Chapter 6- Nursing Process Flashcards
nursing process
Assessment
Diagnosis
Plan
Intervention
Evaluation
mini-mental status assessment
11 questions assessing for cognitive impairment…
general appearance
emotions
cognition
thoughts
judgement and insight
problem-oriented recording
SOAPIE format
Subjective data
Objective data
Assessment (interpret S+O)
Planning
Intervention
Evaluation
PIE charting
assessment
Planning
Intervention
Evaluation
concept mapping
a diagrammatic teaching and learning strategy that allows students and faculty to visualize interrelationships among medical diagnoses, nursing diagnoses, assessment data, and treatments
focus charting
data
focus (diagnosis, current issue, do not need to update unless there is a change)
action
response
advantages of EHR
reduce info redundancy
decrease charting time
facilitate communication
how are nursing diagnosis prioritized?
by life-threatening potential