Documentation
Vital Signs
Assessment
The Nursing Process
Admitting, Transferring, Discharging
100
Contains all orders, tests treatments and care that occurred while a person was under the care of a health care provider
What is medical record
100
Low blood pressure
What is hypotension
100
Looking
What is observation
100
Data that can be observed or measured by another person
What is objective data
100
A federally funded insurance program for the elderly
What is Medicare
200
Used to track the application of the nursing process
What is charting
200
Elevated body temperature
What is fever or hyperthermia
200
Area of the eye that should be white
What is sclera
200
Should be measurable and can be achieved within a shift or a few days
What is short-term goal
200
Examination of a body by a pathologist to determine cause of death
What is autopsy
300
focuses on deviations from predefined norms, using preset protocols and standards of care
What is charting by exception
300
Decreased heart rate below 60
What is bradycardia
300
Listening
What is auscultation
300
An independent nursing action
What is an intervention
300
An RN who organizes and implements a plan for patients leaving the hospital
What is a discharge planner
400
Standards of nursing care
What are protocols
400
Increased respirations
What is tachypnea
400
The proper steps and order of an abdominal assessment.
What is observe, listen, palpate
400
A patient's actual health status or the risk of a problem developing
What is nursing diagnosis
400
The amounts that an insurance company expects a patient to pay for care
What are deductibles and co-pays
500
A computerized, comprehensive record of a patient's history and care across all facilities and admissions
What is electronic health record
500
The volume of blood pushed into the aorta with each heartbeat
What is stroke volume or cardiac output
500
The pulse located at the top of the foot
What is dorsalis pedis
500
Judgement of effectiveness of an intervention or plan
What is evaluation
500
When a patient insists on leaving the hospital even if the doctor things they are not ready
What is leaving AMA (against medical advise)
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