FUNDA - NURSING PROCESS Flashcards
CAN BE AN INTERVIEW
include patient assessments, observations, and direct interactions,
PRIMARY DATA
VERIFICATION OF THE DATA GATHER (DO DOUBLE CHECK)
encompass literature reviews, medical records, and research studies.
SECONDARY DATA
GUIDLINES FOR NURSING CARE PLAN
- Date & sign the plan
- Use category headings
- Standardized, approved medical or English symbol & key words rather than complete sentences to communicate your idea unless agency or policy dictates otherwise
- Be specific
- Refer procedure books or other sources of information rather than including all steps on a written plan
- Tailor the plan to the unique characteristic of the client by ensuring that the client’s choices, such as preference schedule
- Ensure that the nursing plan incorporates preventive & health maintenance aspects as well as restorative outcomes.
- Ensure that the plan contains ongoing assessment of the client
- Include collaborative & coordination activities
- Include plan for the patient discharge & home care.
statement of conclusion regarding the nature of phenomenon P- ROBLEM - E- ETIOLOGY SIGNS & SYMPTOMS
DIAGNOSIS
entry by all health professional (SOAP, PIE, SOAPIER)
PROGRESS NOTE
8 PURPOSE OF CLIENT RECORDS
- Communication
- Planning client care
- Auditing health agencies
- Research education reimbursement
- Legal documentation
- Healthcare analysis
- Documentation systems
- Source-oriented record
- is a formal, legal document that provides evidence of clients care & can be written or computer based. (recording, charting or documents)
RECORD
HOW TO GUARD THE E-DOCUMENTS OF PATIENT (7)
- Personal password - do not share
- Never leave the terminal unattended
- Do not leave client information display
- Shred all documents
- Know the p&p of the hospital for correcting error
- Know the agency procedure for documenting sensitive information
- IT technology must install firewall to protect the server
initial list of orders or plan is made in reference to the active problem
PLAN OF CARE
it is derived from data base itis usually kept at the front of the chart
PROBLEM LIST
The ability to communicate is directly related to the development of thought processes, the presence of intact sensory and motor systems, and the extent and nature of an individual’s opportunities to practice communication skills, as children grow, their communication abilities change markedly.
COMM WITH CHILDREN
consist of all information known about the patient
DATABASE
______ communicate nonverbally, often in response to body feelings rather than in a conscious effort to be expressive.
___________ perceptions are related to sensory stimuli, so a gentle voice is soothing, for example, while tension and anger around them create distress.
INFANTS
is intended to make client the client concerns & strength the focus of care
FOCUS CHARTING
FDAR
FOCUS
DATA
ACTION
RESPONSE
4 THERAPEUTIC COMM TECHNIQUES
USING SILENCE.
PROVIDING GENERAL LEADS.
BEING SPECIFIC AND TENTATIVE.
USING OPEN-MINDED QUESTIONS.
- _______ and young children gain skills in both expressive (i.e. telling others what they feel, think, want, care about) and receptive (hearing and understanding what others are communicating to them) language.
- Allow time for them to complete verbalizing their thoughts with- out interruption.
- Provide a simple response to questions because they have short attention spans.
- Drawing a picture can provide another way for the child to communicate.
TODDLERS AND PRESCHOOLERS
- Talk to the child at his or her eye level to help decrease Intimidation.
- Include the child in the conversation when communicating with the parents.
SCHOOL-AGE CHILDREN
- Take time to build rapport with the adolescent.
- Use active listening skills.
- Project a nonjudgmental attitude and nonreactive behaviors, even when the adolescent makes disturbing remarks.
ADOLESCENTS
2 MODES OF COMMUNICATION
VERBAL AND NON-VERBAL
Endorsement
Change of shift report
Hand over communication
Endorsement report
Telephone report
Verbal orders
Nursing rounds
Care plan conference
NURSING ROUNDS
