Fundamentals of Nursing Exam 1 NUR 112

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Core issues of spirituality

Faith, Hope, Love

FACT system

Flow sheets Assessment Concise Timely entry

Focus

Focus on client concern

SOAPIER

Subj, Obj assesment, Plan, Intervention, Evaluation, Reassess

Verbal orders are only given when..

and emergency

Religion

beliefs; map that outlines essential beliefs, values, etc

Race

biologically similar (skin color)

Medical Administration Records

list of ALL ORDERED MEDICATION provides info on medication allergies

Charting by exception (CBE)

only chart abnormalities/ whats wrong

Narrative Charting

story, chronological order

When given telephone orders you should make sure to

write it down and read back to confirm

Assessment Techniques

Inspection Palpation Percussion Auscultation Olfaction

When would you validate data?

When the subj/obj data do not agree Data is far from the normal range Client words differ at different times

If it is not documented...

... its not done!

How would you conduct an interview?

Actively listen Do not judge or disapprove Try not to be too curious Avoid health care jargon

Hand off report keep it CUBAN (bed side is best)

Confidential Uninterrupted Brief Accurate Named nurse

Percussion: Direct and indirect

Direct: tap on skin (sinus) Indirect: tap on hand on skin to listen for bowl sounds

Directive and Non directive interview

Directive: obtain factual, easy categorized info Nondirective: client controls subj matter, nurse summarizes and clarify

Primary Data

Objective and Subjective info obtained from the client

Objective data

Observed by the nurse or Lab and diagnostic tests

Secondary Data

Obtained from medical record or other provider

Flow sheets

Routine aspects of care (turning, washing) org according to body system Intake and Output record

What do you want to do to prepare for an interview?

Prepare space Read up on patient Eliminate distractions Introduce yourself Compose yourself

PIE

Problem, Intervention, Evaluation

Subjective Data

What the patient says

Ethnicity

common cultural heritage

Occurance report

if you mess up medications you must report it but never put it in the chart bc it could be used for malpractice suits

Electronic entry format

in computer

Auscultation: Direct and Indirect

indirect: listen with instrument direct: listen without one


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