Nursing Process - 2 Flashcards
➤ Nursing models or framework
Gordon’s functional health pattern
Orem’s self-care model
Roy’s adaptation model
Wellness model
➤ Nonnursing models
Body system model
Maslow’s Hierarchy of Needs
Developmental theories
is the act of “double checking “or verifying the data to confirm that it is accurate and factual.
Validation
Subjective or objective data observed by the nurse; is what the client says, or what the nurse can see, hear, feel, smell, or measure.
Cues
The nurse’s interpretation or conclusion is based on the cues.
Example: Red swollen wound with drains = infected wound; Dry skin = dehydrated
Inferences
- Documenting data
A ___ is a permanent written communication that documents information relevant to a client’s health care management.
record
takes place when two or more people share information about client care, either face-to-face or by telephone
REPORTING
Purposes or importance of records
Communication
Legal documentation
Nursing audit
Educational( records are useful for educational purposes in various ways e.g. a client diagnosis, s/s of disease, successful and unsuccessful diagnostic findings, and client behaviors)
A factual record contains descriptive, objective information about what a nurse sees, hears, feels, and smells.
The client’s BP is 80/50 mmHg, and the client’s diaphoretic, restlessness and HR are 102 and regular.*(the use of inferences client appears to be in shock)
Factual
The use of exact measurements establishes accuracy.
Use of institution-accepted abbreviations, symbols, and systems of measures.
Accurate
The information will not be completed without full information.
The information within a record entry or a report needs to be complete and contain appropriate and vital information otherwise it’s considered incomplete.
Completeness
To increase accuracy, quality of care and decrease unnecessary duplication, and prevent errors it’s essential to record timely.
For e.g a client’s BP is 140/90 when you’re admitted to some type of drug the nurse should record the same.
Current
As a nurse, you want to communicate information in a logical order.
For example, an organized note describes the client’s knowledge deficit, nurses’ assessment and interventions, and the client’s response.
The nurse should apply theories, critical thinking, EBP, and the nursing process to give logic and order to nursing documentation
Organized
the nurse records all data collected about the client’s health status
data are recorded factually not as interpreted by the nurse
Record subjective data in the client’s words; restating in other words what the client says might change its original meaning
Communicate/Record/Document Data
This was initially defined by Lawrence Weed, MD, is the official method of record keeping used by most medical centers across the world and thus in most (if not all) undergraduate medical schools
Problem-oriented medical record (POMR)
The ___ note originates from the POMR
SOAP
SOAP is an acronym for
Subjective, Objective, Assessment, and Plan
Methods of recording and documentation
Narrative Charting
Traditional client record
___ is a method of recording the patient’s progress under the headings of problem, intervention, and evaluation. When the PIE method is used, assessments are documented on separate forms and the patient’s problems are given a corresponding number
PIE Charting
P-
I -
E -
problem identification
interventions
evaluation
Otherwise known as FDAR charting, it is a method for organizing health information in the individual’s record. It is a systematic approach to documentation, using nursing terminology to describe an individual’s health status and nursing action.
Focus Charting
An ___ chart is a common tool nurses may use to track patients’ health information. Nurses can monitor patient data and evaluate their treatment progress in an organized way.
F-DAR
