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CH14
client care; planning, processes, reporting, recording
| Question | Answer |
|---|---|
| assessment | evaluation of info collected about the client through observation, reflection, communication |
| nursing diagnosis | statement of describing a health problem that is treated by nursing measures |
| assessment is the __________ step in care planning process | first step |
| nursing diagnosis is the _____________ step in care planning process | second step |
| planning | establishing priorities, goals and developing measures/ actions to help the client meet the goals |
| planning is the ___________ step in care planning process | third step |
| implementation | carrying out/ performing |
| implementation is the ______ step in care planning process | fourth step |
| evaluation | assessing and measuring |
| evaluation is the ______________ step in the care planning process | fifth step |
| care plan | a document that details the care and services the client must receive |
| chart | legal document that details a clients condition/ illness and responses to are |
| charting is also called______________ | documentation |
| documentation | record of care you have given the client and the observations you have made during care |
| intervention | an action/ measure taken y the health care team to help the client meet a goal in the care plan |
| a chart is also called a _____________ | record |
| signs are referred to as _______________ data | objective |
| care planning process | method used by nurses and case managers to plan the clients care with health care team |
| care planning process is also referred to as_______________ process | nursing |
| only nurses and physicians can conduct a _________________ assessment | physical |
| in order for an assessment to be completed the health care team with the clients family must set goals to meet the clients needs t/f | t |
| support worker's _____________ are very important for a nurse to determine a ___________________ | observations, care plan |
| a client can only receive one nurses diagnosis at any given time t/f | f; some clients could have more than one health problem and there for more than one nurses diagnosis |
| a medical diagnosis and a nursing diagnosis are interchangeable to save time t/f | f; a medical diagnosis is made by a dr and used to id a disease or condition |
| nurses diagnosis take into account the whole client and are treated by nurses measures t/f | t |
| part of the planning step in the care planning process is _______________, __________________, _______________, and __________________ | establishing priorities, setting goals, determining interventions, establishing the care plan |
| goals are predictable, achievable, measurable, and time specific for evaluating purposes t/f | t |
| if the client does not meet the predetermined goal they agreed to, the heath care team must exclude them from further discussion t/f | f; they are the first to be consulted in establishing a more realistic goal |
| interventions always needs a dr orders t/f | f; they can come from a drs orders but do not need it |
| the care plan contains clients ___________, goals and _____________ required to achieve goals | diagnosis, the interventions |
| a care plan is important because it ensure the clients care is consistent no matter who provides it t/f | t |
| effective communication is ensured because care plans t/f | t |
| a care plan is a finished document. t/f | f; it is continuously updated and revised depending on clients needs, condition and progress |
| the nurse in charge of the clients care ______________ or ____________ tasks to the health care team, prioritizing that they are within the legal limits of your role and job description | assigns, delegates |
| the implementation process has four main functions, they are ? | 1) providing care 2) OB client during care 3)report/ record care was completed 4)record/ report OB made during care |
| goals must be met in entirety or the client is let go from facility t/f | f; goals can be met completely, partially or not at all. a nurse will assess the reasons why |
| PSW observations help nurses to change the __________________, complete further ______________ and alter the ______________plan | interventions, assessments, care |
| objective data or signs | information you gather with your senses |
| subjective data or symptoms | information reported by client but not directly observed by others |
| focus your observations on the clients _____________, ___________ ,emotional and social conditions | physical, mental |
| assumption is a _________________, usually based on insufficient evidence | guess |
| verbal report | a spoken account of care provided and observations made |
| when reporting always include these four things, what are they? | 1) clients name 2) the room and bed number 3) time you made the observation/ give care |
| ____________ items when reporting, start with most important points | prioritize |
| if a clients condition changes it is ok to wait to report because it may not be emergent t/f | f; immediately report any changes to clients previously reported condition |
| contact your supervisor if the client asks you a question about their diagnosis, condition or treatment plan t/f | t |
| contact your supervisor if the client or family member asks you to do something that contradicts the care plan t/f | t |
| you do not have to contact your supervisor if you have a conflict with a client or family member because you have been taught the skills to handle these situations t/f | f; contact your supervisor |
| all team members must be informed about a clients condition and care weekly t/f | f;during every shift |
| data forms | inc details about long term care clients' physical, emotional, social, cognitive health. eg activities interests, meds, treatments, therapies |
| assessment forms | used by nurses and case managers to record a clients health issues and needs. based on info from data forms and other sources |
| home assessment forms | documents the changes that need to be made to a clients home during rehab |
| progress notes | record info about care given, clients response to care, observations, clients activities, special treatments and meds |
| graphic notes | record measurements and observations made every shift or three to four times a day. eg, P,R<BP, T, ht, wt, I&O, BM, dr visits |
| ADL checklists and flow sheets | record actions relating to hygiene, food, fluids, elim, rest, sleep, mobility, activity, social interactions |
| ADL check list is often called a ________________ sheet | tick |
| task sheets | used by some employers in community settings to record care and services provided |
| other flow sheets | record frequent measurements and observations |
| summary report | summarize care and service provided over a period |
| incident reports | written accounts made after an accident or error or unexpected event |
| in community incident reports are sometimes called ___________ reports | occurrence |
| kardex | card file summarizes info in the chart may inc clients current diagnosis, meds, treatments, special eq needed, routine care measures. |
| when recording focus on these four things, what are they? | 1) what you observed 2)what you did 3) when you did it 4) clients response |
| when recording you should avoid using the third person (he, she, they, clients name) t/f | t |
| you charting is part of a legal document so be consistent and concise t/f | t |
| 1646 | 4:46 |
| 1823 | 6:23 |
| 2050 | 8:50 |
| 2300 | 11:00 |
| 1330 | 1:30 |
| 2200 | 10:00 |
| 1430 | 2:30 |
| 1525 | 3:25 |
| 1700 | 5:00 |
| 1905 | 7:05 |
| 2145 | 9:45 |
| narrative charting | records info about the client and clients acre in chronological order |
| SOAP charting | S=subjective data O= objective data A= analysis/ assessment of data P= plan of care |
| AD/PIE charting | A=Analysis D=diagnosis P= problem I= intervention E=evaluation |
| DAR charting | D=data/ diagnosis A= analysis & action R=response |
| its better to use pencil when recording for easier correcting mistakes t/f | f; always use ink and know employer policies on colors acceptable |
| when recording if you make a mistake, draw a line through it, write error above and sign with initials. t/f | t |
| do not skip lines, instead draw a line through blank space when recording t/f | t |
| each form must be stamped with clients name and other id info when recording t/f | t |
| its ok to chart a procedure you are about to do to save time t/f | f; only chart after you have completed a task |
| when recording remember to record all ____________________ used | safety measures |
| nurses in facilities use a methods called the __________________ to plana nd deliver care to clients | care planning process or nursing process |
| the purpose of the care planning process is to meet the clients need for care and support t/f | t |
| the care planning process in facilities has how many steps? | 5; assessment, nursing diagnosis, planning, implementation, evaluation |
| an _________________ is an action or measure taken by the health care team to help a client meet a goal | intervention |
| a care planning process used by care managers in communities usually has the 5 steps used in facilities t/f | f; usually four steps. assessment, planning, implementation, evaluation |
| what step is generally not included in community care planning process? | nursing diagnosis |
| you may see the way the client shows discomfort when lying down, sitting or walking and this would be considered what type of data? | objective |
| you may observe flushed/ pale skin and reddened/ swollen areas on a clients body, and this is what type of data? | objective |
| Maslows hierarchy of needs may be used to set priorities in the planning stage of the care planning process t/f | t |
| _______________ occurs through the evaluation or information collected about the client through observation, reflection and communication | assessment |
| the care plan lists the care ad services the client will not receive t/f | f; lists the care and services the client must receive each shift |
| the care plan ensures the clients care is consistent, no matter the provider of care t/f | t |
| the health care team communicates effectively by using the details about the clients care in the care plan t/f | t |
| ADL check lists and flow sheets record actions relating to hygiene, food/ fluids, elimination, rest and sleep, mobility and social interactions t/f | t |
| both ADL checklists and flow sheets leave little room for written notes t/f | t |
| other flow sheets record frequent measurements and observations every 15 mins or more often, some may include BP,P, R t/f | t |
| ___________ is the card file that summarizes information in the chart | kardex |
| the kardex usually includes clients current diagnosis, meds, treatments, any special equipment needs and routine care measures t/f | t |
| the ___________ system provides a quick sources of current info and can be updated frequently to reflect changes | kardex |
| ______________ record measurements and observations made on every shift or tid to qid times a day | graphic sheets |
| when recording time in 24 clock numbers use a colon t/f | f; eg1900, not 19:00 |
Created by:
Wil.Wilson
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