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43 Cards in this Set
- Front
- Back
collecting, validating and communicating of patient data
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assessment
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analyzing patient data to identify patient strengths and problems
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diagnosing
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specifying patient outcomes and related nursing interventions
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planning
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carrying out the plan
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implementing
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measuring extent to which patient achieved outcomes
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evaluating
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part of an ordered sequence of activities
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systematic
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great interaction and overlapping among the five steps
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dynamic
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human being is always at the heart of nursing
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interpersonal
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nurses and patients work together to identify outcomes
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outcome oriented
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a framework for all nursing activities
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univerally applicable
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listening to your inside voice
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intuitive thinking
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gossip between nursing staff
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collateral violence
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make sense of the situation and grasp what is necessary to achieve goals
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cognitive skills
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manipulate equipment skillfully to produce desired outcomes
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technical skills
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establish and maintain caring relationships that facilitate
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interpersonal skills
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term for sweats alot
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diaphoretic
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heat comes off head most
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radiation
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fan yourself
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convection
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sweat
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evaporation
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put ice pack on
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conduction
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what regulates the pulse?
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SA node
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what is the most powerful respiratory stimulant
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increase in carbon dioxide
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what is blood pressure measuring?
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force of the blood against arterial walls
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what are you listening for with your stethoscope while checking blood pressure?
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korotkoff sounds
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normal pulse rate?
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60-100 (average 80)
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normal blood pressure?
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135/85
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normal respirations?
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12-20
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each healthcare group keeps data on its own separate form. makes it difficult to track problems chronologically, include progress notes and narrative notes
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source oriented records
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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
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problem oriented medical records (POMR)
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what are narrative notes?
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progress notes written by the nurse
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what format is used in problem oriented medical records?
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SOAP
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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
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PIE charting
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column used for many aspects of the patients needs for the nurse to focus on, ex. therapies, consultations, significant events, charting is holistic
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focus charting
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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
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charting by exception
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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.
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case management model
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when patient fails to meet an expected outcome or a planned intervention is not implemented in the case management model this format is implicated.
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variance charting
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normal charting for case management model
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collaborative pathways/ critical pathoways
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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
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kardex care plan
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documentation tools used to record routine aspects of nursing care, ex. vitals, height, weight, etc.
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flow sheets
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form used to record specific patient variables such as pulse, respiratory rate, weight, height, etc.
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graphic sheets
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what documentation is used in long term care?
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Resident Assessment Instrument (RAI)
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someone giving information on how to best care for your patient
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consulations
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sending a patient to another facility/physician/specialist for care outside of your scope
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referrals
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