Intrapersonal Communication - Answers communication with oneself
Interpersonal Communication - Answers between two or more people
Transpersonal Communication - Answers interaction that occurs within a person's spiritual domain
SOAP Charting - Answers S= Subjective data (how the patient feels)
O= Objective data (results of physical exam, vital signs, etc)
A= Assessment (what is the patient's status)
P= Plan (does the plan stay the same or is change needed?)
SOAPIE Charting - Answers I= Intervention (what did the nurse do?)
E= Evaluation (what is the patient outcome following the intervention?)
PIE Charting - Answers P= Patient problems (teaching needs and discharge planning needs, identified
during initial assessment of the patient)
I= Interventions carried out for each specific nursing diagnosis
E= Evaluate the outcomes of the interventions
DAR - Answers Data: information that supports the focus
Action: the nursing intervention
Response: how the patient responds to the intervention and the outcome
Focus Charting - Answers Eliminates the word "problem" and uses the term "focus"
Includes patient's condition, nursing diagnosis, s&s, or significant event or change in condition
Organized using DAR
Source-Oriented Charting - Answers Most common
Information is organized & presented according to its source
There are separate sections for the doctor's notes, the nurse's notes, the respiratory therapist notes,
etc
Read through all the sections & piece together the data
Charting by Exception - Answers Chart only when there is a significant change or finding different
from the norm
Otherwise use standardized flow sheets, nursing database, SOAP progress notes and care plans
CBE use narrative format
Alerts staff to something unusual that has occurred with the patient
Presumes that unless documented otherwise, all standards have been met with a normal response
A.C. - Answers before meals
P.C. - Answers after meals
NKA - Answers No known allergies
NPO - Answers Nothing per mouth
HOB - Answers Head of bed
W/C - Answers wheelchair
SOB - Answers Shortness of breath
PRN - Answers As needed
TPR - Answers temperature, pulse, respiration
Written Orders - Answers Physically written by the physician on the chart
Verbal Orders - Answers Given to the nurse while in their presence
Not written on the chart
Telephone Orders - Answers Given to the nurse via telephone
Electronic Orders - Answers Written through the electronic health system of the facility
Processing a Verbal Order - Answers Verify
Clarify
Transcribe
Factors that increase Fall Risk - Answers Age
Fear of falling
Footwear and foot care
Medications
Chronic and acute illnesses
Fall Risk Assessments - Answers When admitted
Once a year
When there is a change in client condition (e.g. change in mobility status)
, Code Yellow - Answers Missing client
Code Red - Answers Fire
REACT sequence
Code Black - Answers Bomb threat
Erikson's Theory - Answers integrity vs despair
Drug Responses in Older Adults - Answers Age related changes: decreased gastric motility, increased
gastric PH
Response: stomach irritation, nausea, vomiting
Nursing Interventions: Assess for symptoms of GI discomfort, assess stool for blood
Learning Domains - Answers Cognitive
Affective
Psychomotor
Cognitive Domain - Answers Understanding, intellectual ability to acquire knowledge
Affective Domain - Answers Attitudes
Opinions
Values
Feelings and motivation to learn
Psychomotor Domain - Answers Mental and physical abilities
Younger Adult - Answers Skin condition: elastic, hydrated, firm, smooth
Older Adult - Answers Skin condition: thinner, less elasticity, fragile, decreased moisture
Decreased production of saliva
Factors Influencing Hygiene - Answers Environment: living space
Socioeconomic status: inability to purchase hygiene products, homelessness
Individual characteristics and behaviours:
Cultural considerations: influences self-care practices, preferences, and frequency, different
perspectives on cleanliness and hygiene
Cognitive and functional ability: ability to perform self care dependent on ROM, flexibility, mobility,
balance, energy, motivation
Patients with Diabetes: Care of feet and nails - Answers *Only file the nails of patients with diabetes
and*
Advise patients with diabetes to inspect feet daily for blisters, cuts, cracks, sores, redness, tenderness,
or swelling
Daily cleansing of feet with warm water and gentle soap is required
*FEET SHOULD NOT BE SOAKED B/C THIS CAN LEAD TO DRY SKIN WHICH CAN LEAD TO CRACKING*
Levels of Care: Level 0 - Answers Patient is independent in self-care activities
Levels of Care: Level 1 - Answers Patient uses equipment/devices to perform self-care independently
Levels of Care: Level 2 - Answers Patient requires assistance from another to complete self-care
Levels of Care: Level 3 - Answers Patient requires assistance from another and uses devices or
equiptment
Levels of Care: Level 4 - Answers Patient completely depends on another for self-care
Partial bed bath - Answers Washing patients face, hands, underarms, and perineal region
Bed Bath - Answers Some patients cannot bathe themselves because they are too weak or comatose
Factors that influence oral and mucous membranes - Answers NPO
Dehydration
Chemo or radiation
Malnourished
Immunosuppressed
Unable to perform oral care independently
Infections
Accumulation of excess cerumen is more likely in: - Answers People who use hearing aids
People who put cotton swabs or other items into their ears
Older people
People with developmental disabilities
Skin Assessment for Pressure Ulcers - Answers Assess difficult to reach areas for skin breakdown
Assess perineal area
Factors contributing to the development of pressure ulcers - Answers Pressure
Shearing forces