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SOPN Med Surg - 1
| Question | Answer |
|---|---|
| Narrative | description of info as time moves forward |
| Soap Notes | Problem oriented record contains both subjective and objective data |
| POMR | problem orientated medical notes |
| CBE | Charting by exception |
| DON'T of daily charting | don't include content that suggests risk |
| nursing | defined as the alleviation of suffering through the diagnosis and treatment of human response |
| critical thinking | essential component of professional accountability and quality nursing care |
| NANDA | nursing diagnosis and definations and classifications |
| NOC | nursing outcome classifications |
| NIC | Nursing interventions classifications |
| EHR | Electronic Health Record - computerized record of all health info which can be accessed by a variety of health professionals |
| Acute | disease with sudden onset, short duration |
| Chronic | disease of long duration, onset may be insidious, gradual, subtle, may follow an acute disorder |
| Incidence | frequency of occurences of disease |
| Onset | beginning of a disease |
| Prognosis | ultimate outcome |
| Etiology | cause of disease |
| Sign | observable changes in the body (OBJECTIVE INFO) |
| Symptom | indication of disease preceived by a person (SUBJECTIVE INFO) |
| Morbidity | number of people having disease in a given population |
| Mortality | Number of people who die from a disease |
| ADPIE | Assess - Diagnosis - Planning - Implementation - Evaluation |
| SOAP | subjective - objective - assessment - plan of care |
| soap - IE | intervention - evaluation |
| assessment | systemic collection of patient info, analysis & documentation of info which leads to nsg diagnosis |
| NSG Diagnosis | identifying & labeling human responses to ACTUAL or POTENTIAL health probs or life processes using NANDA nsg. diagnosis |
| Nursing Process | systematic rational method of planning, organizing, & delivering nsg. care |
| Primary Source | PATIENT (most reliable if patient is alert and oriented) also BEST SOURCE! |
| Secondary Source | Family and other professionals |
| Expectations | where most lawsuits come from |
| Subjective Data | patient preception about their health professionals, what the patient states or tells you. |
| Objective Data | observations or measurements made by the nurse |
| 3 PHASES | Orientation, Waking, Termination |
| Orientation Phase | Introduction. Patient is not obligated to answer every question |
| Waking Phase | gather pertinent info to clients health status |
| Termination Phase | Clue patient that the interview is about to end |
| Consistancy | degree to which patient operates at some level of functionality throughout assessment & day by day |
| Congruency | agreement by which two things subjective & objective data should agree |
| Diagnostic and Lab Tests | provide data assessment |
| 3 classifications of characteristics | CRITICAL, MAJOR , MINOR |
| major characteristics | those S & SX usually present when the diagnosis exists |
| Minor characteristics | when identified are evidence of a possible nsg. diagnosis |
| Data Clustered | nurse is able to identify emerging patterns of patient needs |
| Actual Nsg Diagnosis | clinically validated by presence of critical or major defining characteristics |
| 3 types of NSG DIAGNOSIS | At risk - wellness - |
| Nursing Diagnosis Format - PES | P = nursing problem (pain)E = etiology (probable cause, etiology)S = signs and symptoms aka defining characteristics |
| medical diagnosis | identification of a disease / condition based on specific evaluation of physical S & SX, history, diagnositic tests, & procedures |
| Nursing Diagnosis | statement of identifying adn labeling human responses to an actual or potential health problem / life process that the nurse is licensed & compentant to treat |
| Priorities are classified as | high - intermediiate - low |
| Maslows Hierarchy of Needs | Physical, safety, love, & belonging, esteem, and self actualization |
| High Nsg Diagnosis | if left untreated could result in harm to client or others. Can be psychological or physiological, ABC |
| Intermediate Nsg Diagnosis | non-life threatening needs of patient ie: pain, abnormal lab values, mental changes, acute urinary probs |
| Low Client Needs | may not be directly related to a specific illness or prognosis but may affect the patient's well being. |
| GOALS SHOULD BE | specific, measurable, realistic |
| specific | patient behavior to be accomplished by a specific date |
| Measurable objective or response | reflects clients highest level of wellness and independence in function |
| Patient and Nurse | goals must be mutually agreed upon by both |
| realistic | attainable goals |
| short term goal | goal achieved in 1 -2 weeks ie: Pt. will state pain level <3 on scale 0-10 within 30 min of receiving Percocet 2 tabs within 3 days |
| long term goal | goals worked on over an extended period of time - weeks to months |
| SMART | specific - measurable - achievable or realistic - reasonable - time frame |
| measurable | goals must be |
| time frame | goals must have a set |
| nurse initiated | response of nurse to patient's health care needs & nursing diagnosis, requires no supervision or direction from others |
| physician initiated | based on MD response to medical diagnosis. Carrying out medical orders. |
| dependent actions | nurse cannot prescribe or order meds, txs, or procedures, BUT as a nurse can carry out these orders. |
| protocols | written plan that specifies procedures to be followed during an assessment or when providing a treatment for a specific condition or nsg problem |
| standing order | document containing orders for the conduct of routine therapy for specific pts with clinical problems |
| reassess | what action do you take prior to each action taken on a patients behalf |
| Integrated Care Plan | care plan developed by all disciplines in order to deliver care for a projected legnth of stay for a specific diagnosis |
| consultations | specialists help is sought to identify ways to handle patient's problems |
| Kardex | card filing system allows quick reference to the particular needs of the patient for certain aspects of nsg care. Always check orders not always upto date |
| evaluation | results. Patients response to nsg action and progression twords goal achievment |
| assess | to establish a database |
| diagnosis | identifies clients health care needs and prepares diagnostic statements |
| plannning | identifies clients goals and appropriate nsg interventions |
| implementing | carrying out planned nsg interventions to help the client attain goals |
| evaluating | to determine the extent to which goals of nsg care have been achieved |
Created by:
Beezle
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