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Nursing 1111 Wk4
Medical Records, Pt HX, PE
| Question | Answer |
|---|---|
| 1. List the standard information that should be found in all patients’ medical records. | name/initials of vet name, addy, ph of client name/id of pt/s age/sex/breed/species/color except herd or flock dates hx data from pe tx/tx plan sx dx prognosis meds/txs including dosing and admin info daily progress |
| 2. What is the AVMA’s position on Ethics and Medical Records? | Records must comply with state /federal law Records are property of practice Medical records are confidential Obligated to provide a copy when req'd by client Cannot use records for personal or professional gain |
| 3. What does “VCPR” stand for? | Veterinarian–Client–Patient Relationship |
| 4. What is meant by “Informed Consent”? Why is this important? | Agreement to allow smthg to happen, based on full disclosure of facts to make an intelligent decision. Must use language client can understand. 3 STDs: what the dr believes relevant, what a reasonable client understands, what the individual understands |
| 5. List consent forms that are commonly used in clinical practice. | Surgery euthanasia necropsy fee estimation treatment restraint |
| 6. Know the “Rules of Thumb” with regards to documentation in medical records. | 1. Written or in electronic medical record (EMR) or it did not happen 2. If the writing is ellegible, it was not written down 3. If one part of the EMR shows signs of tampering or is inaccurate, the integrity of the ENTIRE record is questionable |
| 7. Know the basic guidelines for generating accurate medical records. | 1. typed/written neatly in black ink 2. all entries signed 3. single line strikethrough with "error" in margins, signed, dated 4. initials ok if form has a signature box or practice keeps log of initials 5. Use only approved, standard abbreviations |
| 8. Who owns the medical records? | The practice/practice owner |
| 9. Define patient signalment. | identifying info about pt MC# or tattoo species, breed, sex and repro status (intact, neutered, pregnant), age, color distinctive markings: ear notch/crop, scar, tail dock |
| 10. What is the current information that should be obtained for a patient history? | Client info Pt name & signalment Pertinent history Previous history PE Diagnosis Prognoses Therapeutic Plans Cautionary Notes |
| 11. What information should be obtained for previous history? | Previous: Problems Treatments and responses Surgeries Medications Diagnostic tests Immunization hx weight hx diet Geography/travel |
| 12. Describe the “SOAP” format for medical records. (Know the general information that should be included in each section.) | Vet tech's SOAP - differs from dr's. (search for cause/cure illness) Tech's focus physiologic and psychosocial responses to illness and strives to ameliorate those responses - COMFORT FIRST |
| 13. What information should be included in Discharge Instructions? | Summary of pet's illness, prognosis, and treatment |
| HX | History |
| DSH/DLH | Domestic Short Hair/Domestic Long Hair |
| DX | Diagnosis |
| TX | Treatment |
| PE | Physical Examination |
| BW | Body Weight |
| BAR | Bright, Alert, Responsive |
| TPR | Temperature, Pulse, Respiration |
| HR | Heart rate |
| CRT | Capillary Refill Time |
| MM | Mucous Membrane |
| EENT | Eyes, Ears, Nose, Throat |
| V-D or V/D | Vomiting and Diarrhea |
| WNL | Within Normal Limits |
| NSF | No Significant Findings |
| HBC | Hit by Car |
| 1. What can you do to ensure that nothing is overlooked when obtaining a patient history? | Use a consistent, organized system for obtaining historical information about each and every patient |
| 2. What should you do when you first enter an exam room prior to obtaining patient information? | Introduce oneself and explain what is being done so that the client feels comfortable and willing to share information. Be familiar with pet's name, sex, etc. to avoid mistakes |
| 3. Define signalment. Why is signalment important? | age, breed, sex and repro status Important bc provides important clues abt the case. Certain diseases appear more commonly in animals of certain signalments |
| 4. Why is it important to ask about travel history of a pet? | Important when there is a suspicion of a disease that is endemic to a region visited w/in last 6 months |
| 5. What background information should be obtained for each patient? | General-duration owned, breeder info, husbandry, diet Preventative-vx, fthwp Behavior-normal behavior, any changes Household info-health other members (infectious/zoonotic/toxicity) Allergy-known allergies or adverse rxns Repro-add'l to signalment |
| 6. Why is it important to note the age at which an animal was spayed or neutered? | May pertain to disease prevalence. Ex.1 mammary tumors are much more common in dogs that have gone thru a single heat than those spayed before it Ex.2 Recent heat (if intact), since pyometra occurs 2 weeks to 2 months after heat cycle |
| 7. What is meant by Chief Complaint or Presenting Complaint | What brings the client into the practice, the most important info to be addressed in medical hx Can be more than one May not all be associated with same medical disorder |
| 8. When inquiring about the Presenting Complaint, what information should be obtained? | Last normal - helps determine duration, create clear timeline and problem list Progression - better, same, worse Systems Review - c/s, v/d, pu/pd, appetite, energy lvl, wt↑↓ Medications - dose, freq, otc meds, and topicals, fthwp |
| 9. What questions should you ask a client about any medication that he/she has been giving their pet? | Type of medication Dose and frequency (exact time for some, ie insulin, t4) Duration been given Reason given Provided any benefit? Include OTC meds, vitamins, supplements Include topical shampoos/dips FT/HWP |
| 1. Identify normal and abnormal mucous membrane colors and know the significance of each | pink, pale/white, blue/purple, Yellow, (Red) |
| 2. Be able to identify the major skeletal structures. | |
| 3. Be able to identify the major internal organs. | |
| 4. Identify the location of the heart valves. | |
| 5. Identify the location of the important superficial lymph nodes. | |
| 6. Why is a thorough physical exam so important? | To learn normal/abnormal Symptoms can be vague, PE helps determine source of illness Helps guide nursing process, identify issues and formulate technician interventions |
| 7. Why is it important to develop a routine when performing a physical exam? | Routine and repetition = proficiency Helps avoid forgetting to evaluate an area/missing a finding May need to vary from pt to pt |
| 8. When performing a physical exam on a stable animal, what do you want to assess prior to touching the animal; what are you evaluating? | Assessment of pt in its surroundings/from a distance -mentation: bar or qar, depressed, unresponsive -Visual inspection of RR/effort -Look for lameness, ataxia, asymmetry, swelling -Eval BCS |
| 9. What is the most accurate way of obtaining the temperature of a patient? | Rectal temperature |
| 10. Define hyperthermia. What can cause mild hyperthermia? Moderate to severe hyperthermia? | Hyperthermia - elevated body temperature Mild hyperthermia can be secondary to anxiety (due to visit) Mod/severe: infection, inflammation, neoplasia, heat stroke, certain drugs (seizures?) |
| 11. Define hypothermia. What can cause hypothermia? | Hypothermia - decreased body temperature Less commonly seen Usually results in impaired thermoregulation, esp. in cats Inability to maintain body temp > young, old, or thin pts Conditions: Renal fail, hypothyroid, CNS disease |
| 12. Instead of counting the heart and respiratory rates for 1 full minute, what is an easy way to calculate the HR / RR? | Count for 15 seconds then multiply by 4 Double then double again |
| 13. Describe what should be checked during an oral exam. | Teeth - missing, discoloration, fx, tartar, loose, pain Gums - redness/gingivitis, swelling, ulcers Tongue - swelling, discoloration, ulceration; under for swelling, masses, or foreign body roof - soft/hard palate back - pharynx/larynx |
| 14. Describe what should be checked during an ocular exam. | eyelids, external and internal structures of the eye assessment of visual status general visual inspection of the globes |
| 15. During an exam of the respiratory system of an animal, what could you do to help auscultate a purring cat? Panting dog? | Purring - cover the nares, running water, alcohol soaked cotton or tapping the nose Panting in dog - hold the mouth closed |
| 16. What information can you get from looking at the oral mucous membranes? | Perfusion status, hydration status, CRT |
| 17. Define CRT, as related to a PE, and know how this would be performed. | Capillary Refill Time - serves as indicator of perfusion. With pt's lip raised, the gingival surface is gently pressed to occlude blood flow until color fades. Remove finger and measure time takes to return to normal. Normal = less than 2 seconds |
| 18. What are you assessing during cardiac auscultation? | Heart rate, heart rhythm, and heart sounds |
| 19. During abdominal palpation, what organs are you assessing? | Liver - usu, no Spleen - yes Kidneys - usu no in dogs, more so in cats Urinary Bladder - easy yes assuming not empty Prostate gland - occ yes esp. if enlarged Stomach - usu no unless distention or mass Sm/Lg intestines - usu yes, occ masses/feces |
| 20. How would you perform abdominal palpation on most dogs? Small dogs and cats? | Most dogs, 2 handed technique is best small dogs and cats, use 1 handed technique |
| 21. What are you assessing during a rectal exam / anus / external genitalia? | rectal - prostate, urethra, iliac LNs, inner mucosa, rectal wall, stool, AGs anus - external exam for redness, swelling, masses, d/c, other external genitalia - distal urethra, penis, vag (unusual), testicles |
| 22. What should you be looking at when assessing the integument? | Hair, skin (inc. pads/nails), and subcutaneous tissues Evaluate for thinning & alopecia Fleas Papules/pustules, scales/crusts, excoriations, erythema, petechiae/ecchymoses, nails and pads for red, d/c, ulceration Masses |
| 23. What are the 3 peripheral lymph nodes that can be palpated in a normal patient? | Mandibular, prescapular, popliteal |
| 24. What should you be looking at when assessing the musculoskeletal system? | Can vary No presenting complaint - observe walking, standing for symmetry, palpation of ea. limb, neck, & back Complaint - above as well as flexion and extension of joints |
| SOAP - S | Subjective All nonmeasurable information Relevant HX, presenting complaint, most of the PE, FAS, |
| SOAP - O | Objective All measurable information Lab results TPR skin retraction time, CRT number of bowel movements measured urine output pain score if uniformly applied throughout clinic |
| SOAP - A | Assessment Analysis of all sub/ob data - NOT DR'S DX Use critical thinking skills to generate a list of technician evals of pt to reflect physical, psychological, social & environmental conditions to generate a custom nursing plan to address pt's needs |
| SOAP - P | Plan Tech develops intervention for each eval listed in assessment. Interventions constitute the tech's care plan to restore the pt's comfort &wellbeing Can include: admin of meds, client edu, compresses, f/u appts Augments/supports medical tx plan |
| Pink/Pale Pink MM | Normal |
| Pale/White MM | Inadequate blood volume or hemoglobin concentration Anemia; shock |
| Blue/Purple MM= Cyanosis/Cyanotic | Inadequate oxygenation of tissues Heart or Respiratory problems |
| Yellow MM = Icterus/Icteric | Hyperbilirubinemia = liver or blood problem |
| Bright/Brick Red MM = Hyperperfusion = Hyperemia | Hyperemia = sepsis, shock, heatstroke |
| Normal dog pupil Normal cat pupil | dog pupil = round cat pupil = vertical slit |
| Basic Anatomy of the Eye: Lateral Canthus and Medial Canthus | Lateral (outer) and Medial (inner) corners of the eye Angular junction of the upper and lower eyelids at their medial and lateral ends; the angles of the palpebral fissure |
| Basic Anatomy of the Eye: Upper and lower eyelids and Cilia | Cilia = lashes Eyelid margins should be evaluated for masses or abnormal hairs(irritation), entropion and ectropion |
| Basic Anatomy of the Eye: Nictitating Membrane | Called the 3rd eyelid Rests beneath the lower eyelid on the medial aspect of the orbit and usually is not visible or only partially visible |
| Basic Anatomy of the Eye: Cornea | The transparent covering of the front of the eye, and it should be clear. Examine for cloudiness or other precipitates/pigment, ulcers, blood vessels |
| Basic Anatomy of the Eye: Nasolacrimal duct | Carries tears away from eye to the nose |
| Basic Anatomy of the Eye: Iris | The colored part of the eye Should be evaluated for swelling, discoloration, irregularity, or masses |
| Basic Anatomy of the Eye: Pupil | The opening of the iris Should be evaluated for degree of constriction or dilation and symmetry of size PLR - Pupillary Light response should be examined in all pts |
| Basic Anatomy of the Eye: Conjunctiva (Conjunctivitis) | The pink membrane that can be seen by pulling back the upper or lower eyelids. Covers the outer part of the eye up to where the cornea begins Conjunctivitis - swelling /inflammation of conjunctiva |
| Basic Anatomy of the Eye: Sclera | The normally white part of the eye. An easy place to examine for yellow discoloration seen w/ icterus Examined for any redness |
| Basic Anatomy of the Eye: Lens | Part of the eye responsible for focusing images onto the retina Located inside the pupillary opening and cannot be seen w/o special equipment, however Increased lens opacity can be seen w/ nuclear sclerosis or cataracts |
| Abnormal Exposure of Nictitating Membrane | Should be evaluated for swelling, redness, masses, or foreign material |
| Anisocoria | When pupils are of differing sizes When PLR is measured, both pupils should constrict Anisocoria and abnormal PLR can indicate various ocular an neurologic diseases |
| Skeleton of a Dog: Skull | Skull |
| Skeleton of a Dog: Orbit | |
| Skeleton of a Dog: Lower Maxillary | |
| Skeleton of a Dog; Cervical Vertebrae | |
| Skeleton of a Dog: Thoracic Vertebrae | |
| Skeleton of a Dog: Lumbar Vertebrae | |
| Skeleton of a Dog: Sacrum | |
| Skeleton of a Dog: Caudal Vertebrae | |
| Skeleton of a Dog: Pelvis | |
| Skeleton of a Dog: Femur | |
| Skeleton of a Dog: Fibula | |
| Skeleton of a Dog: Tibia | |
| Skeleton of a Dog: Carpus | |
| Skeleton of a Dog: Metacarpus | |
| Skeleton of a Dog: Tarsus | |
| Skeleton of a Dog: Metatarsus | |
| Skeleton of a Dog:Phalange | |
| Skeleton of a Dog: Humerus | |
| Skeleton of a Dog: Radius | |
| Skeleton of a Dog: Ulna | |
| Skeleton of a Dog: Rib | |
| Skeleton of a Dog: Scapula | |
| Superficial Lymph Node: Mandibular Lymph nodes | Palpable on Exam |
| Superficial Lymph Node: Superficial Cervical/Prescapular | Palpable on Exam |
| Superficial Lymph Node: Axillary Lymph Node | Usually only palpable when enlarged |
| Superficial Lymph Node: Inguinal Lymph Node | Usually only palpable when enlarged |
| Superficial Lymph Node: Popliteal Lymph Node | Palpable on exam |
| Location of Pulmonic Heart Valve | |
| Location of Aortic Heart Valve | |
| Location of Mitral Heart Valve | |
| Location of Tricuspid Heart Valve |
Created by:
shawamber