Documentation + Vital Signs Flashcards
What are 6 Principles of Documentation?
Accurate
Complete
Factual
Concise
Timely/Organised
Legible
What are intergrated progress notes?
Notes that address care, findings, and patient problems
What are 4 types of reporting?
Change of shift reports
Telephone reports
Telephone Orders
Transfer reports
What is variance charting?
used when a person fails to meet an expected outcome
What is SOAPIER?
SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLAN
INTERVENTION
EVALUATION
RESPONSE
What is PIE?
PROBLEM
INTERVENTION
EVALUATION
What is AIE?
ASSESSMENT
INTERVENTION
EVALUATION
What is ISBAR?
IDENTIFICATION
SITUATION
BACKGROUND
ASSESSMENT
RECOMMENDATION
What does TPR + BP stand for?
TEMPERATURE
PULSE
RESPIRATIONS
BLOOD PRESSURE
What is the function of the Hypothalamus?
Temperature Regulation
Nerve impulses to sweat glands, muscles and BV
Is the oral temp lower or higher?
lower - 37 degrees
Is the axillary (armpit) temp lower or higher?
lower - 36.5 degrees
What is Afebrile?
Normal Basal body temo 36-37.5
Where are the 4 places to assess temperature?
Tympanic (ear)
Orally
Axillary (armpit)
Rectally
What is the Sinus Node?
In the right atrium
Acts as the pacemaker
What regulates the Sinus Node?
Nervous System
Neurotransmitters
Hormones
Where are the different pulse points?
Temporal (side of skull)
Carotid (either side of neck)
Brachial (arm)
Apical (chest)
Radial (wrist)
Ulnar (wrist)
Femoral (groin)
Dorsal Pedis (foot)
What is Brachycardia?
Slow heart rate
What is Tachycardia?
Fast heart rate
What is Apnoea?
When you stop breathing for periods of time
What is Bradypnoea?
Abnormally slow breathing rate
Tachypnoea
Abnormally fast breathing rate
What is Hyperventilation?
Rapid or de
Not taking enough oxygen
What is decrease BP detected by?
The Kidney
Systolic
120
heart beat
Diastolic
80
heart rest between beats
