Test 2 Flashcards
The art of recording client assessments and care in written or electronic form
Documentation
The purpose of the written record that states members of the multidiscipinary team uses the health record to communicate about the patient’s status and care
Communication between providers
Purpose of the written record that is served as a shanpshot of what is going on with the client so that you are able to research unfamiliar diagnoses, orders, and treatments before direct care begins
Educational Tool
The purpose of the written record that discusses how the health record will be scrutinized by legal experts if a dispute about a client’s care arises.
Legal documentation of care
The purpose of the written record used to formulate strategies to improve care, decrease length of stay, control costs, and pinpoint knowledge and practice gaps that can be addressed through continuing professional education
Quality improvement
The function of the written record to be used to gather data for clinical research
Research
The function of the written record for insurance companies to gather data for clinical research, budget managers & staff billing.
Reimbursement
Standard terminologies are constructed by
NANDA (NIC & NOC)
A documentation system where the disciplines document in separate sections of the chart
Source-oriented system
Advantage of source oriented system
each discipline is easily found
Disadvantages of this system include
- data may be fragmented & scattered
- difficult to track the treatments and client outcomes associated with a particular problem
source oriented system
Documentation system that is organized around client problems
Problem oriented system
Four components of the problem-oriented system
database, problem list, plan of care, progress notes
Advantages of this system include:
- common problem list
- easy to monitor progress
- may encourage greater collaboration
problem oriented system:
Disadvantages of this system include:
- have to read through entire chart to find information
- lengthy
- different people chart differently
problem oriented system
This type of charting may be used with source- or problem-oriented systems
Narrative charting
Advantages of Narrative charting:
story in chronological format
tracks the client’s changing status
Disadvantages to this type of charting include:
-timely
-have to read whole note to fine outcomes
inconsistent
-difficult to track problems day to day or see trends
narrative charting
P in PIE charting
problem
I in PIE charting
Interventions
E in PIE charting
Evaluation
This is a step in ___ charting that uses data from the original assessment to identify appropriate nursing diagnoses
PIE, P
This is a step in ___ charting that documents the nursing actions taken for each nursing diagnosis
PIE, Interventions
This is a step in ____ charting that documents the patient’s response to interventions and treatments
Evaluation
The primary disadvantage of PIE charting
no planning portion of the nursing process
PIE charting is used only in ______ charting
problem oriented
S in SOAP charting
Subjective Data
O in SOAP charting
Objective
A in SOAP charting
Assessment
P in SOAP charting
Plan
I in SOAP modified charting
Intervention
E in SOAP modified charting
Evaluation
R in SOAP modified charting
Revision
Charting that highlights the client’s concerns, problems or strengths in 3 colomns
Focus Charting
Column 1 of Focus charting
Time and date
Column 2 of focus charting
focus or problem being addressed
column 3 of focus charting
charting in a DAR format
DAR
Data, Action, Response
Subjective and objective information that supports the focus.
Data
Aspect of focus charting that reflects the assessment phase of the nursing process
Data
Describes interventions performed
Action
Aspect of focus charting that reflects the planning and implementation phases of the nursing process
Action
Advantages of focus charting
-holistic
Disadvantages of this type of charting include:
- lacks a common problem list
- leads to inconsistency in labeling the focus of notes
- difficult to track progress
focus charting
This type of charting only charts significant findings or exceptions to norm
Charting by Exception
Advantages in charting by exception:
- streamlines charting
- saves time
Disadvantage to charting by exception
omissions
Documentation that includes only exceptions to the norm or significant information about the patient.
FACT Documentation
F in FACT documentation
flow sheets individualize specific services
A in FACT documentation
assessment with baseline data
C in FACT documentation
Concise progress notes
T in FACT documentation
Timely entries
A patient being able to administer their own SQ insulin would be what letter in focus charting?
R-Response
The nursing admission assessment determines:
a baseline to data to monitor change
Allows you to monitor change and view patterns
flow sheets and graphic records
Comprehensive list of all ordered medications
MAR
Document medications according to times they are given, examples of orders would be:
scheduled, unscheduled, continuous, prn, stat
contains:
- demographics
- diagnosis
- allergies
- dietary/activity orders
- safety precautions
- IV therapy orders
- ordered treatments
- medication summary
- special instructions
Kardex or Client Care Summary
Are the kardex & electronic care summary part of the patient’s permanent record?
no
A combined charting and care plan form
integrated plans of care
Maps out on a daily basis, from admission to discharge
Integrated plans of care
IPOCs help administrators predict:
- length of stay
- cost of care
- staffing needs
Advantages of using these include:
eliminate duplicate charting, increases team effort, enhances the nurse’s teaching about what patient can expect
Integrated plans of care
A formal record of unusual occurrence or accident
occurrence reports
In the occurrence report, identify:
client, date, time, location
Method to inform other caregivers about the client’s condition, vital info & plan of care
Reporting
Handoff report may be:
verbal, walking rounds, audio-recorded
the process of adapting to one’s body and environment over time, enabled by increasing complexity of function and skill progression
Development
A child who recognizes right from wrong, an older adult who recognizes nearness of death, are both examples of:
Development
physical changes that occur over time
growth
Development = ___ + _____
Growth + behavioral
genetic endowment
nature
Usual patterns of growth and development occur in these 3 patterns
predictable
cephalocaudal
proximodistal
when an infant is born, their head is largest and progressively other body parts grow to proportion is an example of :
cephalocaudal growth
An infant’s tendency to use their arms before their legs is an example of:
cephalocaudal development
in utero, the baby’s central body is formed before the limbs is an example of:
proximodistal growth
when an infant first opens it eyes, then lifts head, then pushes up and rolls over is an example of:
proximodistal development
T/F each body system grows at its own rate
true
body system functions become increasingly ____ over time
differentiated
midway between an individual need and societal demand. Assumes an active learner interacting with an active social environment
developmental task
Advantage to Havighurts’s developmental task theory:
it is easy to evaluate a client’s completion of the tasks
Disadvantage to Havighurts’s developmental task theory:
nonspecific time frame limits the ability to assess whether an individual is developing within an expected range
Theory involving the id, ego, superego and unconscious mind
Freud’s psychoanalytic theory
instinctual urges, present from birth on, dominant in children and older adults who cannot control their urges
id
begins to develop around 4-6 months, represents reality, balances urges and what is possible to obtain
ego
conscience, develops at age 5-6 as a result of the internalization of primary caregiver responses to environmental events
superego
composed of thoughts and memories not readily recalled
unconscious
thought patterns or behaviors that the ego makes use of in the face of threat to biological or psychological integrity
defense mechanisms
Principle of development described with: Later they are integrated into more complex skills. Many complex skills represent a combination of simple skills.
simple skills develop separately and independently
Principle of development described with: In the years leading up to puberty, the cardiovascular, respiratory, and nervous systems grow and develop dramatically, yet the reproductive system changes very little. Puberty is a series of changes that leads to full development of the reproductive system.
Each body system grows at its own rate
Principle of development described with: Have you ever seen a newborn respond to a loud noise? The newborn’s startle response involves the whole body. With maturity, the response becomes more focused, for example, covering the ears. An adult is often able to state the location of the sound and distinguish the origin of the sound.
Body systems functions become increasingly differentiated over time
Robert Havighurst theorized that learning is a lifelong process. He believed that a person moves through six life stages, each associated with a number of tasks that must be learned.
Developmental task theory
Freud believed human development is maintained by instinctual drives, such as libido (sexual instinct), aggression, and survival (Sadock & Sadock, 2010). Different drives predominate, depending on the age of the individual. Each factor or force, has a unique function.
Psychoanalytic theory
Piaget: Cognitive development requires three core competencies; adaptation, assimilation, and accommodation.
Cognitive development theory
Cognitive development occurs from birth through adolescence in a sequence of four stages:
sensorimotor, preoperational thought, concrete operations, and formal operations.
The rate at which a child moves through the four stages of Piaget’s theory is determined by
the inherited intellect and the influence of the environment.
individuals must negotiate eight stages as they progress through the life span. Most people successfully move from stage to stage; however, a person can regress during times of stress to earlier stages or be forced to face tasks of later stages because of unforeseen life events. Failure to successfully move through a stage leads to maladjustment.
Psychosocial development theory
by studying the development of 84 boys over a period of 20 years. In this theory, moral reasoning appears to be somewhat age related, and moral development is based on one’s ability to think at progressively higher levels.
Moral development theory (Kohlberg)
developed a theory of faith development, which includes a pre-stage (stage 0) and six stages of faith
James Fowler’s Spiritual developmental theory
The time between conception and birth is called the
gestational period
A key developmental task of infants:
trust
