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Nursing Fundamentals > Unit III > Flashcards

Unit III Flashcards

1
Q

purpose of the nursing process

A
  • guide to caring for the client
  • provide continuity of care from all nurses
  • scientific problem solving method
  • EBP (evidenced based practice)
  • challenge you
  • gather, interpret, and drive nursing judgements
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2
Q

EBP

A

evidenced based practice

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3
Q

nursing process

A

-approach on great quality care
-an organization framework for professional nursing practice
an ongoing, multidimensional, cyclic approach in which data are collected, critically analyzed and incorporated into the client’s treatment plan in accordance with the client’s fluctuating responses to health and illness
*as your patient makes progress you have to adjust treatment plan
-a critical thinking compentency that allows nurses to make judgments and take actions based on reason
-identifying, diagnosing, and treating human responses to health and illness

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4
Q

health perception-health management pattern

A
  • describes the patient’s self-report of health and well-being
  • how health is managed (ex. frequency of physician visits, adherence to prescribed therapies at home)
  • knowledge of preventitive health practices
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5
Q

nutritional-metabolic pattern

A

describes the patient’s daily/weekly pattern of food and fluid intake (ex. food preferences, special diet, food restrictions, appetite)

  • actual weight
  • weight loss or gain
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6
Q

elimination pattern

A

describes patterns of excretory function (ex. bowel, bladder, and skin)

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7
Q

activity-exercise pattern

A
  • describes the patterns of exercise, activity, leisure, and recreation
  • ability to perform activities of daily living
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8
Q

sleep-rest pattern

A

describes patterns of sleep, rest, and relaxation

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9
Q

cognitive-perceptual pattern

A
  • describes sensory-perceptual patterns
  • language adequacy
  • memory
  • decision-making ability
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10
Q

self-perception- self concept pattern

A

describes the patient’s self-concept pattern and perceptions of self (ex. self-concept/worth, emotional patterns, bosy image)

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11
Q

role-relationship pattern

A

describes the patient’s pattern of role engagements and relationships

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12
Q

sexualty-reproductive pattern

A
  • describes the patient’s patterns of satisfaction and dissatisfaction with sexualty pattern
  • patient’s reproductive pattern
  • premenopausal and postmenopausal problems
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13
Q

coping-stress-tolerance pattern

A

describes the patient’s ability to manage stress

  • sources of support
  • effectiveness of the pattern in terms of stress tolerance
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14
Q

value-belief pattern

A

describes patterns of values, beliefs (including spiritual practices), and goals that guide the patient’s choices and decisions

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15
Q

analyze data related to functional health patterns

A
  • organization of data
  • general to specific
  • determine the client’s health issues
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16
Q

five steps of the nursing process

A
  1. assessment
  2. diagnosis
    - nursing diagnosis
  3. planning/outcomes
  4. implementation
    - interventions
    - take action to help patients reach their outcomes
  5. evaluation
    - did my patient reach my expected outcome?
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17
Q

assessment

A
  • step 1 in nursing process

- gather, verify, and communicate data about patient so that database is established

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18
Q

diagnosis

A
  • step 2 in nursing process
  • medical
  • nursing
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19
Q

planning

A

step 3 in nursing process

  • to identify patient’s goals
  • determine priorities of care
  • determine expected outcomes
  • design nursing strategies to achieve goals of care
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20
Q

implementation

A
  • step 4 in nursing process
  • interventions
  • take action to help patients reach their outcomes
  • carry out nursing actions necessary for accomplishing plan of care
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21
Q

evaluation

A
  • step 5 in nursing process
  • did my patient reach my expected outcome?
  • to determine extent to which interventions helped achieve goals of care
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22
Q

purposes of nursing assessment

A
  • establish a database about the client’s perceived needs, health problems and responses to those problems
  • gather, verify and communicate data about the client
  • to identify pertinent experiences, health practices, values, lifestyle and expectations of the health care system
  • validate information is current
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23
Q

primary source

A

collect patient data

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24
Q

secondary source

A
  • family

- health care record

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25
Q

subjective data

A
  • the patient
  • client’s perceptions about their health problems
  • feelings of mental or physical distress
  • difficult to measure
  • pain
  • anxiety
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26
Q

objective data

A
  • observations or measurement made by the nurse or another staff member
  • bassed on accepted standards
  • lab values, diagnostic results
  • observations of behavior
  • information from medical record
  • does not include interpretive statements
  • “I think she’s pretty confused.”
  • “Patient is nice.”
  • needs to be descriptive, concise, complete
  • “Client does not know her name, the date or where she is.”
  • “Client is cooperative with the interview process.”
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27
Q

physical assessment skills

A
  1. inspection
  2. auscultation
  3. palpation
  4. percussion
  5. olfaction
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28
Q

inspection

A
  • careful, critical observation
  • inspect for size, shape, color, symmetry, position and abnormalities
  • compare to opposite side when possible
  • need to know normal to identify abnormal
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29
Q

auscultation

A
  • listening with a stethoscope to:
  • cardiovascular system
  • respiratory tract
  • gastrointestinal tract
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30
Q

cardiovascular system

A

heart

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31
Q

respiratory tract

A

lungs

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32
Q

gastrointestinal tract

A

bowel sounds

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33
Q

palpation

A
  • touching, feeling of body:
  • skin
  • organs
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34
Q

percussion

A
  • tapping and listening
  • listen to character of sound
  • hollow
  • solid
  • be sensitive to patient’s condition
  • injury
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35
Q

olfaction

A
  • odor
  • identify nature and source of smells
  • recognize odors that are characteristics of some disorders
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36
Q

vital signs

A
  1. blood pressure
  2. temperature
  3. pulse
  4. respirations
  5. pain
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37
Q

blood pressure

A
  • the force exerted on walls of an artery created by pulsing blood under pressure from heart
  • systolic
  • maxuimum pressure
  • normal: less than 120
  • blood is forced from heart
  • diastolic
  • lowest pressure at all times
  • normal:less than 80
  • relaxation
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38
Q

systolic

A
  • maximum pressure
  • normal: less than 120
  • blood is forced from heart
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39
Q

diastolic

A
  • lowest pressure at all times
  • normal: less than 80
  • relaxation
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40
Q

systolic prehypertension

A

120-139

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41
Q

hypotension

A
  • systolic is 90 or below
  • decreased blood or volume
  • decreased cardiac output
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42
Q

hypertension

A

systolic is above 120-139 (prehypertension)

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43
Q

stage 1 hypertension: systolic

A

140-159

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44
Q

stage 1 hypertension: diastolic

A

90-99

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45
Q

stage 2 hypertension: systolic

A

greater than 160

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46
Q

stage 2 hypertension: diastolic

A

greater than 100

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47
Q

normal temperature

A
  • 98.6

- 36 to 38 C

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48
Q

oral temperature

A

98.6

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49
Q

aural temperature

A
  • 98.6

- ear

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50
Q

axillary temperature

A
  • 97.7 (-0.9)

- armpit

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51
Q

rectal temperature

A

99.5 (+0.9)

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52
Q

temperature

A

stored at hypothalamus

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53
Q

aural

A

ear

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54
Q

axillary

A

armpit

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55
Q

fever

A

abnormal elevation of temperature

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56
Q

febrile

A

have a fever

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57
Q

afebrile

A

without a fever

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58
Q

hypopyrexia

A

abnormally high body temperature

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59
Q

heat exhaustion

A

loss of fluids and electrolytes because exposed to high temperature

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60
Q

heat stroke

A
  • body fails to regulate temperature

- inability to regulate temperature

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61
Q

hypothermia

A

extremely low body temperature

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62
Q

pulse

A
  • rhythm
  • regular
  • irregular
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63
Q

pulse rate

A

60-100 bmp

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64
Q

if abnormal pulse

A

do apical

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65
Q

fast pulse

A

tachycardia

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66
Q

slow pulse

A

bradycardia

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67
Q

strenght pulse

A
  • strong
  • weak
  • thready
  • bounding
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68
Q

pulse sites

A
  • radial
  • brachial
  • corrotid
  • temporal
  • pedo pulse
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69
Q

respirations

A

exchange of gases between atmosphere and body

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70
Q

normal respirations

A

12-20 breaths per minute

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71
Q

fast respirations

A

tachypnea

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72
Q

slow respirations

A

bradypnea

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73
Q

rhythm respirations

A

regular or irregular

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74
Q

ventilation

A

movement of air in and out of the lungs

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75
Q

pain

A
  • 5th vital sign
  • onset and duration
  • location
  • whatever the patient says it is
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76
Q

quality of pain

A
  • sharp
  • dull
  • crushing
  • stabbing
  • radiating
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77
Q

how severe the pain is

A

pain scales

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78
Q

pulse oximetry

A
  • vital sign
  • measures oxygen saturation
  • be 90 or greater
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79
Q

pulse oximetry measurements influences

A
  • oxygen therapy
  • respiratory rate
  • hypotension
  • hemoglobin level
  • medications
  • body temperature
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80
Q

hyperventilation

A

increased volume of respirations

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81
Q

apnea

A
  • not breathing

- temporary sesation of breathing

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82
Q

dyspnea

A

shortness of breath

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83
Q

hypercarbia

A

high CO2

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84
Q

hypoventilation

A

decreased in rate and depth of respirations

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85
Q

hypernea

A

increased in respirations after working out or doing something strenous

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86
Q

health history

A

use of systems like Functional Health Patterns

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87
Q

reasons for seeking health care

A
  • goals of care
  • expectation of the services and care delivered
  • expectations of the health care system
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88
Q

present illness or health concern

A
  • onset
  • symptoms,
  • nature of symptoms (ex. sudden or gradual)
  • duration
  • percipitating factors
  • relief measures
  • weight loss or gain
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89
Q

health history

A
  • prior illnesses throughout development
  • injuries and hospitalizations
  • surgeries
  • blood transfusions
  • allergies
  • immunizations
  • habits (ex. smoking, caffeine intake, alcohol or drug abuse)
  • prescribed and self-prescribed medications
  • work habits
  • relaxation activities
  • sleep
  • exercise
  • eating or nutritional patterns
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90
Q

family history

A
  • health status of the immediate family and living relatives
  • cause of death of relatives
  • risk factor analyses:
  • cancer
  • heart disease
  • diabetes
  • mellitus
  • kidney disease
  • hypertension
  • mental disorders
91
Q

environmental history

A
  • hazards
  • pollutants
  • physical safety
92
Q

psychosocial and cultural history

A
  • primary language
  • cultural group
  • community resources
  • mood
  • attention span
  • developmental stage
93
Q

review of systems

A
  • head-to-toe review of all major body systems
  • patient’s knowledge of and compliance with health care (ex. frequency of breast or testicular self-examination or last visual acuity examination
94
Q

sources of information for assessment

A
  • patient
  • family/significant other
  • chart
  • test/results/lab values
  • other staff
95
Q

normal values for lab results: WBC

A

5,000-10,000/mm^3

96
Q

normal values for lab results for men: RBC

A

4.7-6.1 x 10^6

97
Q

normal values for lab results for women: RBC

A

4.2-5.4

98
Q

normal values for lab results for men: Hbg

A

14.018 gm/dl

99
Q

normal values for lab results for women: Hbg

A

12.0-16.0 gm/dl

100
Q

normal values for lab results for men: Hct

A

42-52%

101
Q

normal values for lab results for women: Hct

A

37-47%

102
Q

leukocytosis

A

elevated WBCs

103
Q

leukopnea

A

low WBCs

104
Q

other test results

A
  • X-ray
  • MRI
  • CT
  • ultrasound
  • blood glucose
105
Q

medical diagnosis

A
  • identification, treatment and cure of a disease, or pathological process
  • physicians treat illness
106
Q

nursing diagnosis

A
  • identification of a client’s actual or potential response to a health problem
  • nurses treat the client’s response to illness
  • to examine patient data to identify their health care needs to formulate nursing diagnoses
107
Q

nursing diagnoses

A
  • formal statements of an actual or potential response to a health problem
  • result from collecting and analyzing data (assessment) and identifying responses; naming the condition reflected by the responses
108
Q

nursing diagnoses part 1

A
  • diagnostic statement:
  • the actual or potential client response to health problem
    1. P=problem
  • after determining problem from assessment data, select an appropriate diagnosis from NANDA list
109
Q

diagnostic statement

A

the actual or potential client response to health problem

110
Q

P=

A

problem

111
Q

NANDA

A
  • North American Nusing Diagnosis Association, Dr. Marjory Gordon, FAAN
  • 1973
  • to assist nurses by developing a recognized taxonomy of diagnoses that would be universally understood by nurses
  • updated every 2 years by NANDA
112
Q

etiology

A

-also known as the the “related to” phrase
-what is causing or contributing to the nursing diagnosis?
-written: r/t
-must be within the domain of the nurse to treat, alon or in collaboration with team
-must be amenable to change through nursing action
-can be psychologic, biologic, relational, environmental, sexual, spiritual, situational, development or sociocultural
-it is not advisable to use medical diagnoses, because they are not usually amenable to change through nursing actions alone
-think in terms of the causes of illness that CAN be modified or affected by nursing care
-sometimes nursing and medical diagnoses are the same, but only if nursing can effect a change
exs.
-anxiety
-diarrhea
-constipation

113
Q

E=

A

etiology

114
Q

appropriate etiology

A
  • medication side effects
  • no fluid intake for 48 hours
  • no bowel movement for 72 hours
115
Q

characteristics

A
  • nursing diagnoses part 3
  • signs and symptoms the nurse has gathered during assessment
  • phrased as “evidenced by” or AEB
  • s=signs or symptoms
  • observable, measureable manifestations of the client’s response to the identifies health problem
  • may be behaviors, signs, responses to illness/situation, expression of feelings
116
Q

s=

A

signs and symptoms

117
Q

diagnostic statement examples (PES)

A
  • caregiver role strain related to isolation from friends AEB feelings of depression, disturbed sleep, states “I don’t think I can do this much longer.”
  • excess fluuid volume related to excess fluid and sodium intake AEB 10 pound weight gain over 2 days, dyspnea, decreased hemoglobin and hematocrit
118
Q

AEB

A

as evidenced by

119
Q

potential at risk diagnosis

A
  • differ from actual problem diagnoses in 2 ways
    1. no defining characteristics (AEB)
    2. no etiologic factor because nothing has yet happened
120
Q

part 1 to potential or At Risk diagnoses

A

problem client is at risk for

121
Q

part 2 to potential or At Risk diagnoses

A
  • risk factors:
  • why do you think client is at risk for the problem (can also be written related to)?
  • examples:
  • risk for violence related to history of violence, panicm hyperactivity, low impulse control
  • risk for infection related to invasive procedure (surgery), immunosuppression, skin is not intact
122
Q

client-centered goals

A
  • priorities are set
  • most clients have more than one problem
  • use Maslow to determine highest priority
  • keep the big picture in front of you
  • sometimes it is not the “obvious” that needs attention first
123
Q

expected outcomes of care

A
  • goals/outcomes are determined and developed
  • realistic
  • measurable/observable
  • cleint-centered vs. nurse-centered
124
Q

client-centered

A
  • goal reflects the client’s expected behavior
  • upon completion of the nursing action, this is what the client will be doing or will experience
  • use to evaluate client progress
125
Q

SMART

A

to write a goal

126
Q

S=

A

specific

127
Q

M=

A

measureable

128
Q

A=

A

attainable

129
Q

R=

A

realistic

130
Q

T=

A

timed

131
Q

nurse-centered

A
  • describes the outcomes of nursing care

- useful to evaluate overall quality of care and effectiveness of care

132
Q

client-centered example

A

ex. Mrs. Smythe is suffering from depression and has cut off interaction with most of her friends and family.
ans. Client will participate in ongoing positive and relevant social activities.

133
Q

goals for the client

A
  • singular factors
  • address only one outcome per goal
    ex. client will maintain adequate oral intake (1500-2000 cc) and will describe measures to assure adequate intake continues.
  • time-limited
  • when should goal be accomplished?
    ex. client will state 2 positive things about himself each day until discharge.
134
Q

singular factors

A

address only one outcome per goal

135
Q

time-limited

A

when should goal be accomplished?

136
Q

short-term goals

A
  • can be met quickly, generally less than a week
  • focus on managing client’s care while they are dependent
  • focus on immediate needs
  • focus on symptom relief
137
Q

long-term goals

A
  • achieved over longer periods of time, more than a week
  • outcomes more appropriate for those with chronic illness
  • meeting short-term goals leads to achievement of long-term goals
138
Q

purposes of the nursing care plan

A
  • written guideline for lient care
  • coordinate nursing care: 24/7/365
  • decreases the risk of incomplete, incorrect, inaccurate care
  • helps organize information for charting and change of shift report
  • provides outcome criteria on which to assess quality of care
  • for students:
  • teaches nursing process and critical thinking
139
Q

dimensions of caring practice

A
  • nursing interventions are nursing actions performed to prevent harm to client, prevent complications, provide comfort or to improve the mental, emotional, physical or social functions of the client
  • actions to promote, maintain and restore health
  • reflect caring through thoughtful and holistic care
140
Q

nursing interventions: characteristics of the nursing diagnosis

A
  • interventions should alter the etiological (related to) factor associated with the diagnostic label
  • when an etiological factor cannot change, direct interventions toward treating the signs and symptoms
  • NANDA-I defining characteristics
  • for potential or high-risk diagnoses, direct interventions at altering or eliminating risk factors for the nursing diagnoses
141
Q

nursing interventions: expected outcomes

A
  • specify expected outcomes before choosing interventions
  • identify for each patient the outcomes that can be reasonably expected and attained as the result of nursing care
  • use the Nursing Outcomes Classification to specify outcomes
142
Q

nursing interventions: evidence base

A
  • know the research base for an intervention
  • research will indicate the effectiveness of using an intervention with certain types of patients
  • when research in not available, use scientific principles (ex. safety) or consult experts
143
Q

nursing interventions: feasibility of the intervention

A
  • a specific intervention has the potential for interacting with other interventions
  • consider cost:
  • is the intervention clinically effective and cost efficient?
  • consider time:
  • are time and personnel resources available?
144
Q

nursing interventions: acceptability to the patient

A
  • an intervention must be acceptable to the patient and family and match a patient’s goals, health care values, and culture
  • promote informed choice: help patient know how he or she is expected to participate
145
Q

nursing interventions: capability

A
  • be prepared to carry out the intervention
  • be competent in knowing the scientific rationale for the intervention, possessing necessary psychomotor and interpersonal skills and being able to function in the particular setting
146
Q

client advocacy

A
  • nursing intervention
  • nurse will objectively provide the client with the information they need to make decisions, (specify) and support the client in whatever decision they make
147
Q

implementation

A
  • nursing process
  • category of nursing behaviors in which the actions necessary for achieving the goals of nursing care are initiated and completed
  • is not completed until documentation is done
148
Q

reassess the client

A

to assure that the plan is still appropriate

149
Q

review and revise the Care Plan

A
  • taking into account any changes

- modify if needed

150
Q

organize resources and care delivery

A
  • have all equipment and supplies on hand
  • if you need extra help, have them ready when you approach the client
  • make sure environment is safe and private, well lit
  • assist client to be as comfortable as possible
  • inform them of what you are going to do
151
Q

anticipate and prevent complications

A
  • plan to stay with patient if they may be unsafe during care
  • be aware of possible complications
  • be alert to catch problems quickly
152
Q

implement nursing interventions

A
  • performing, assisting or directing ADLs
  • teaching or counseling
  • providing direct care
  • delegating, supervising and evaluating the work of other staff
  • recording and exchanging information
  • at shift change
153
Q

cognitive

A
  • knowledge based skills
  • knowing rationale for actions
  • understanding of normal and abnormal responses
  • recognizing client needs
  • planning in accordance with client’s developmental level
154
Q

interpersonal

A
  • ability to develop a trusting relationship with clients
  • ability to communicate clearly
  • open-ended questions
  • sensitivity to client’s emotional needs
  • proper use of interpersonal skills
155
Q

psychomotor

A
  • integration of cognitive and motor activities

- ability to do physical care competently

156
Q

independent interventions

A
  • nurse initiated
  • autonomous action based on scientific rationale that is executed to benifit the client in a predicted way related to nursing diagnosis and client centered goals
  • actions nurses are licensed to do without supervision or direction from others
  • does not require an order from another discipline
157
Q

dependent interventions

A
  • physician initiated
  • based on the physician’s medical diagnosis, require an order that is carried out by the nurse
  • are not actiond that the nurse can take based upon their own knowledge, education and licensure
  • still require critical thinking to assess safety, appropriateness
158
Q

interdependent interventions

A
  • collaborative interventions
  • therapies that require the knowledge. skills expertise of multiple health care professionals
  • includes consultation with others, such as dieticians
159
Q

evaluation

A
  • nursing process

- determining whether the patient has achieved the outcomes of the plan of care

160
Q

process of evaluation

A
  1. Examine the goal statement to identify the exact desired client behavior or response
  2. Assess the client for the presence of that behavior or response
  3. Compare established outcome criteria with behavior or response observed
161
Q

degree of agreement

A
  • step 4
  • Met (completely)
  • Partially met
  • Has only part of outcome been achieved?
  • Is the behavior present, but not consistently?
  • Not met
162
Q

met or only partially met

A
  • step 5
  • what prevented the outcome from being achieved?
  • did the client not accept the plan?
  • were there new problems that interfered?
  • were the goals unrealistic?
163
Q

recording findings

A

-step 6
exs.
-goal met, client ambulating length of hall once each shift
-goal partially met, client ambulating one half length of hall each shift
-goal not met, client refuses to bear weight on hip, ambulation only from chair to bed

164
Q

reassessment

A

if goal has not been not been reached

165
Q

steps of reassessment

A
  1. assess current health status to determine if problem was correctly identified
  2. delete inappropriate diagnoses, add new if needed
  3. adjust outcomes to make more realistic or measurable
  4. add, change or delete outcomes or change time frames
166
Q

examine each intervention

A
  • 5
  • are the specific?
  • were they realistic and appropriate?
  • were interventions implemented consistently?
  • are they appropriately individualized?
  • were there environmental problems?
  • change, add or delete interventions based on answers to those 5 questions
  • set new target date for evaluation
167
Q

documentation

A

anything written or printed that is a record or proof of activities

168
Q

reports

A

accurate, organized accounting of care given by one provider to assist another with information needed to provide continuity of care

169
Q

primary purpose of documentation

A
  • provide an accurate accounting of care in the order it happened
  • demonstrates continuity
170
Q

quality of care the client receives

A

depends not only on the skill of the providers, but on the of information between providers

171
Q

if you don’t document…

A

it never happened

172
Q

purpose of a health care record

A
  • communication
  • leagal documentation
  • fincancial billing
  • education
  • nursing process
  • research
  • auditing and monitoring
173
Q

parts of the client record

A
  • admission sheet
  • client ID and demographics
  • informed consent for general treatment and any specific invasive procedures
  • types of assessments
  • health history
  • physical exam
  • diagnostic studies
  • SW
  • OT
  • diagnoses
  • medical
  • nursing
  • plan(s) of care
  • therapeutic orders
  • physician
  • nursing
  • progress notes
  • all disciplines
  • medication administration record (MAR)
  • labd, advanced directives, DNR
  • discharge plan and summary
174
Q

admission sheet

A
  • client ID

- demographics

175
Q

informed consent

A

for general treatment and specific invasive procedures

176
Q

types of assessments

A
  • health history
  • physical exam
  • diagnostic
  • SW
  • OT
177
Q

therapeutic orders

A
  • physician

- nursing

178
Q

progress notes

A

all disciplines

179
Q

other parts of the client record

A
  • medication administration record (MAR)
  • labs, advanced directives, DNR
  • discharge plan and summary
180
Q

types of documentation

A
  • problem oriented
  • SOAP
  • SOAPIE
  • narrative
  • focus charting
  • PIE
181
Q

problem oriented

A
  • data are arranged according to the client’s problems
  • components:
  • database
  • problem list: chronological
  • care plan: by discipline
182
Q

problem list

A

chronological

183
Q

care plan

A

by discipline

184
Q

progress notes

A
  • narrative:
  • traditional
  • use of story-like format to document client information
    ex. 9/29/03 1310. Patient requesting medication for leg pain. Reports “6” on scale of 1-10. VS: T-100.4 F, P 110, R 32, BP 150/90. Patient received Codeine 60 mg po for pain. Pillow placed below leg, pt states “I feel much more comfortable now.” “2” on pain scale. Call bell within reach. A. Kramer RN ——————————-
  • needs to say when patient was reassesed and time
  • needs second set of vitals
185
Q

narrative

A

traditional, use of story-like format to document client information

186
Q

SOAP

A 
-headed by problem numer and title; originates from medical model
S=subjective data
O=objective data
A=assessment
P=plan
187
Q

S=

A

subjective data

188
Q

O=

A

objective data

189
Q

A=

A

assessment

190
Q

P=

A

plan

191
Q

SOAP example

A

9/29/03 1310. ND 1: Pain——————–
S. Reports “6” on 1-10 pain scale———-
O. VS, T-100.4 F, P 110, R 32, BP 150/90.
A. Pain——————————————
P. Administer PRN Codeine 60 mg po per order. Reposition for maximum comfort.
A. Kramer RN ————————-

192
Q

SOAPIE

A 
S=subjective data
O=objective data
A=assessment
P=plan
I=intervention
E=evaluation
193
Q

I=

A

intervention

194
Q

E=

A

evaluation

195
Q

SOAPIE example

A

9/29/03 1310. ND 1: Pain——————–
S. Reports “6” on 1-10 pain scale———-
O. VS, T-100.4 F, P 110, R 32, BP 150/90.
A. Pain——————————————
P. Administer PRN Codeine 60 mg po per order. Reposition for maximum comfort.
I. PRN Codeine administered. Pillow placed under legs. Call bell within reach.
E. Patient states “I feel much more comfortable”. “2” on pain scale.
A. Kramer RN ————————–
*needs a second set of vitals

196
Q

PIE

A

-originates from nursing process
-based on daily assessments charted elsewhere
P=problem or nursing diagnosis
I=intervention, action taken
E=evaluation of outcome of Intervention

197
Q

P=

A

problem or nursing diagnosis

198
Q

I=

A

intervention, action taken

199
Q

E=

A

evaluation of outcome of Intervention

200
Q

PIE example

A

9/29/03 1310.———————————
P. Pain related to tissue trauma———–
I. Administered PRN codeine 60 mg per order. Repositioned in bed. Call bell within reach.——————————–
E. Patient states “I feel much more comfortable now.” Pain reduced from 6 to 2 on 10 point scale. A. Kramer RN ——-

201
Q

charting by exception

A
  • notation made only when care deviates from standardized plan of care
  • assumes everything not noted is completed as stated
  • simple check-off or intialing suffices
  • any notation is an easy way to see if the client is experiencing anything unusual
202
Q

source records

A

all data grouped by discipline

203
Q

focus charting

A

-focus in on current client situation
-does not label client concerns as “problems”
-DAR method used with each entry
D=data
A=actions
R=client response

204
Q

D=

A

data

205
Q

A=

A

actions

206
Q

R=

A

client response

207
Q

DAR example

A

9/29/03 1310 Focus: Pain—————–
D. Patient requesting medication for leg pain. Reports 6 on scale of 1-10. VS: T 100.4 F, P 110, R 32, BP 150/90.
A. Given prn Codeine 60 mg po. Pillow placed below leg.————————-
R. States “I feel much more comfortable”. Pain 2 on scale 1-10. A. Kramer RN ——–

208
Q

critical pathways

A
  • one or two paged multidisciplinary standardized plans of care
  • charting is done on the form, by all disciplines
  • resembles charting by excretion in that only variances (abnormal) are noted, positive or negative
209
Q

reports

A
  • shift reports
  • basic information
    1. name, age, admission date
    2. room number
    3. physician
    4. medical diagnoses
    5. surgical procedures
    6. nursing diagnoses
  • give exact information
  • NOT “Mr. Jones got Demerol for pain.” Rather: “Mr. Jones received Demerol 100mg IM at 2130 for pain in his left leg.”
  • include vital signs and reassessment
  • do not include unremarkable measurements
  • report emotional responses that need attention or are of particular note
  • keep it quick and efficient
  • keep in objective
  • may be given live or via audiotape
210
Q

shift reports

A
  • basic information:
    1. name, age, admission date
    2. room number
    3. physician
    4. medical diagnoses
    5. surgical procedures
    6. nursing diagnoses
211
Q

charting tips

A

-use black ink and be legible. print if handwriting is not clear
-write notes as soon as possible after giving care: improves accuracy
-be precise. exactly how, when and where events occurred
-sign all entries, first initial, last name plus credential, or as agency requires
ex. A. Kramer RN
-no blank spaces. draw a line
-be concise, yet descriptive
-to correct an error draw a single line through entry, write ‘error’ above and initial
-be specfic, don’t use vague terms
exs.
-ate poorly—ate1/2 meal and drank 80ml fluid
-intoxicated—BAL 0.25, slurring of words, unable to walk without assistance
-uncooperative—refused to brush teeth or wash own face
-cofused—did not recognize wife and children

212
Q

telephone orders and reports

A

-if significant events or changes are reported over the phone, document in permannet record
ex.
-R. Kiley, MD notified at 1530 that pt’s potassium level is 2.7 mEq/L.————
A. Kramer RN———————————–
-receipt of physician orders over the telephone:
*must be received by an RN (or per agency policy)
*state your name, patient’s name, room number and diagnosis when speaking to physician
*always repeat order back to assure accuracy
-document immediately in following format:
T.O. 9/29/03, 1500. Diphenhydramine 50mg IM q 1 hour PRN for dystonic response. R. Kildare MD/ A. Kramer RN, read back and confirmed
-some agencies require 2 RNs to verify
-physician must sign within agency time period
-never use for physician convenience or for routine orders
-verbal orders, when physician is present are not to be accepted except in dire circumstances

213
Q

transfer reports

A
  • when client is moved from unit to anither same shift report, plus:
  • medical progress summary
  • current status
  • any critical assessments or treatments that are due soon
  • any special equipment needs
  • time to answer questions
214
Q

SBAR

A

Situation
Background
Assessment
Recommendation

215
Q

SHARED

A 
Situation
History
Assessment
Recommendation
Evaluation
Documentation
216
Q

flow sheets

A
  • allow for documentation of routine observations or specific measurements made repeatedly
  • negates need for other charting
  • only significantchanges charted elsewhere
217
Q

graphic sheets

A

allow for graphing of things like vital signs, weight

218
Q

kardex

A
  • nursing information needed for daily care and quick access

- kept separetly from chart

219
Q

incident reports

A

-any incident that is not consistent with the routine of the unit, client, visitors
exs:
-falls
-needle sticks
-visitor becoming ill
-medications errors
-chemical spills
-not part of permanent client record
-primarily a tool to assist in quality improvement. needs for changes in practice, policy, education, are tracked
-person who witnesses or finds problem is one who writes report
-if incident involves client, seperate note is placed in char. chart only what is observed and reported, no assumptions

220
Q

well written incident report

A

Responded to call bell. Client observed on floor near bathroom. He was attempting to stand up. Assisted to chair. VS WNL, PERRLA. No cognitive problems noted. Pt states “I feel a little foolish. I didn’t wait for you to come. I didn’t put my slippers on and my socks were slippery on the tile.” Physician notified. Continue to monitor.

221
Q

incident reports should include

A
  • Date and time of incident
  • Condition of patient when found
  • Witness information
  • Assessment for injury
  • Actions taken
  • Any follow up notations
222
Q

medication incident reports

A
  • An accurate and concise description of the error
  • Relevant information-without making excuses
  • Any adverse reaction by client
  • How you will prevent the error from recurring
  • practice policies and procedures
223
Q

mecation error incident report example

A

Received Codeine 60 mg PO at 1530. Order was for 30 mg PO at 1530. Dr Jones notified. Mr. Smith became drowsy within an hour, VS WNL. He was responsive to stimulation, states “I feel like I could sleep all night, just like when I usually get the 60 mg dose.” Physician notified, VS monitored q hour until HS. A. Kramer RN———

Nursing Fundamentals (6 decks)

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