168 complete solutions.
NFDN 1002 MIDTERM UNITS 1-4 with
168 complete solutions.
Intrapersonal Communication - ANSWER communication with oneself
Interpersonal Communication - ANSWER between two or more people
Transpersonal Communication - ANSWER interaction that occurs within a person's spiritual domain
SOAP Charting - ANSWER 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 - ANSWER I= Intervention (what did the nurse do?)
E= Evaluation (what is the patient outcome following the intervention?)
PIE Charting - ANSWER 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 - ANSWER Data: information that supports the focus
Action: the nursing intervention
Response: how the patient responds to the intervention and the outcome
Focus Charting - ANSWER Eliminates the word "problem" and uses the term "focus"
,NFDN 1002 MIDTERM UNITS 1-4 with
168 complete solutions.
Includes patient's condition, nursing diagnosis, s&s, or significant event or change in condition
Organized using DAR
Source-Oriented Charting - ANSWER 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 - ANSWER 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. - ANSWER before meals
P.C. - ANSWER after meals
NKA - ANSWER No known allergies
NPO - ANSWER Nothing per mouth
HOB - ANSWER Head of bed
W/C - ANSWER wheelchair
SOB - ANSWER Shortness of breath
, NFDN 1002 MIDTERM UNITS 1-4 with
168 complete solutions.
PRN - ANSWER As needed
TPR - ANSWER temperature, pulse, respiration
Written Orders - ANSWER Physically written by the physician on the chart
Verbal Orders - ANSWER Given to the nurse while in their presence
Not written on the chart
Telephone Orders - ANSWER Given to the nurse via telephone
Electronic Orders - ANSWER Written through the electronic health system of the facility
Processing a Verbal Order - ANSWER Verify
Clarify
Transcribe
Factors that increase Fall Risk - ANSWER Age
Fear of falling
Footwear and foot care
Medications
Chronic and acute illnesses
Fall Risk Assessments - ANSWER When admitted
Once a year
When there is a change in client condition (e.g. change in mobility status)