Proper Documentation
This acronym is commonly used in nursing documentation to ensure completeness and accuracy.
What is SOAP (Subjective, Objective, Assessment, Plan)
The term describes the type of heart failure that causes fluid buildup in the lungs, leading to dyspnea and crackles
What is left-side heart failure
This condition, often caused by atherosclerosis, leads to poor blood flow to the lower extremities
What is Peripheral Arterial Disease (PAD)
In a healthcare setting, this color-coded bracelet is typically used ot indicate a high fall risk.
What is yellow
This normal age-related vision change results in difficulty seeing up close.
What is presbyopia
In documentation, avoid these types of statements, such as "The patient was uncooperative."
What are subjective or judgement statements
This common symptom of right-sided heart failure causes swelling in the legs, feet, and abdomen
Patients with this conditions often experience a brownish discoloration and edema in their legs
What is Peripheral Venous Disease (PVD)
This bedside safety measure should be used only when necessary and requires a physician's order.
What is restraints?
This normal age-related hearing change results in difficulty hearing.
What is presbycusis
When correcting an error in paper documentation, you should do this instead of using correction field
What is draw a single line through the error, write, "error," initial, and date it
A CHF patient may experience this symptom, characterized by difficulty breathing when lying down.
What is orthopnea
In PAD, this painful symptom occurs during exercise due to reduced oxygen to the muscles
The assistive devices that older adults need to use to risk falling
What is canes, walkers
What is constipation
This type of charting uses key phrases rather than full sentences and focuses only on abnormalities
This diagnostic test measures the ejection fraction to determine heart function in CHF patients
What is an echocardiogram
Patient with PVD are advised to elevate their legs, while patients with PAD should do this instead.
Nurses should ensure that these safety devices are applied correctly on a patient's feet to reduce falling
What is non-slip socks
A normal age-related change in the cardiovascular system leads to increased blood pressure due to this condition
If a patient refuses medication, the nurse must document both the refusal and this important detail.
CHF patients are often placed on this type of medication to remove excess fluid and reduce swelling?
What are diuretics?
In severe PAD, this late-stage symptom may develop, requiring immediate medical attention.
What is tissue necrosis or gangrene
The best way to prevent falls in a confused patient is to use this non-restraint intervention.
What is frequent rounding and bed alarms?
What is problem-focused diagnosis