• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

Card Range To Study

through

image

Play button

image

Play button

image

Progress

1/235

Click to flip

Use LEFT and RIGHT arrow keys to navigate between flashcards;

Use UP and DOWN arrow keys to flip the card;

H to show hint;

A reads text to speech;

235 Cards in this Set

  • Front
  • Back
Steps of the Nursing Process
ADPIE
Assess
Diagnose
Plan
Implement
Evaluate
Systematically collect patient data, health history, and physical assessment portion of nursing process
Assess
Clearly identify patient strengths and actual or potential problems - nursing process
Diagnose
Individualized care with goals and time frames. Select nursing interventions and communicate plan.
Plan
Goals must be
Measureable, Time sensitive, and specific. Outcomes will be better when pt is involved in the goal setting process.
Execute, continue to collect data, modify plan of care as needed
Implementation
Evaluate effectiveness of plan, measure how well pt has achieved goals. Identify factors that have contributed to pt success or failure
Evaluation
Establishes Standards of Practice, Code of Ethics, encourages and conducts research, and represents nursing in legislative action
ANA - American Nurses Association
Main focus is education. Provides testing and also provides accredidation of schools; develops NCLEX testing for nurse licensing.
NLN - National League of Nurses
Issues licenses and educational criteria. Sets up Nurse practice act. They answer to state legislature, define and enforce rules, regulations, and titles
State Board of Nursing
This person..
Identified personal needs of patient-established standards of hospital management-established education-respectable career for women-recognized and identified health and illness-established and maintained records for research
Florence Nightingale (Crimean War)
Superintendent of the Female Nurses of the Army during the Civil War; was given the authority and the responsibility for recruiting and equipping a corps of army nurses; was a pioneering crusader for the reform of the treatment of the mentally ill
Dorothea Dix
Founded American Red Cross. Volunteered to care for wounds and feed union soldiers during civil war.
Clara Barton
The state of optimal functioning or well-being. It includes physical, social, and mental components and is not merely the absence of disease or infirmity.
HEALTH
genetic inheritance
cognitive abilities
educational level
race and ethnicity
culture
age and gender
developmental level
lifestyle
environment
socioeconomic status
A person's level of health can be affected by these things
Nursing care is both a _ _ _ and a _ _ _ _ _ _ _
art and science
Caregiver must meet
physical, emotional, intellectual, sociocultural, and spiritual needs.
Communicator, teacher, counselor, leader, researcher, advocate
Nurse acts in all of these roles
Promote wellness, prevent illness, restore health, facilitate coping
Nursing goal is to
The use of effective interpersonal and therapeutic communication skills to establish and maintain helping relationsips with patients of all ages in a variety of healthcare settings
Communicator
The use of communication skill to assess, implement, and evaluate individualized teaching plans to meet learning needs of patient and their families
Teacher/Educator
The use of therapeutic interpersonal communication skills to provide information, make appropriate referralsm and facilitate the patient's problem solginv and decision making skills
Counselor
The assertive, self confident practice of nursing when providing care, effecting change, and functioning with groups.
Leader
The participation in the conduct of research to increse knowledge in nursing and improve patient care
Researcher
The protection of human or legal right and the securing of care for all patients based on the belief that patients have the right to make informed decision about their own health and lives
Advocate
Facilitates decisions about lifestyle that enhance quality of life and encourage acceptance of responsibility for one's own health - accomplish through pt education
Promote health
Increses health awareness by teaching that the state of health is more than no being ill
Promote health
Teaches self care activities to maximize achievement of goals that are realistic and attainable; serves as role model
Promote health
encourages health promotion by providing information and referral
Promotes health
By teaching and personal example - educational programs (prenatal care, smoking cessation, stress-reduction), community programs to encourage healthy lifestyles
Prevent Illness
Preforming diagnostic assessments that may detect illness (vitals), reporting abnormals, direct physical care for ill, collaborating with other healthcare providers, planning, teaching, carrying out rehabilitation for illness
Restore health
Facilitate an optimal level of functioning through maximizing the person's strengths and potentials through teaching and community referrals
Facilitate coping with disability and death
How to write a nursing dx statement
1-Nursing dx based on assessment 2-r/t (reason for the dx) 3- objective finding that justify your nursing dx AEB _______rt________AEB_______
Nursing is
human response to actual or potential health problems
Delegation
Know state and institutional policies, know training and background of any licensed assistive personell, assess what tasks can be safely delegated
Ericksons theory of development
based on freuds work but was expanded to include cultural and social influences in addition to biologic processes.
Ericksons psychosocial theory is based upon 4 major organizing concepts
1-stages of development
2-developmental goals/tasks
3-psychosocial crises
4-process of coping
Infancy - infant learns to rely on caregivers to meet basic needs of warmth, food, and comfort, forming trust in others. Mistrust is result of inconsistent, inadequate, or unsafe care
Erickson - Trust vs mistrust
Toddler 1-3, learns from environment and gains independence thru encouragement vs too high expectations and overprotectiveness
Erickson - Autonomy vs Shame and doubt
Preschooler 4-6, toddler seeks out new experiences and explores how and why. restrictions and reprimands child hesitates for new experiences
Erickson - Initiative vs. Guilt
School age children, focusing on end result of acheivement, child gains pleasure from finishing projects and recieving recognition. Child not accepted/rewarded inferiority results.
Erickson - Industry vs Inferiority
Young adult, task for young adult is to unite self-identity with identities of friends and to make commitments to others.
Erickson - Intamacy vs Isolation
Adolescent, hormonal changes, transition from childhood to adulthood. Trying on roles and rebellion normal behaviors. Role confusion occurs when adolescent is unable to establish identity/sense of direction
Erickson - Identity vs Role Confusion
Middle Adulthood, time of concern for next generation, Desire to make contribution to the work, if this not met person becomes self absorbed and regresses to earlier level of coping.
Erickson - Generativity vs Stagnation
Later Adulthood, reminiscence about life events provides sense of fulfillment. Despair if feelings of failures or missed directions
Erickson - Ego Integrity vs Despair
Increase in size and changes in body cell structures (anatomy changes in growth)
Growth
An orderly pattern of changes in structure or behaviors resulting from maturation, experiences, and learning
Development
Both ______ and _____ are results of genetics and environment
Growth and Development
In aging process abilities from development are generally lost __________ of the order in which they are acquired
opposite
Healthy fetal development dietary - prevent fetal megaloblastic anemia and neural tube defects
Folic acid
Healthy fetal development dietary - ensure adequate bone calcification
Calcium and vit d
Healthy fetal development dietary - to prevent hypothyroidism
Iodine
Healthy fetal development dietary - to provide amino acids necessary for Growth and development of fetus
Protein
Mother of fetus should increase calorie intake by ____ calories per cay
300 calories
Alcohol, nicotine, excessive caffeine, some OTC (aspirin, ibuprofin, antihistamines), radiation, pesticides, certain environmental chemicals
Aviod during pregnancy
Interventions when communicating with the elderly
Allow longer response and reaction time and make sure pt has hearing aid in and turned on if they have one
Kubler-Ross's 5 stages of grieving
1-Denial and Isolation
2-Anger
3-Bargaining
4-Depression
5-Acceptance
Kubler Ross - Pt denies that he or she will die, may repress and isolate self. May think doctor has records mixed up or mistaken diagnosis
Stage 1 - Denial and Isolation
Kubler Ross - Pt expresses rage and hostility and adopts a "Why me" attitude
Stage 2 - Anger
Kubler Ross - pt tries to barter for more time. Many pt's put personal affairs in order, make wills, and fulfill last wishes.
Stage 3 - Bargaining
Kubler Ross - pt goes through a period of grief before death. Grief is often characterized by crying and not speaking very much
Stage 4 - Depression
Kubler Ross - the patient feels tranquil. Pt has accepted death and is prepared to die
Stage 5 - Acceptance
Qualification for eligibility of hospice
Pt has a diagnosis of terminal illness with 6 months or less to live.
Threating to kill/hurt self, looking for ways to kill self (finding weapons etc), increased substance abuse, no reason for living/sense of purspose, anxiety/agigation, unable to sleep, hopelessness, withdrawing from friends/family/society
signs of suicide
Highly concentrated, hypertonic solution. Provides calories, restores nitrogen balance, replaces essential fluids vitamins, electrolyes, minerals, and trace elements intravenously.
TPN - total parenteral nutrition
a pliable single or double lumen tube that is hollow allowing for removal of gastric secretions and instillation of solutions into the stomach.
NG tube - nasogastric tube
tube passed through the nasopharynx into the stomach
NG tube
To check placement of NG tube
visual assessment/aspiration gastric contents and measure ph of aspirate, tube length in comparison to initial placement should be assessed
surgically inserted tube through the abdomen wall into the stomach
G tube
surgically insterted through the abdomen wall into the stomach and down into the jejunum or small intestine
J tube
Small intestine placement aspirate check of ph should be
>7
Recommendations are made for feeding pattern/schedule by
the nutritionist or dietician
Intestinal feeding
always continuous delivered through a pump
Stomach feedings
intermittent feedings are preferred. these are delivered at regular intervals in equal portions. This allows for the formula to be introduced gradually
What is checked before each feeding or q4-6 hours during continuous feeding
Residuals in the stomach.
Foods high in Na
Salt and processed foods - meat, poultry, processed cheese,
Foods high in K
whole grains, leafy vegetables, bananas, tomato juice
Vit C and B-Complex vitamins (ascorbic acid, thiamin, riboflavin, niacin, pyridoxine, biotin, folate)
Water soluble
Vit A, D, E, and K
Oil Soluble
How many calories is 1lb of body fat
3500 calories. Therefore, to gain or lose 1 lb in a week, dail calorie intake should be increased or decreased by approx. 500 calories
inability to effectively maintain homeostasis is
characteristic of elderly
wrinkling and sagging of skin, balding common in men, hair loses pigmentation, nails thicken becoming brittle and yellow
elderly characteristic
Decrease in subQ tissue and weight common, muscle mass and strength decrease, bone demineralization, joint stiffening, overall mobility commonly slows
Elderly characteristic
CNS responds more slowly to multiple stimuli. rate of reflex response decreases, temp regulation and pain perception less efficient, loss of sensation in extremities, difficulty with balance, coordination, fine movements, sleep at noc shortens
Elderly characteristic
diminished visual acuity (presbyopia) and hearing acuity, senses of taste and smell decreased.
Elderly characteristic
blood vessels less elastic and often rigid and tortuous. venous return less efficient. less able to ^hr and co with activity, electrolyte balance fragile
Elderly characteristic
Maslows Heirarchy of Needs
1-Physiologic 2-Safety 3-Love and Belonging 4-Self-esteem needs 5-Self-actualization needs
What needs must be met before a person can progress on the heirarchy
basic physiological needs must be met before all others.
Episode of pain that lasts from seconds to less than 6 months
Acute pain
Episode of pain that lasts for 6 months or longer; may be intermittent or continuous
Chronic pain
Pain that is categorized as cutaneous, deep somatic, or visceral in nature
Nociceptive pain
pain that results from an injury to or abnormal functioning of peripheral nerves or the central nervous system
Neuropathic pain
pain originating in the internal organs in the thorax, cranium, or abdomen
Visceral pain
Pain originating in structures in the body's external wall
Somatic pain
Pain in an area removed from that in which stimulation has it's origin
Referred pain
Three different ways to measure pain
Numerical scale
FLACC (face,legs,activity,cry, consolability)
Wong-Baker (faces 1-5)
abbreviation for the World Health Organization 3step analgesic ladder. Idea is to start low and go slow
WHO ladder
What function does pain have for the body
Pain is a warning sign that something is going on in the body. Pain is the 5th vital sign
Educational factors patient need to know about pain
They do not need to be in pain. Also, addiction will not occur if there actually is pain in the body. The drugs will work on the nerves.
Prepare restful environment, promoting bedtime rituals, offering appropriate dedtime snack and beverages, relaxation, comfort
facilitate rest and sleep for patients
physical discomfort, pain, emotional discomfort, anxiety, stress, changes in bedtime rituals or sleep environment
Factors that can affect sleep pattern
Signs of insufficient sleep in a patient
decreased energy level, facial characteristics (narrowing or glazing eyes), behavioral characteristics (yawning, rubbing eyes, slow speech), physical data( obesity, enlarged neck)
Questions you need to ask to assess pain
Characteristic
Onset
Location
Duration
Intensity
Symptoms that accompany pain
Distraction, humor, music, imagery, relaxation, cutaneous stimulation, accupuncture, hypnosis, biofeedback, therapeutic touch
non-medication treatments for pain
a drug that produces stupor or narcosis Opium or opium derivative
Narcotic
Medication that blocks receptors in the CNS so that the perception of peripheral pain is blocked
Narcotic
(aspirin, ibuprofen) anti-inflammation, analgesic, and antipuretic effects
NSAIDs
Medication that inhibits prostaglandins by blocking cyclooxygenase
NSAIDs
Acetominophen and NSAIDs in this category - These block peripheral pain impulses by inhibition of prostaglandin synthesis
Nonnarcotic analgesics
An antagonist used to counteract the effects of narcotics (especially to counteract the depression of respiration) (ex Narcan). These drugs produce their opioid antagonistic activity by competing with opioids for CNS receptor sites
Narcotic antagonist
(Flumazelin) acutely reverses the actions of benzodiazepines (sedative/hypnotic) on the CNS by directly competing for binding sites in CNS
Versed antagonist
Information percieved ONLY by the affected person; information can not be verified by another (nervousness or pain)
Subjective Data
Observable and measureable data that can be seen, heard, or felt by someone other than the person experiencing it
Objective data
A medical term meaning there is a pathological change in the structure or function of the body or mind
Disease
The response of the person to a disease; an abnormal process in which the person's level of function is changed
Illness
Phases of infection (4 stages)
Incubation
Prodromal stage
Full stage of illness
Convalescent
Illness phase - interval between the pathogens invasion of the doby and the apperance of symptoms of infection
Incubation
Phase of infection - stage when a person is most infectious. Early signs and symptoms of disease are present, symptoms vague and nonspecific.
Prodromal Stage
Phase of illness - presence of specific signs and symptoms. The type of infection determines the length and severity of illness's manifestations.
Full stage of illness
Phase of illness - Recovery period from an infection. Varies according to severity of infection
Convalescent period
Phases of wound healing
Hemostatis
Inflammation
Proliferation
Maturation
Phases of wound healing - occurs immediately after the initial injury, blood vessels constrict, clotting. beginning of healing process
Hemostatis phase
phase of wound healing - lasts 4-6days. WBC's move to wound. Leukocytes and macrophages.
Inflammation phase
Acute inflammation is characterized by
pain, heat, reness, and swelling at site of injury
Phase of wound healing - fibroblastic, regenerative or connective tissue phase. O2 is important at this time.
Proliferation phase
Phase of wound healing - final stage of healing, begins about 3 weeks after injury and can continue for months or years
Maturation phase
Well approximated, skin edges tightly together. Usually after intentional wounds such as a surgical procedure without much loss.
Primary Intent Healing
Edges aren't well approximated. Large or open wounds from burns or major trauma
Secondary (Tertiary) Intention healing.
Basic Steps for wound change
1-Check physician order
2-Gather all neccessary supplies
3-Identify pt, explain proc
4-Verify whether analgesia needs to be given
5-Assist pt to comfortable position
6-Comfort and lighting
7-Keep trash can close
8-Remove tape and old dressings carefully
9-Note any drainage and characteristics of it
Cardiovascular side effects of immobility
excessive workload, risk for orthostatic hypotension, risk for venous thrombosis
Respiratory side effects of immobility
depth of resp, rate, pooling of secretions, impaired gas exchange
Gastrointestinal effects of immobility
disturbance in appetite, altered protein metabolism, altered digestion and utilization of nutrients
Unrinary effects of immobility
increased urinary stasis, increased risk for renal calculi, decreased bladder tone
Musculoskeletal effects of immobility
decreased muscle size, tone, and strenth, decreased joint mobility and flexibility, bone demineralization, decreased endurance stability, increased risk for contractures
Metabolic system effects of immobility
increased risk for electrolyte imbalance, altered exchange of nutrients and gases
Integument effects of immobility
increasesd risk for skin breakdown and formation of pressure ulcers
Psychological well being effects of immobility
increased sense of powerlessness, decrease in self-concept, decrease in social interaction, decrease in sensory stimulation and altered sleep/wake pattern
Intervention to prevent conditions caused by immobility
exercise(in bed or ambulating), breathing exercises (IS/deep breathing), monitor dietary intake, fowlers position, kaegel exercises, repositioning
COPD, pneumonia, bronchitis, RSV, Apnea, anxiety related disorders, asthma
Respiratory disorders
Rapid breathing, change in pulse, bluing around mouth and lips, dry lips, deep cough, lightheadedness, dizziness
S&S of respiratory distress
COPD nursing dx
Ineffective airway clearance. Interventions - pursed lip breathing, fowlers position
FX ribs nursing dx
Ineffective breathing pattern. Interventions - monitor resp pattern, splint painful areas
Potassium (K)
3.5-5.3
Sodium (Na)
135-145
Blood Urea Nitrogen (BUN)
5-25
Creatinine
0.5-1.5
Hemoglobin (hgb)
Males 13.5-17
Females 12-15
Hematocrit (Hct)
Males 40-54%
Females 35-46%
Albumin
3.5-5
Chloride (Cl)
95-105
WBC (White Blood Cell)
5000-10,000
Fasting Blood Sugar (FBS)
60-100
Platelets
100,000-400,000
Co2
21-32
PT
9.5-12sec
PTT
20-45sec
Assessment of patients learning needs is vital to develop a ______ __ _____ with which the patient can comply
Plan of Care
Occurs when patients ignore instructions or do not folow them appropriately
Noncomplaince
____________ can be associated with lack of learning rediness and motivation, confusion, disappointment, misunderstanding, fear, inability to learn, or inadequate finances
Noncompliance
To promote compliance
be sure instructions are understandable and designed to support patient goals, include patient and family as partners in the teaching-learning process
strengthen pelvic floor muscles and sphincter muscles.
Kegel Exercises
Fluid intake averages ______ml/day
2600ml - 1300 from ingested water, 1000ml from ingested food, 300ml from metabolic oxidation.
Fluid output averages ____ to _____ ml per day
2500-2900ml/day. approx 1500 from urine, 200-400 insensible loss from skin, 300-500ml sensible loss from skin, 400ml as insensible loss from lungs, 100ml in feces via GI tract
Mode of transmission of organism determines
types of precautions required
Most serious postoperative wound complicationss
Dehiscence and evisceration
Partial or total seperation of wound layers as a result of excessive stress on wounds that are not healed
Dehiscence
Wound completely seperates with protrusion of viscera through the incisional area
Evisceration
Pt's are at greater risk for dehiscence or evisceration if...
they are obese, malnourished, smoke tobacco, use anticog's, have infected wounds, or experience excessive coughing, vomiting, or straining.
increase flow in serosanguineous fluid from wound between post op day 4,5 is sign of
impending dehiscence
The pt's voluntary agreement to undergo a particular procedure or treatment.
Informed consent
Informed consent means the pt has been given what information
description of proc along with alternative therapies, underlying disease process, name and qualifications of person performing proc/treatment, risks of damage/disfigurement, know they have right to refuse, expected outcome and R&R phase
Informed consent protects...
The patient, physician, and healthcare institution.
Who has the responsibility to secure an informed consent
The person who will perform the procedure
Involves the administration of drugs by inhalation, intravenous (IV), rectal, or oral route to produce CNS depression.
General anesthesia
Desired actions of general anesthesia are
loss of consciousness, analgesia, relaxed skeletal muscles, and depressed reflexes.
Three phases of general anesthesia
Induction, Maintenance, and Emergence
Induction of anesthesia begins________ and goes until __________
with administration of the anesthetic agent and continues until the patient is ready for the incision
Maintenance of anesthesia continues from the end of induction phase until
near completion of the procedure
Emergence of anesthesia starts
as the patient begins to emerge from the anesthesia and usually ends when the pt is ready to leave the OR
It can be used for pt's of any age and for any surgical procedure, with the pt unaware of the physical trauma of the surgery.
Advantages of general anesthesia
Risks of general anesthesia
circulatory and respiratory depression, postop nausea and vomiting, and alterations in thermal regulation
Anesthetic agent is injected near a nerve or verve pathway in or around the operative site, inhibiting the transmission of sensory stimuli to CNS receptors
Regional anesthesia
Pt is awake but loses sensation in specific area or region of the body. In some instances, reflexes may also be lost
Regional anesthesia
Regional anesthesia may be accomplished through
Major nerve blocks or spinal (subarachnoid) block, caudal, or epidural blocks.
Prescreening surgical tests
CXR, EKG, CBC, electrolyte levels, and urinalysis
Prescreening surgical tests provide
objective data of normal body function. In cases of abnormalities, such tests provide data for medical intervention to improve the patients physical status and thus decrease the risks for surgical complication
Abnormal findings - WBC can indicate
infection
Decreased hematocrit and hemoglobin can indicate
presence of bleeding or anemia
hyperkalemia or hypokalemia can indicate
increased risk for cardiac problems
elevated blood urea nitrogen (bun) or creatinine levels can indicate
possible renal failure
abnormal urine constituents can indicate
infection or fluid imbalances
PACU care involves
assessing the pt with emphasis on preventing complications from anesthesia or surgery
PACU assessments are
continuous, using preoperative and intraoperative data as bases for system status, fluid status, wound status, and general condition.
Respiratory function is assessed by monitoring
respiratory rate, rhythm, and depth, auscultating breath sounds and by noting SaO2
Ineffective respiratory function is indicated by
restlessness and anxiety, unequal chest expansion with use of accessory muscles, shallow, noisy respirations, cyanosis, and tachycardia
Most common PACU emergency
Respiratory obstruction
Respiratory obstruction may occur as a result of
secretion accumulation, obstruction by the tongue, laryngospasm (sudden violent contraction of vocal cords), or laryngeal edema.
To maintain patent airway and tissue oxygenation
position patient, administer humidified oxygen, encouraging pt to deep breathe, suctioning
Cardiovascular function assessed by
taking vital signs, monitoring ekg rate and rhythm, observing skin color and condition. BP finding comparison with baselin data from preop.
Hypotension post op may be a result of
varied factors including anesthetic agents, preoperative meds, position changes, blood loss, resp alterations and peripheral blood pooling
Oxygen administration, deep breathing, leg exercises, verbal stimulation, and maintaining accurate IV flow rates can increase
low BP
Inadvertent hypothermia (in surgery) can lead to
complications of poor wound healing, hemodynamic stress, cardiac disturbances, coagulopathy,delayed emergence from anesthesia, and shivering and it's associated discomfort.
Assess all pulses for
bilateral equality, rhythm, rate, and character.
Of special significance are post op assessments of
ABNORMAL function
CNS function is assessed through response to
stimuli and orientation
Consciousness returns in ________ order.
Reverse
Consciousness returns in this order (usually)
1-unconsciousness
2-response to touch and sounds
3-drowsiness
4-awake but not oriented
5-awake and oriented
Fluid imbalance may result from
preop fluid restriction, fluid loss during surgery, wound drainage, or surgical stress response (retention of Na and water)
Assess fluid status includes
skin turgor, vital signs, urine output, wound drainage, and IV fluid intake.
PACU assesses wound for
amount, consistency, and color of drainage as well as for any tubes or drains and the amount and type of drainage by that route
Pain is both _________ and _________
subjective and objective
The pt is dc'd from PACU when
his or her physical status and level of consciousness are considered stable then pt is moved back to their room
What is the most common degenerative disorder that accounts for 2/3 of all dementia in US
Alzheimers disease
A progressive degenerative neuroligical disorder characterized by bradykinesia, tremor, and rigidity
Parkinsons disease
Aricept, Namenda
Medications for Alzheimers
Selegiline, Levodopa, Ropiniode, Symmetrel, Artane
Parkinsons medications
Rigidity
Increased muscle tone
Bradykinesia
Slowness in initial movement
Tremor
Usually noted in hand as a pill rolling tremor
Diffuse Lewis Body Disease
Parkinsons with dementia
process by which healthcare providers give appropriate, uninterrupted care and facilitate pt's transistion between settings and levels of care
Continuity of Care
Pt's record is the only legal document that details the nurses interactions with the pt and is the nurses best defense if pt alleges nursing negligence. Not documented, didnt happen
Documentation is important
Each healthcare group keeps data on it's own seperate form, chronologically.
Source Oriented
All medical professionals record information on same form, organized around a pts problem.
Problem Oriented Medical Record (POMR)
Used to organize data entries in the progress notes of POMR
SOAP (subjective data, objective data, assessment, plan)
No seperate plan of care. Plan of care is incorporated into the progress notes, and identified by number. Complete pt assessment done at beginning of each shift
PIE charting (Problem Intervention Evaluation)
Focus of care back to pt and pt concerns
Focus charting
Narrative portion of focus charting
DAR (data, action, response)
Shorthanded codumentation, lists only significant findings, or exceptions to standards.
CBE (charting by exception)
Interdisciplinary documentation tool that clearly identify outcomes that select groups of pt's are expected to acheive on each day of care
Case Management Model
Documents pts failure to meet an outcome, or planned intervention
Variance Charting
Used to record routine aspects of nursing care
Flow Sheets
Record specific pt variables, such as temperature or pulse
Graph sheets
Information that is observable and measureable, and that may also be verified by antoher person. It is also called signs or overt data
Objective data
Perceived only by the affected person, cannot be eprceived or verified by another person also called symptoms, or covert data
Subjective data