records/charting
What does SOAP stand for
Subjective, Objective, Analysis of data and Plan of care
This is a written or printed list of the clients problems, goals and nursing orders
Nursing care plan
Introductory phase, Working, Terminating
The length of stay in hospital generally more than 24 hours is called
inpatient
this is a process of sending someone to another person or agency for special services
Referral
The nurse documents the BP as 170/100 and nothing else what is this an example of
Charting by Exception
This is used for quick reference of current patient information centrally located
Kardex
when it comes to proxemics social space is considered
4-12ft
supports the family and terminally ill clients who choose to stay at home
hospice
what are the 4 roles of nurse client relationship
Caregiver, educator, collaborator, delegator
this type of charting should take too much time writing or reading and goes in chronological order
Narrative
this boosts client confidence and security in their care when nurse's do this
Client rounds
Rubbing nose , downcast eyses shifting from foot to foot is an example of what
Negative body language
Older adults live in their own small apartments and share common areas for meals this housing option
Assisted living facility
people who need this type of care need supervision because they tend to wander or are confused
Intermediate care
This describes the clients responses to what has been done and revisions to the initial plan
Progress notes
This serves as a guide for making nursing assignments
Kardex
This restates what the client has said to demonstrate listening
Paraphrasing
This provides short-term temporary relief to full time caregivers of homebound clients
Respite care
This provides one or two hot meals per day delivered either at home or at a community meal site
Meals on wheels.
These are the 4 components of problem oriented records
Database, problem list, plan of care, progress notes
the use of this is to promote continuity of care and collaboration among healthcare providers
written/verbal forms
Your'e concerned about your weight loss, but you didn't eat any breakfast is an example of what
Confronting
1. Ordered by PCP, 2. must be homebound, 3. needs skilled nursing care, 4. requires intermittent but not full-time care, 5; care must be provided by Medicare certified provider
List 4 things when communicating with a patient with Alzheimer Disease
1. approach from front, 2. smile, 3. maintain eye contact, 4. relaxed posture, 5. speak naturally, 6. wait for response, 7. rephrase if necessary 8. patience, 9. Use Visual cues, 10. avoid correcting