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43 Cards in this Set

  • Front
  • Back
collecting, validating and communicating of patient data
assessment
analyzing patient data to identify patient strengths and problems
diagnosing
specifying patient outcomes and related nursing interventions
planning
carrying out the plan
implementing
measuring extent to which patient achieved outcomes
evaluating
part of an ordered sequence of activities
systematic
great interaction and overlapping among the five steps
dynamic
human being is always at the heart of nursing
interpersonal
nurses and patients work together to identify outcomes
outcome oriented
a framework for all nursing activities
univerally applicable
listening to your inside voice
intuitive thinking
gossip between nursing staff
collateral violence
make sense of the situation and grasp what is necessary to achieve goals
cognitive skills
manipulate equipment skillfully to produce desired outcomes
technical skills
establish and maintain caring relationships that facilitate
interpersonal skills
term for sweats alot
diaphoretic
heat comes off head most
radiation
fan yourself
convection
sweat
evaporation
put ice pack on
conduction
what regulates the pulse?
SA node
what is the most powerful respiratory stimulant
increase in carbon dioxide
what is blood pressure measuring?
force of the blood against arterial walls
what are you listening for with your stethoscope while checking blood pressure?
korotkoff sounds
normal pulse rate?
60-100 (average 80)
normal blood pressure?
135/85
normal respirations?
12-20
each healthcare group keeps data on its own separate form. makes it difficult to track problems chronologically, include progress notes and narrative notes
source oriented records
designed around a patients problems rather than around sources of information, advantages: entire healthcare team works together in identifying a master list of patient problems
problem oriented medical records (POMR)
what are narrative notes?
progress notes written by the nurse
what format is used in problem oriented medical records?
SOAP
plan of care is incorporated into the progress notes in which problems are identified by number, saves time and promotes continuity of care, but does not have a formal plan of care
PIE charting
column used for many aspects of the patients needs for the nurse to focus on, ex. therapies, consultations, significant events, charting is holistic
focus charting
a shorthand documentation method that makes use of well-defined standards of practice, only significant findings are documented in narrative notes, decreases charting time but does not prove high-quality safe care
charting by exception
managed care's emphasis on quality, cost effective, care delivered within a limited time frame. promotes collaboration, communication and teamwork among caregivers, however it works best when there are few individualized needs.
case management model
when patient fails to meet an expected outcome or a planned intervention is not implemented in the case management model this format is implicated.
variance charting
normal charting for case management model
collaborative pathways/ critical pathoways
a folded card where patient info is recorded and stored in a central place where all health professionals can access it easily to get info about the patient
kardex care plan
documentation tools used to record routine aspects of nursing care, ex. vitals, height, weight, etc.
flow sheets
form used to record specific patient variables such as pulse, respiratory rate, weight, height, etc.
graphic sheets
what documentation is used in long term care?
Resident Assessment Instrument (RAI)
someone giving information on how to best care for your patient
consulations
sending a patient to another facility/physician/specialist for care outside of your scope
referrals