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Fundamentals 9,12,13
Recording and Reporting, Vitals, Physical Assessment
| Question | Answer |
|---|---|
| Uses of Medical Records | Share info among health care workers; investigate quality of care |
| Shift Change Report | Discussion between nursing staff at the end of one shift and beginning of another |
| Legally defensible charting | Never scribble over entries or use correction fluid; leave no empty spaces or lines between entries and signature; sign each entry with name and title |
| Narrative charting | style generally used in source-oriented records; involves writing information about the client and care in chronological order |
| SOAP charting | more likely used in problem-oriented record; 4 essential components: S-subjective data O- objective data A- analysis of data P- plan for care |
| Focus charting | modifies SOAP; used focus rather that problem; data, action, response |
| PIE charting | problem, intervention, evaluation |
| Charting by exception | chart only abnormal assessment findings or care that deviated from standard |
| Computerized Charting | documented client information electronically |
| Kardex | quick reference for current information about the client and care |
| Nursing care plan | written list of client's problems, goals, and nursing orders for client care. |
| subnormal body temperature | hypothermia; less than 95 degrees F |
| treatment of subnormal temp | raise room temp; remove wet clothing; apply layers of dry clothing; warm blankets; position patient so arms are next to chest and legs are tucked towards abdomen; cover heard with cap or towel;warm fluids; apply warm water bags; massage skin |
| hypothalamus | temperature regulating part of the brain |
| What can influence core body temperatures? | Food intake (protein=higher) |
| Factors affecting body temp | Age, climate, gender, exercise, circadian rhythm, emotions, illness or injury, medications, |
| Infants body temperatures | difficulty maintaining body temp, experience temperature fluctuations because they have 3x greater surface area where heat is lost |
| Best way to monitor temp | ear |
Created by:
jj1022w
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