considered best considering the rest of patient's body

What is High Fowler's Position?

an upright seated position (HOB 60-90 degrees)

Why are Patients put into High Fowler's Position?

While allowing easy breathing, this position is also considered the best position for defecating, eating, swallowing and also for taking the x-rays.

What is Supine Position?

lying on back, facing upward

What is Prone Position?

lying face down on stomach

What is Trendelenbreg?

the body is laid supine, or flat on the back on a 15-30 degree incline with the feet elevated above the head. The reverse Trendelenburg position, similarly, places the body supine on an incline but with the head now being elevated.

What is the Lateral position?

lying on either side of the body

What is Surgical Consent?

is defined by giving your physician permission to perform surgery and may not always be in written form.

What are some Isolation types?

Four isolation categories are widely recognized are

standard,

contact,

airborne,

and droplet precautions

Standard (Isolation Type)

- Associates following Standard Precautions for care of ALL patients.

- Applies to blood, all bodily fluids, secretion, excretion (except sweat), mucus membrane and non-intact skin.

- All associates wear the appropriate personal protective equipment (PPE) to prevent contact of their clothes, skin, eyes, or mucus membranes to any substance listed above.

Contact (Isolation Type)

- Patient out of room only when necessary.

- Trash and linen hamper must be in the patients room.

- Use disposable medical equipment that are non-critical ( Ex: Stethoscope, Thermometer)

- Wash hands immediately after removing gown and gloves (when still in room) and don't touch anything before leaving.

Airborne (Isolation Type)

- Keep both doors of the anti-room closed at all times except when entering or exiting the room.

- Keep UV lights on at all times.

- Wear your appropriately fit tested N95 particulate respirator upon entering after you've been fit checked.

- Limit visitors and any visitors must be fit tested as well.

Droplet (Isolation Type)

Must have clean hands are is wearing gloves, gowns and eye protection (Mask as well)