Military Time
a CNA is entering vitals she took at 6:30 pm, in military time she writes
what is: 1830
resident request a copy of their medical record, the CNA does what
What is: report the request to the nurse
symptoms are what kind of data?
what is: subjective
* what a person tells you
a fever is
what is objective data
the nursing process has ____steps
what is: five
a nurse request that the CNA takes vitals promptly at 2200, the CNA knows this is what in conventional time
what is: 10:00pm
the nurse is recording in the medical record, another word for this is?
what is: charting
signs are what kind of data?
what is: objective- something you can see, hear, feel, or smell.
a stomach ache is
what is subjective data
what needs to be reported immediately
a. the person can no longer move a body part
b. the person has questions about their medical record
c. the person had a bowel movement
what is: a. the person can no longer move a body part
the CNA records vitals for the patient at 7:45 pm, in military time this is
what is: 1945
the medical record is a _______ document
what is: legal document
the nursing process step that involves measuring if the goals set in planning were met is what?
what is: evaluation
the patient feels hot and sweaty
what is objective data
an example of a nursing diagnosis would be:
a. cancer
b. pain
c. heart attack
what is: b- pain
the doctor request vital signs be taken at 6:00 am and 4:00 pm, in military time this is written as
0600 & 1600
when charting you should always try to use the patient's _____ words.
what is: exact
a medical diagnosis is what?
the identification of a disease or condition done by a Doctor
i have a headache
the what in medical records/ charts is a summary of information?
what is: the kardex
the time is currently 2140, the nurse request the CNA recheck a temperature in one hour, the time would be in military time
what is: 2240
the CNA reports to the nurse when?
what is:
1. a change in patient condition
2. an abnormal finding
3. at end of shift or before breaks
4. if the nurse request it
a nursing diagnosis is what?
what is: a health problem that can be treated by nursing measures
the patient has blood in their urine
what is objective data
the acute care phone is ringing, how do you answer it?
"hi, my name is, nursing assistant speaking, how may I help you today?"