Fundamentals of Nursing Exam 1 NUR 112
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
