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Definitions
Sense Observation
Body System Observations
Documentaion
Reporting
100
Information that is obtained by using one's senses.
What is observation?
100
Your ______ make observations like blood in urine, bruises or breaks in the skin, the patient crying, changes in the way the patient walks.
What is eyes?
100
In the integumentary system, what observations can be used using the sense of sight?
What is color or abnormality?
100
A medical record
What is a chart?
100
One method used to relay information from one person to another.
What is oral report?
200
Involves the collection of data about the patient.
What is assessment?
200
What sense cannot help make observations in the medical field?
What is taste?
200
In the respiratory system, using your ears you can make observations of what?
What is regular/irregular breathing, and coughing?
200
Where nursing assistants document.
What is flow sheets or nurse's notes?
200
What do you write in the chart exactly as told word for word?
What is the patients exact words?
300
Observation that is factual or measurable in some way.
What is objective observation?
300
Your ______ makes observations like body odor, discharge from wound or body cavity, stool or urine when patient is incontinent,. etc.
What is nose?
300
What sense can have drainage or bleeding?
What is the nose?
300
A medical report
What is a document?
300
You record these often in the charts.
What is vital signs?
400
A statement or complaint made by the patient.
What is subjective observation?
400
Your _______ make observations like wheezing, blood pressure, comments from patient.
What is ears?
400
Using your sense of touch, in the cardiovascular system you can check what?
What is pulse or pulse palpate?
400
What words do you not use when charting?
What is patient, or the patient's name?
400
The nurse uses _________ to record the amount of a meal the patient has eaten.
What is percentage?
500
The statement of a patient problem and the cause of the problem.
What is nursing diagnosis?
500
Your _________ makes observations like lumps, radial pulse, warm or cool skin,. etc.
What is hands?
500
When making observations 3 things you always need to note are..?
What is pain, behavior, and function?
500
What do you use when writing in charts rather then full sentences?
What is phrases?
500
Normally either the _________ or _____________________ gives oral reports.
What is nurse or nursing assistant?