1
Q
ADC
A
Ambulatory Day Care
2
Q
ABS
A
admit before surgery
3
Q
APS
A
acute pain service
4
Q
AK
A
above knee
5
Q
BK
A
below knee
6
Q
BSO
A
Bilateral Salpingo-oophorectomy
7
Q
CBI
A
continuous bladder irrigation
8
Q
C/S
A
caesarian section
9
Q
D & C
A
dilatation and curettage
10
Q
FB
A
foreign body
11
Q
FOB
A
foot of bed
12
Q
FS
A
frozen section
13
Q
I & D
A
incision and drainage
14
Q
NG
A
nasogastric tube
15
Q
NWB
A
non-weight bearing
16
Q
ORIF
A
Open Reduction Internal Fixation
17
Q
PAC
A
Pre Admission Clinic
18
Q
PAR
A
Post Anaesthetic Room
19
Q
PARR
A
Post Anaesthetic Recovery Room
20
Q
PCA
A
Patient controlled analgesia
21
Q
POD
A
post operative day
22
Q
PWB
A
partial weight bearing
23
Q
ROS
A
removal of sutures/staples
24
Q
SAP
A
Surgical Admission Program
25
SDA
Same Day Admission
26
SDC
Surgical Day Care
27
SSU
short stay unit
28
T & A
tonsils and adenoids
29
TAH
total abdominal hysterectomy
30
TKR/TKA
Total Knee Replacement/Arthroplasty
31
TUPR
Transurethral Prostrate Resection
32
Tx
treatment/traction
33
WBAT
weight bearing as tolerated
34
Admit before surgery
patients who need to be admitted one or more days prior to surgery
35
Admission orders
written instructions by the doctor for the care and treatment of the patient upon entry into the hospital
36
Blood transfusion consent
a patient's written consent to receive blood or blood products
37
Blood transfusion refusal
a patient's written permission to refuse blood or blood products
38
Direct Admission
a patient who was not scheduled to be admitted and is admitted from the doctor's office, clinic, or emergency room
39
elective surgery
surgery that is not emergency or mandatory and can be planned at a time of convenience
40
Emergent procedure/add on
an urgent or emergency surgical procedure not preplanned
41
Extubation
removal of a tube
42
intubation
insertion and placement of a tube within the trachea
43
Surgery Schedule/OR Slate
a list of all the surgeries to be performed on a particular day
44
perioperative
pertaining to the time of surgery
45
post operative orders
orders written immediately after surgery
46
Pre Admission Clinic
department where the patients are scheduled to see the pre admission nurse, have all necessary pre op diagnostic tests done and see the Anesthetist if required
47
Preoperative Care Unit
a unit within the surgical area where a patient is prepared for surgery
48
Pre Operative Orders
orders written by the doctor before surgery to prepare the patient for their surgical procedure
49
Scheduled admission
a patient admission planned in advance, it may be urgent or elective
50
Surgical Day Care
patients who are not staying overnight in the hospital after their surgical procedure
51
Surgical Consent
a patient's written permission for an operation or invasive procedure
52
5 reasons a patient may have surgery?
1) take a biopsy of a suspicious lump 2) remove diseased tissues or organs 3) remove an obstruction 4) reposition structure to their normal position 5) transplant tissue or whole organs
53
What are 3 types of surgeries?
1) Elective 2) Urgent 3) Emergency
54
What do Surgeons/specialists have to have in order to use OR time in a hospital?
They have to be given practicing privileges in the hospital or hospital privileges.
55
How do they know which day they will be in the OR?
They will be appointed certain days to use the OR for his/her patients.
56
What are the usual hours of routine/elective surgical procedures?
Monday-Friday 07:00-18:00.
57
How does the attending Physician get the opinion of another Doctor?
The doctor must write an order requesting a consultation or the doctor may page the consulting Doctor and do a verbal Doctor to Doctor consult
58
What type of procedures does the Anaestatist take care of?
Administration of anesthetic drugs, pre anesthetic assessments, airway management, post op analgesia, post op pain relief, cardio and respiratory monitoring.
59
What does general anaesthesia imply?
It is the anesthetic used to induce unconsciousness during surgery or for a patient experiencing major trauma where the patient needs to be unconscious to heal or to not harm themselves further, ex., severe burns. The medication is administered through IV or is inhaled through a breathing mask or tube.
60
What are the most common drugs used for pre-medication?
Narcotics and sedatives.
61
What does the Surgeon's office do once he/she has recommended surgery?
Submits a surgical booking form along with a consult report to the hospital booking department where he/she has privileges.
62
Who assigns surgery date and times?
The OR Booking Clerk with the OR Manager according to the assigned surgical days, surgeon, and priority.
63
Once an OR date and time has been assigned what happens next?
If the patient requires a hospital stay of one or more days he/she will be referred to a Pre Admission Clinic.
64
What happens at the Pre admission visit?
The patient will see a Nurse. The nurse will give the pre-op testing instructions lab/diagnostics as well as seeing the Anesthetist. The patient will be given all the information regarding the surgical procedure/stay in the hospital, as well as the time to arrive the morning of surgery.
65
What time does the patient arrive at the hospital on the day of their surgery?
Usually several hours prior to their scheduled OR time.
66
What happens after the patients arrive the day of surgery?
The patient has the final pre-op preparations completed. This is usually done in the designated pre operative care unit.
67
Once the patients surgical procedure is complete where do they go an for how long?
The patient goes to the (PACU) Post Anaesthetic Care Unit for several hours for monitoring before being sent to the surgical unit.
68
How and when does the Surgical Nursing Unit receive a copy of the OR slate/Surgery Schedule?
Daily M-F for surgeries scheduled for the following day.
69
What information is on the OR Slate/Surgery Schedule?
Patients Name, Age, time of surgery, diagnosis, surgical procedure, surgeon performing the procedure, anaesthetist, Family GP, allergies, any other pertinent info related to the procedure.
70
What are the 6 surgical forms found in the Surgical Chart Pack?
1) Surgical Consent Form
2) Pre-Op Checklist/ OR Check Off List
3) Anesthetic Record
4) Surgical Count Sheet/OR Count Sheet
5) Post Anesthetic Recovery Record
6) Operation Report/Operating Room Record
71
Where does the surgical chart pack go pre-op, once addressographed/labeled?
In the very front of the inside of the chart.
72
What are the 6 miscellaneous Surgical Chart forms?
1) Post Surgical Ward Assessment
2) Fluid Balance Record
3) Surgical Pathology Report
4) Consent For Health Care/Blood Transfusion Consent
5) Refusal for Blood Transfusion
6) Blood Administration Record
73
Blood Administration Record
Record used to record all blood products administered given during the patient's surgical procedure
74
Blood Transfusion Consent
Consent signed by the patient to allow transfusion of blood
75
Surgical Consent Form
Patient must sign authorizing the Surgeon to carry out the surgical procedure
76
Operation Report/Operating Room Record
A report detailing all aspects of surgical procedure from start to finish
77
Post Surgical Ward Assessment
is completed by the RN when the patient returns to the nursing unit
78
Surgical Pathology Report
A report detailing specimen collected information that may have been removed from the patient during surgery and requires Pathological investigation
79
Fluid Balance Record
Record used by the RN for monitoring all patient fluid intake and outputs
80
Refusal for Blood Transfusion
Form signed by patient refusing administration of blood
81
Post Anesthetic Recovery Record
PAR RN will record all observations
82
Surgical Count Sheet/OR Count Sheet
Purpose of this form is to record all instruments used during the surgical procedure
83
Anesthetic Record
Used by the Anesthetist to record their observations
84
Pre-Op Checklist/OR Check Off List
Checklist is compete by the RN to ensure all pre-operative tests and procedures have been done
85
Pre-op love notes
1) SCPA & CTC:surgical chart pack addressographed and clipped to the inside of the chart
2) CFCS: consent form completed and signed
3) POTP&RF: pre-op tests processed and reports filed
4) SDTOWB: surgery date and time on white board
5) OCSTOR: old chart sent to OR
6) ALIC: addressograph/labels in chart
7) MIC: MAR in chart
86
Post-op love notes
1) NAPAFP: nurse aware patient's arrival from PARR/PACU
2) R&FA: removed and filed addressograph
3) FOTC: filed old/thinned charts
4) UWB: update white board
5) OCFORRIPC: organized chart filed OR records in chart
87
Pre op orders may consist of the following:
1) Lab orders
2) Diagnostic orders
3) Parenteral Therapy
4) Skin Prep orders
5) Bowel Prep Orders
6) Pre op Medication Orders;Pre Op ABX
7) Misc.
88
List the most common pre op laboratory tests ordered
CBC, Lytes, Urea, Creatinine, INR, PTT, U/A
89
What type of diagnostic tests may be ordered pre op?
CXR, x-ray Lt Hip to rule out Fx, Abd U/S to rule out appendicitis
90
Why is an IV started prior to surgery?
To ensure a patient does not become depleted, ensure IV access is obtained, administration of pre op meds and for meds given during surgery from the anaestatist.
91
Why does the doctor order skin prep before surgery?
To help prevent post op infections.
92
Why are the following medications ordered pre op? Sedatives, Anti-reflux/antiemetics
Sedatives: To help the patient sleep, and the morning of surgery to help the patient relax
Anti-reflux/antiemetics: to help prevent regurgitation and aspiration
93
What other types of medications may be ordered pre op?
Antibiotics, pt.'s regular meds at home
94
List 3 guidelines for Anaesthesia consults for most surgical procedures:
1) All pt.'s with diabetes who are over 40 yrs. old
2) All pt.'s with signs and symptoms of cardiovascular disease - HTN, MI, Angina
3) All pt.'s over 40 who smoke or have a significant family hx of cardiovascular disease
95
Name 3 miscellaneous pre op orders and where are they recorded?
1) ensuring Old chart is requested from HR and goes with the patient to the OR
2) Glucometer prior to OR
3) insert foley catheter prior to surgery
They are all to be recorded in the appropriate section of the K
96
What pre op orders are continued after surgery?
All pre op orders are D/C'd prior to surgery and reordered after surgery.
97
What must the Unit clerk ensure is done prior to surgery?
1) NA of OR date and time
2) NA any pre op meds
3) SCP is addressographed/labeled and clipped to the inside of the chart
4) Consent form completed and clipped to chart for physician
5) all pre-op orders have been processed
6) Record OR d and t on all pre op requ's in Red Ink
7) Record surgery d and t on K in pencil
8) update WB with OR date and time
9) OC received from HR
10) ensure all pre op orders have been processed and reports filed in chart
11) ensure consent form is completed and signed
98
What must the unit clerk ensure is done prior to transferring a patient to the OR?
1) attach addressograph/labels to the chart
2) send any old or thinned charts to the OR with the pt.
3) attach the most current MAR to the patients chart
4) draw a line after the last physician's order and write "TO OR" in red
5) Draw diagonal lines through the rest of the blank form
6) stuff chart with several blank physician's orders
7) flag chart for nurse to check
99
What is noted on any pre operative requisitions?
OR date and time in red ink.
100
What are the post op order components?
1) Medication orders
2) Dietary orders
3) Positioning orders
4) intake and output orders
5) IV orders
6) wound and skin tx orders
7) activity orders
8) urinary catheter orders
9) vital sign orders
10) suction orders
11) incisional suction orders
12) Abd drain orders
13) referrals to various multidiscinary team orders
14) discharge and f/u post op orders
101
What are the guidelines for patient returning to the OR/PARR?
1) Nurse aware pt.'s arrival from PARR/PACU
2) remove and file addressograph
3) filed old/thinned charts
4) update white board
5) organize chart and file all OR records behind the OR section in pt.'s chart
6) scan surgeon/anaesthetist order and fax to pharmacy
7) transcribe the post op orders as per regular routines
8) record date and surgery performed on the K under "operations/surgery" in black ink.
102
What are pre and post op Clinical/surgical Pathways used for
They are pre-printed orders that are a method of ordering a patient's medications and care of treatment for a specific diagnosis or surgical procedure.
103
Give 5 examples of Clinical/Surgical Pathways:
Elective Total Hip and Knee Replacement, TUPR Radical Retropubic Prostatectomy, C-Section, Fractured Hip, Anaesthetic PCA/Spinal, BSSO.
104
List the guidelines for processing surgeons pre printed Clinical/Surgical Pathways:
1) All bulleted/numbered orders are automatically ordered and transcribed
2) all blank boxes/lines must be marked or details completed by doctor before processing
3) transcribe as per regular routines onto the Kardex/MAR/Requisitions/Order Entry
4) medication orders written by the Anaesthetist override any duplicates when both surgeon and anaesthetist have written similar orders for pain control
5) use abbreviations/protocol short cuts where applicable
6) fax stamp all pages to pharmacy
7) sign off pages after checking and completing orders
105
What is the definition of PCA?
Medications administered intravenously by means of a special infusion pump controlled by the patient within order ranges written by the Anaestetist.
106
Who sets up, orders and discontinues the PCA medications?
The Anaestetist is the only one who can do this. A doctor cannot DC the PCA
107
How are the PCA orders transcribed?
K: in the IV/treatment section PCA Morphine
MAR: on the scheduled/routine section PCA Morphine "as per standing order sheet"
108
What are the most common meds ordered for the PCA?
Morphine, Hydromorphone, Demerol
109
What is spinal anaesthesia often used for?
genital, urinary tract, or lower body procedures
110
What is Epidural anaesthesia often used for?
during labour and delivery and surgery in the pelvis and legs
- labour is too painful without any pain meds
- the procedure in the belly, legs, or feet
- your body can remain in a comfortable position during your procedure
- you want fewer side effects and a shorter recovery time than you would from general anaesthesia.
111
How are Epidural orders transcribed on the:
K: in the IV/Tx section - Epidural bupivacaine with fentanyl
MAR: on the scheduled/routine section - Epidural as per standing order sheet
112
Name 3 Multidisciplinary teams in the Rehabilitation Department?
1) PT
2) OT
3) Speech/Language Pathology
113
What does each team do?
1) PT: treats patients to improve and restore their functional mobility
2) OT: works toward rehab of patients to the greatest functional independence
3) SLP: therapy for patients with speech/language impairment as a result of a stroke, dementia, and various neurological disorders, swallowing disorders
114
How are these OT, PT, SLP, orders communicated to the various departments?
By computer or requisition.
115
What are the guidelines for processing Multidisciplinary Orders?
1) Transcribe in the appropriate referral section of the K
2) Addressograph and complete the appropriate req with the following info.
Dept., Unit, Bed #, Dx, precautions, weight bearing status
3) CTCFP
4) Fax to dept.
5) Page, phone, for any STAT orders, symbolize paged (OT, PT, SLP)
6) symbolize PO- K, RMO, Nurse/Dept. Aware for any stats
116
Give 5 examples of Doctor's orders for PT?
1) Whirlpool bathe LLE BID
2) AA (Active assisted) exercise lt shoulder and elbow daily
3) ROM bid to UE
4) PROM BLE bid
5) PT to eval and treat
117
Give 3 examples of orders for OT?
1) OT for evaluation and treatment if needed daily
2) Training in ADLs
3) OT to increase mobility
118
Give 2 examples of orders for Speech Therapy
1) Speech therapy to evaluate motor speech disorder
| 2) Consult Speech Therapy for swallowing risk
Nursing Unit Clerk
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