Documentation Chpt 7
Military time of 1600
what is 4pm?
The ability to place yourself in another persons place
what is empathy?
A cholesterol diet consists of:
what is animal products (steaks, chicken) and oils such as palm and coconut?
page 484
A way of thinking and acting based on the scientific method.
What is the nursing process.
The belief that ones own culture determines the standards
What is Ethnocentrism?
nursing action of educating patient on side effects of medication
what is independent nursing action?
page 75
What kind of response is this? "I don't think that is appropriate for you to do you have diabetes"
What is judgmental response?
page 111 table 8.3
Name at least 3 conditions that the body requires more protein
ADPIE
What is Assessment, Data analysis, Planning, Implementation, Evaluation?
Applying certain beliefs and behaviors about a culture to an individual or group of individuals
what is Stereotyping?
This means Documentation about a problem and what you did about it.
What is brevity and completeness?
page 96
A BP of 140/83, pulse of 75, RR of 16 is what part of ISBAR?
What is assessment?
page116,117, and 118
A diet high in saturated fat
what is red meats, eggs, and high fat dairy products?
page 506
goal that is achievable within 7-10 days or before discharge.
page 67 and 68
What is short term goal?
A practice about practicing health care practices linked to spirituality, and living in harmony with the universe.
What is native americans
Provides documentation of comprehensive care by focusing on specific problems the patient is experiencing.
What is Problem-oriented Medical Record (POMR)?
page 90
Patient is normally alert and oriented is an example of what part of the ISBAR?
What is background?
A deficiency in this vitamin can cause hemorrhage in infants
what is vitamin K?
page 486 table 27.4
Patient complains of aching pain
What is subjective data?
Herbal remedy that helps with migraines and allergic rhinitis.
What is butterbur?
Gives information on the patients condition and care in chronological order.
What is source oriented or narrative documentation?
page 88
Name at least 3 reasons why documentation is important?
track patient progress, insurance purposes, information of patient care and patient response, legal record that can be used in a court of law. (chpt 7)
A nurse educates a vegan patient on an appropriate source of protein
What is soybeans?
page 480 and 481
Gathering of data, organizing of data, and documenting of data occurs at what phase of NRSG process
What is the assessment phase?
Act of focusing on something specific such as mood, while tuning out other stimuli
What is meditation?