Week 2 - Admissions, Diagnostic Tests, and Documentation

Admissions, Diagnostic Tests, and Documentation

Admission Process

• Check documented information prior to the interview

  • Avoids repetition of information

  • Occurs in advance of the day of surgery

• Patients are typically seen in the Preoperative Admission Clinic (PAC)

• Information provided includes:

  • Protocol for routine medication on the day of surgery

  • Medications or herbal remedies to stop before surgery

  • Nothing-by-mouth (NPO) instructions

  • Pain management options

  • Infection prevention and wound care

  • Postoperative exercises

  • Postoperative discharge and care

Medication Reconciliation

• Systematic review process of all medications prescribed

  • Ensures necessary medications are continued, changed, or stopped

  • Tool for evaluating medications during care transitions to improve safety

  • Aims to reduce medication discrepancies

Documentation

• Must be accurate and comprehensive

  • Reflects standards of nursing practice

  • Varies among institutions and jurisdictions

• Influenced by ethical, legal, medical, and agency guidelines

Communication in Healthcare

• Records or Charts:

  • Confidential permanent legal documents

• Reports:

  • Oral, written, or audio-recorded exchanges of information

• Consultations:

  • Professional advice provided formally by one caregiver to another

• Referrals:

  • Arrangements for services by another care provider

Guidelines for Quality Documentation

• Must be:

  • Factual

  • Accurate

  • Complete

  • Current

  • Organized

  • Compliant with standards

Pre-Operative Diagnostic Testing

• Surgeon orders tests based on patient history and surgical needs

• Severe health problems revealed may postpone surgery until stabilization

Importance of Diagnostic Testing

• Enables diagnosis, monitoring, and treatment of conditions

• Assists in anticipating changes in health status

• Involves LPNs in patient care and diagnostics procedures

• Patient teaching is vital for cooperation and accuracy of results

Types of Diagnostic Tests

Biopsy

• Tissue analysis for determining cell morphology and abnormalities

• Types include:

  • Endoscopic

  • Open

  • Percutaneous Needle

• Nursing Responsibilities:

  • Educate the patient about expectations

  • Manage medications and procedural care

X-ray

• Electromagnetic radiation for imaging internal structures

• Chest X-ray commonly used to evaluate cardiac and respiratory structures

• Patient preparation: No food, fluid, or activity restrictions unless ordered

Computed Tomography (CT) Scan

• Visualizes internal organs, assessing conditions pre- and post-surgery

• No activity restrictions unless specified; fasting may be required with contrast

• Nursing roles: patient education and monitoring for complications post-scan

Magnetic Resonance Imaging (MRI)

• Assesses internal organs/structures; monitors post-procedure complications

• Inquiry about implanted devices is crucial due to magnetic fields

Ultrasound

• Visualizes and guides procedures with no specific restrictions unless directed

Endoscopy

• Direct visualization of the digestive tract; may require NPO status pre-procedure

• Monitor patient closely for complications post-procedure

Bronchoscopy

• Visualizes bronchial structures; restricts intake pre-procedure

Other Diagnostic Tests

• Allergy Testing

• Pulmonary Function Tests

• Diagnostic Mammograms

Laboratory Tests

• Evaluate health needs, aid diagnosis, and monitor therapy effectiveness

• Influence clinical decision-making and care plans

Common Lab Tests

Complete Blood Count (CBC)

• Basic screening test for diagnostic information

• Evaluates cellular elements in the blood

• Reference ranges included

PT/INR

• Prothrombin time test for monitoring blood clot risk

• Reference ranges included

Blood Glucose

• Assists in diabetes evaluation/treatment; various teaching responsibilities

• Reference ranges included

Kidney Function Tests:

• Blood Urea Nitrogen (BUN) and Creatinine assess kidney health

• Reference ranges included

Electrolytes

• Tests assess electrolyte balance; reference ranges are delineated

Urine Tests

• Screens for various disorders, aiding in diagnosis and hydration assessment

Other Important Aspects

• Nursing Diagnoses for Abnormal Lab Values:

• Telephone and Verbal Orders:

  • Procedures for receiving orders during emergencies

• Discharge Summary Report:

  • Importance of planning and revising care for timely discharges