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Fundamentals 9,12,13

Recording and Reporting, Vitals, Physical Assessment

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