Module 2 Flashcards
Writing a diagnosis
Actual:
Diagnostic label
R/T (etiology or cause)
As evidenced by (defining characteristics)
Risk for:
Diagnostic label
R/T (etiology or cause)
Wellness/health promotion:
Diagnostic label
use Maslow’s for order, even a risk of respiratory events is higher priority than acute pain
ADPIE (nursing process)
Assessment
Diagnosis
Planning
Implementation
Evaluation
SMART (planning goals for patients)
Specific - contains behavioral verb
Measurable
Attainable
Realistic
Timebound (short, long term)
General Adaptation Syndrome
Alarm Reaction - release of hormones, fight or flight, increase of vital signs
Stage of Resistance - Body attempts to resist or adapt to stressor
Stage of Exhaustion - body has depleted energy, immune system weakens
Defense mechanisms
Compensation - overachievement in one area to offset deficiencies in another area
Denial - refusing to admit reality
Displacement - Transfers an emotional reaction from one source of stress to an unrelated person
Projection - Attributing undesirable feelings to another person
Rationalization - a person tries to give a logical or socially acceptable explanation for behavior
Reaction formation - conscious attitude & behaviors that are opposite of their true feelings
Regression - reverting to behaviors consistent with earlier stages of development
Repression - storing painful feelings in unconscious
Sublimation - Transformation of unwanted impulses into something less harmful
Undoing - using an act to negate a previous unacceptable act
Requirements of EBP
Research and critical thinking
One’s own clinical expertise
Client preferences and values
PICO format
Patient, population, problem of interest
Intervention of interest
Comparison of interest
Outcome of interest
PICO example
P - adult patients
I - when measuring B/P with patient’s legs crossed
C - versus patient’s feet flat on floor
O - have a more accurate B/P
3 questions for critical thinking
What do I know?
How do I know it?
What options are available to me?
Health definition
State of complete physical, mental, and social well being
An active state, includes 6 dimensions of self (emotional, physical, social, environmental, spiritual, mental)
Morbidity vs Mortality
Morbidity - frequency of a disease
Mortality - number of deaths from a disease
Illness
The response of the person to a disease, how their level of functioning changes, may be a pathologic change in structure or function
Illness stages
- experiencing symptoms
- assuming the sick role
- Assuming the dependent role (accepts treatment)
- Achieving recovery and rehabilitation
Health promotion
Primary - prevent condition from ever happening, promoting health
Secondary - identifying high risk individuals and screening for illness, catch early
Tertiary - after an illness diagnosed, goal is to improve maximum function of individual
We use 24-hour clock for documenting.
True
Specifics for charting
Complete, current, organized
Use black ball point pen
Correct errors by drawing a single line through the error, then sign with your initials
No white out or erasers
Use a horizontal line to fill up a partial line
Date each entry and time
What to chart
Assessment at start of shift
Changes in mental, psychological, physiological conditions
Reactions to medications or procedures
Left and returned from unit
Teaching
Physician visits
Time client left and returned including transportation and destination
Medications: dose, route, site, pain, side effects
Late entry
SOAPIE (documentation)
Subjective info
Objective info
Assessment
Plan
Implementation
Evaluation
ISBARR
Identity/introduction
Situation
Background
Assessment - what you think problem is
Recommendation
Read back (restate your orders)
Cranial nerve I
Olfactory - smell
Cranial nerve II
Optic - vision
Cranial nerve III
Oculomotor - pupil constriction
Cranial nerve IV
Trochlear - downward and inward eye movement
Cranial nerve V
Trigeminal - jaw clenching, chewing, neck sensation
