Modules 7,10,11,12, &19 Flashcards

be clear, accurate, concise, and accessible, should provide a clear understanding of the client

Problem, Intervention, Evaluation

Subjective

Objective

Assessment

Plan

symptoms the client is describing / telling you

what the provider observes -smells, hears, sees, measures, touches

combines subjective and objective information to arrive at a nursing diagnosis

Steps to treat clients and suggests need for consultation or additional testing to address client needs

the traditional format for documenting. divided into history and physical, progress notes, nurse notes lab reports, and diagnostic testing

Focus charting centers on specific health care problems, changes in condition, client events, and concerns.

Data - information related to a patient's condition or situation

Action - interventions by healthcare providers in response to data

Response - patients' response to intervention or treatment provided

Factual

Accurate

Complete

Timely

Keep the original document.

• • Draw a single line through the entry and write “error” along with your initials.
  • Record the date and time when the correction was made.
  • Document the correct information without obscuring the original entry.

• Identify the entry as a "late entry."
• Specify which event the late entry is for.
• Ensure all new entries are signed and dated.
• Reference the event or previous note the new note is addressing.
• Avoid leaving blank lines.

provide a systemic, digitized documentation system that improves client care. They provide comprehensive records of a person’s health history and serve as a communication tool for all healthcare providers involved in the client’s care. They are also used for billing and can be used in court.

The ISMP is devoted to preventing errors that occur within health care facilities and compiles a list of abbreviations appropriate for documentation.

Priority setting is the delivery of nursing care based on the urgency or importance of client needs. It involves organizing client care so that the most critical intervention or action is completed first.

The five levels are:

1. Physiological Needs
2. Safety Needs
3. Love and Belonging
4. Esteem
5. Self-Actualization

<ul> <li>A: Airway</li> <li>B: Breathing</li> <li>C: Circulation</li> <li>D: Disability</li> <li>E: Exposure</li> </ul> <br>

• Critical, Urgent, Routine, Extras.

- Prioritization involves ranking potential nursing actions in order of importance. Triage, on the other hand, assigns priority based on a quick initial assessment followed by assigning an acuity level, indicating how long a client can safely wait for screening and treatment.

• The 5-level triage system categorizes patients based on urgency, with Level 1 being the most urgent (life-threatening conditions) and Level 5 being the least urgent (stable, nonemergency conditions). Common systems include the Emergency Severity Index (ESI) and the Canadian Triage Acuity Scale (CTAS).

Resource allocation is the process of assigning portions of services or resources in caring for clients. Priority setting often involves deciding how to distribute these resources effectively based on client needs.

• 1. Assessment: Gather objective and subjective data.
  2. Analysis: Determine the client's problems.
  3. Planning: Create a plan to address the problems.
  4. Implementation: Provide care as outlined in the plan.
  5. Evaluation: Assess the effectiveness of interventions and document the response.

• 1. Data Collection: Collect and report subjective and objective data.
  2. Planning: Create a plan under the RN's supervision.
  3. Implementation: Collaborate with the RN to take action as planned.
  4. Evaluation: Evaluate interventions within the LPN's scope and under RN supervision.

Critical thinking is the skill of analyzing and interpreting data to solve a problem and achieve a desired outcome. It includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity.

Clinical reasoning is the mental process of analyzing all data in a clinical situation to make informed decisions. It involves assessing data, selecting relevant information, and making decisions based on nursing knowledge while applying critical thinking in the practice setting.

Clinical judgment is the outcome of critical thinking and decision-making that considers nursing knowledge, client situations, prioritization of problems, and evidence-based practice. It develops over time and improves with practice.