NURS 210 gastrointestinal pharmacology Top-
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Medical Surgical nursing - Medical & Surgical nurses practice primarily on hospital units
that care for adult patients who are acutely ill with a wide variety of medical issues, or who are
recovering from surgery
Difference between medical and surgical - Medical - No SX component
-care of patients who require care for disease/illlness but may not need sx
Surgical - SX component
-patients that require sx
-lots of post-op assessments
List medical pre-op vital checks - Day 1: Admission to first 24 hours (Initial vitals and then
Q4H)
Day 2: 24-48hrs (x2/shift or every 6 hours = QID or Q6H)
Day 3: 48hrs to discharge (x1/shift = BID, Q12H)
List sx post-op vials checks - Day 1: Arrive on unit to first 24hrs (Initial vitals and then Q30
minutes x2 = every thirty minutes for one hour THEN every hours for 2 hours = Q1H x2 THEN
every 4 hours = Q4H)
Day 2+: From 24 hours to discharge (Twice per shift/every 6 hours = QID or Q6H)
What to use to know your client (resources) - Client chart
Nursing Kardex
MAR
Checks for room safety equipment and safety for care - 1) Is the client breathing?
2) Is there O2 flowing? What rate? Is it on?
3) What equipment is at the bedside and does it work?
4) Is the bed safe? (height and position)
5) Is there equipment blocking access to the patient?
,6) Trace all tubing back to the source
What does SAFE stand for? (Universal falls precautions) - S- Safe environment
A - Assist with mobility
F - Falls risk reduction
E - Engage patient and family
What are the 3 easy universal falls precaution questions? - 1) Do you need to use the
toilet?
2) Do you have any pain or discomfort?
3) Do you need anything before I leave?
What is the most common cause of delay in discharge? - Lack of Mobilizing
What needs re-assessment? - Every intervention needs a re-assessment.
Legally what does every patient in the hospital need daily? - Full assessment and vital
signs
What is the most commonly forgotten vital sign? - Temperature
What do you update daily using pencil when patient status changes? - Kardex
What do you need to know for every patient? - Code status
What is the difference between indirect and direct care? - Indirect - Prime IV, document
Direct - interventions doing with or for client
What legal requirements does documentation encapsulate? - BC Coroner's Act
Controlled Drug and Substance Act
Evidence Act
Health Professions Act
Hospital Act
Mental Health Act
**Statutory regulations
, What is the purpose of documentation? - 1) Facilitates communication (nurse-nurse or
other care providers)
2) Promotes safe and appropriate nursing care (accountability)
3) Meets professional and legal standards
4) Supports collaboration and teamwork
5) Quality improvement tool
6) Guides resource allocation (evidence for more funding)
7) Data for nursing research
*Chart like you are going to court*
How do nurses document? (format) - DARP
D- Data (subjective and objective)
A - Action (what are we going to do about it?)
R - Response (follow-up/reassess post-intervention)
P - Plan (what are we going to do moving forward? Do we need to make another plan?)
What are the 4 legal principles of documentation? - 1) Document at the time of care
2) only document when you have personal knowledge of what matters being documented
(what YOU have seen - ALWAYS need to confirm...can't just write what others tell you)
3) Charting by exception can provide admissible evidence (long-hand narratives if findings are
unusual)
4) Alterations and additions and errors are suspicious therefore be clear and don't make
mistakes
List some documentation standards - -Blue or black ink
-Sign all entries
-Use DARP format
-Never skip lines
-Don't use acronyms unless know its correct/only use employer approved abbreviations
-Write clearly
Rated Content | Accurate and Complete Solutions
Medical Surgical nursing - Medical & Surgical nurses practice primarily on hospital units
that care for adult patients who are acutely ill with a wide variety of medical issues, or who are
recovering from surgery
Difference between medical and surgical - Medical - No SX component
-care of patients who require care for disease/illlness but may not need sx
Surgical - SX component
-patients that require sx
-lots of post-op assessments
List medical pre-op vital checks - Day 1: Admission to first 24 hours (Initial vitals and then
Q4H)
Day 2: 24-48hrs (x2/shift or every 6 hours = QID or Q6H)
Day 3: 48hrs to discharge (x1/shift = BID, Q12H)
List sx post-op vials checks - Day 1: Arrive on unit to first 24hrs (Initial vitals and then Q30
minutes x2 = every thirty minutes for one hour THEN every hours for 2 hours = Q1H x2 THEN
every 4 hours = Q4H)
Day 2+: From 24 hours to discharge (Twice per shift/every 6 hours = QID or Q6H)
What to use to know your client (resources) - Client chart
Nursing Kardex
MAR
Checks for room safety equipment and safety for care - 1) Is the client breathing?
2) Is there O2 flowing? What rate? Is it on?
3) What equipment is at the bedside and does it work?
4) Is the bed safe? (height and position)
5) Is there equipment blocking access to the patient?
,6) Trace all tubing back to the source
What does SAFE stand for? (Universal falls precautions) - S- Safe environment
A - Assist with mobility
F - Falls risk reduction
E - Engage patient and family
What are the 3 easy universal falls precaution questions? - 1) Do you need to use the
toilet?
2) Do you have any pain or discomfort?
3) Do you need anything before I leave?
What is the most common cause of delay in discharge? - Lack of Mobilizing
What needs re-assessment? - Every intervention needs a re-assessment.
Legally what does every patient in the hospital need daily? - Full assessment and vital
signs
What is the most commonly forgotten vital sign? - Temperature
What do you update daily using pencil when patient status changes? - Kardex
What do you need to know for every patient? - Code status
What is the difference between indirect and direct care? - Indirect - Prime IV, document
Direct - interventions doing with or for client
What legal requirements does documentation encapsulate? - BC Coroner's Act
Controlled Drug and Substance Act
Evidence Act
Health Professions Act
Hospital Act
Mental Health Act
**Statutory regulations
, What is the purpose of documentation? - 1) Facilitates communication (nurse-nurse or
other care providers)
2) Promotes safe and appropriate nursing care (accountability)
3) Meets professional and legal standards
4) Supports collaboration and teamwork
5) Quality improvement tool
6) Guides resource allocation (evidence for more funding)
7) Data for nursing research
*Chart like you are going to court*
How do nurses document? (format) - DARP
D- Data (subjective and objective)
A - Action (what are we going to do about it?)
R - Response (follow-up/reassess post-intervention)
P - Plan (what are we going to do moving forward? Do we need to make another plan?)
What are the 4 legal principles of documentation? - 1) Document at the time of care
2) only document when you have personal knowledge of what matters being documented
(what YOU have seen - ALWAYS need to confirm...can't just write what others tell you)
3) Charting by exception can provide admissible evidence (long-hand narratives if findings are
unusual)
4) Alterations and additions and errors are suspicious therefore be clear and don't make
mistakes
List some documentation standards - -Blue or black ink
-Sign all entries
-Use DARP format
-Never skip lines
-Don't use acronyms unless know its correct/only use employer approved abbreviations
-Write clearly
