Documentation + Vital Signs

Question 1

What are 6 Principles of Documentation?

Answer 1

Accurate
Complete
Factual
Concise
Timely/Organised
Legible

Question 2

What are intergrated progress notes?

Answer 2

Notes that address care, findings, and patient problems

Question 3

What are 4 types of reporting?

Answer 3

Change of shift reports
Telephone reports
Telephone Orders
Transfer reports

Question 4

What is variance charting?

Answer 4

used when a person fails to meet an expected outcome

Question 5

What is SOAPIER?

Answer 5

SUBJECTIVE
OBJECTIVE
ASSESSMENT
PLAN
INTERVENTION
EVALUATION
RESPONSE

Question 6

What is PIE?

Answer 6

PROBLEM
INTERVENTION
EVALUATION

Question 7

What is AIE?

Answer 7

ASSESSMENT
INTERVENTION
EVALUATION

Question 8

What is ISBAR?

Answer 8

IDENTIFICATION
SITUATION
BACKGROUND
ASSESSMENT
RECOMMENDATION

Question 9

What does TPR + BP stand for?

Answer 9

TEMPERATURE
PULSE
RESPIRATIONS
BLOOD PRESSURE

Question 10

What is the function of the Hypothalamus?

Answer 10

Temperature Regulation
Nerve impulses to sweat glands, muscles and BV

Question 11

Is the oral temp lower or higher?

Answer 11

lower - 37 degrees

Question 12

Is the axillary (armpit) temp lower or higher?

Answer 12

lower - 36.5 degrees

Question 13

What is Afebrile?

Answer 13

Normal Basal body temo 36-37.5

Question 14

Where are the 4 places to assess temperature?

Answer 14

Tympanic (ear)
Orally
Axillary (armpit)
Rectally

Question 15

What is the Sinus Node?

Answer 15

In the right atrium
Acts as the pacemaker

Question 16

What regulates the Sinus Node?

Answer 16

Nervous System
Neurotransmitters
Hormones

Question 17

Where are the different pulse points?

Answer 17

Temporal (side of skull)
Carotid (either side of neck)
Brachial (arm)
Apical (chest)
Radial (wrist)
Ulnar (wrist)
Femoral (groin)
Dorsal Pedis (foot)

Question 18

What is Brachycardia?

Answer 18

Slow heart rate

Question 19

What is Tachycardia?

Answer 19

Fast heart rate

Question 20

What is Apnoea?

Answer 20

When you stop breathing for periods of time

Question 21

What is Bradypnoea?

Answer 21

Abnormally slow breathing rate

Question 22

Tachypnoea

Answer 22

Abnormally fast breathing rate

Question 23

What is Hyperventilation?

Answer 23

Rapid or de
Not taking enough oxygen

Question 24

What is decrease BP detected by?

Answer 24

The Kidney

Question 25

Systolic

Answer 25

120
heart beat

Question 26

Diastolic

Answer 26

80
heart rest between beats