client care: planning, processes, reporting, and recording
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| Objective data | signs
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| Subjective data | symptoms
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| process facilities have to follow | assessment, nursing diagnosis, planning, implementation, and evaluation
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| basic observations | ability to respond, movement, pain or discomfort, skin, eyes, ears, nose, mouth, respirations, bowels and bladder, appetite, and activities of daily living
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| SOAP stands for | subjective data, objective data, assessment, and plan of care
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| PIE stands for | Problem, intervention, and evaluation
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| assessment involves | collecting information about the client
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| the statement, "urinary elimination, impaired" is on a care plan. this statement is a | nursing diagnosis
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| if you make an error when recording, you should | draw a single line through the error, and write "error" over it
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| in a long- term care facility, who has access to residents charts | it depends on facility policy and procedures
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Created by:
mackenziemarie21
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