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This is the acronym used to identify the nursing process.
What is ADPIE?
When is an incident report used?
documentation of events that shouldn’t have happened, may have led to injury, or put patients at risk, an incident report should be used for anything that isn’t consistent with routine operations, used to benefit staff, patients, and prevent future errors, used to show when education is needed, DO NOT DOCUMENT AN INCIDENT REPORT IN A PATIENT'S CHART
Convert 4.8 KL to L
4800 L
What does ADPIE stand for?
Assessment, Diagnosis, Plan, Implement, Evaluate
Convert 7:48 PM to 24-hr format
1948 hours
Define ADPIE.
The nursing process is a systemic method by which nurses plan and provide care for patients and problem-solve.
List some purposes of patient records.
(I have 7 listed)
1. Documented communication
2. Permanent record for accountability
3. Legal record of care reached
4. Research and data collection
5. Audits
6. Legalities
7. Types of charting systems
What does an assessment entail?
A complete and focused data collection, as well as completing a head-to-toe assessment
Describe Narrative Charting.
Contains subjective and objective data, written in paragraph form, documents specific patient needs and problems, identifies if/who has been contacted/consulted, documents treatment/care/interventions, follow interventions with patients response. Anything patients state or report has to be in quotations, don’t repeat data in a note that was previously inputted as a data entry.
Convert 0.682 kg to mcg
682000000 mcg
Discuss patient problem statement.
Explains the patient current health problem and the nursing interventions needed to care for a patient.
When is SBAR beneficial?
SBAR is beneficial for healthcare providers to use when performing quality communication as it pertains to patient care. It was created as a safety measure to prevent any errors during communication. It is used when giving reports to any other medical personnel caring for the patient.
What do you do in the Planning stage?
The nurse establishes a priority of care, and nursing interventions are chosen that will address the nursing diagnosis.
Define Diagnosis, as used in ADPIE.
A type of health problem that can be identified by the nurse
What is Implementation?
The nurse and other members of the team put the established plan into action to promote outcome achievement
What do the letters in SOAP stand for
Subjective, Objective, Assessment, Plan
What is focused charting?
It focuses on a specific patient and their concerns, will be localized assessments, and will be charted based on location, concern, and findings. As the nurse, you will look, auscultate, and palpate the localized problem area. Comprehensive charting is a broad assessment that is head-to-toe rather than localized.
What happens in the Evaluation?
The nurse determines the extent to which patient goals have been achieved.
What is charting by exception?
This is used when you only chart what is wrong with the client, and you must know normal vs abnormal to use this charting method. It is not usually recommended because it leaves room for error due to missing additional things that may be wrong with the patient.
What is a discharge summary?
This begins developing upon admission and is given to patients which must include treatments given, medications, diet recommended, activity limitations, when to call for help, and follow up instructions. They include information that is needed to provide appropriate care and develop a plan of care for the patient, they do not replace report on the patient
This is the use of evidence to perform nursing practices that would positively impact patient outcomes.
What is the definition of Evidence-Based Practices?
What are examples of therapeutic communication with individuals with special needs? (I have 9 listed)
1. Clock face communication
2. Computer-assisted communication
3. eye blinks
4. lip reading
5. magnetic boards
6. paper and pencil or magic slate
7. picture board
8. sign language
9. word or picture cards.
Convert 3:42 PM to 24-hr format.
1542 hours
Convert 682 mcg to mg
0.682 mg
Convert 754 mcg to g
0.000754 g