r/t data
Data that is observed through senses of hearing, sight, smell and touch.
What is objective data?
What is the nursing process?
A type of goal that is not expected to be met by discharge from the hospital
What are long-term goals?
A medication error or pt injury should be recorded in an ________ ________.
What is an incident report?
Subjective Data, Objective Data, Assessment Data, Plan, Intervention, Evaluation
What is the SOAPIER Method of Charting?
Data that is information known only by the pt or family members.
What is subjective data?
Labels a problem resulting from medical diagnosis
What is a nursing diagnosis?
What is the nursing process in order?
Assessment, Diagnosis, Planning, Implementation, Evaluation (ADPIE)
Name 5 guidelines for documentation
use black ink, sign each entry, include date and time with each entry, follow chronological order, make entries in a timely manner, be succinct, use punctuation, use only approved abbreviations, be accurate, do not leave blank lines, use continued notes, correct mistaken entries, keep medical record intact.
Problem, Interventions, Evaluation
What is PIE charting?
Information provided by the pt
What is primary data?
Overall direction to improve a problem
What are nursing goals?
Skillful reasoning, logical thinking, avoiding jumping to conclusions and validating information obtained are all......
What are critical thinking skills?!
Define these abbreviations: 1. HTN, 2. NPO, 3. AEB, 4. PPP
1. Hypertension, 2. Nothing by mouth, 3. As evidenced by, 4. Peripheral pulses palpated
Data (Objective, Subjective), Action (interventions), Response (pts response to interventions, evaluation phase of nursing process)
What is a DAR (focused charting)?
*you will write a DAR for each individual problem.
information obtained from family members, friends, and the pts chart
What is secondary data?
Statements of measurable patient actions
What are expected outcomes?
A technique that involves listening to body organs for abnormal sounds in the lungs, heart or bowels.
What is auscultation?
The privacy protector, it provides for confidential maintenance of protected health information.
What is HIPAA?
(Only health-care providers involved in pt care have access, pts written consent must be obtained to send med records.)
Situation (what is currently happening), Background (brief hx of pt and current problem), Assessment (your assessment of pt and current problem), Recommendation (what do you want)
What is SBAR?
What are the data gathering techniques in order?
Inspection, Auscultation, Palpation.
A type of nursing intervention that involves working with other health-care professionals in the hospital setting.
What is a collaborative intervention?
What are the first 3 categories in Maslow's Heirarchy of Human Needs?
What are physiological needs, safety and security needs and love and belonging needs?
Anything the pt tells you should be in ________.
What are "quotations"?
"Not ______, not ____."
(pertaining to documentation)
"Not charted, not done."