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What is the purpose for the patient chart?
- provides communication between health care professionals
- legal documentation
- used for financial billing
- used as educational tools
- used for auditing and monitoring
What is the purpose of the client admission assessment.
admission assessment is to establish a baseline
What are the guidelines for charting error.
draw a line through the error and initial. Then write "mistaken entry" or "error"
- Be Factual
- Be Objective
- Do Not write Opinions "seems like" or "appears"
- Use only accepted Abbreviations
What are the guidelines for a late entry?
put the current date and time then write (late entry for date and time)
what are the guidelines for writing an incident report?
- Write incident report when something out of the normal happens (needle stick, client fall, med error, injury..)
- Note in the chart that incident reports was written
- Keep incident report separate from the chart
- Write exactly what you saw, if pt tells you something write pt states " "
Arte and Science of Teaching Adults
- Discipline involved with teaching children
- helping children learn
- the process involved in teaching older adults
- Helping older adults learn
a learning theory applied to teaching that states "learning is based on the learners behavior and what is directly observable"
- a theory that recognizes the development level of the learner and acknowledge the learners motivation and environment.
- Emphasize the importance of social, environmental and physical contexts
A theory that focuses on the feelings and attitudes of the learner and the importance of learners needs
What are the 3 domains of learning?
- Intellectual behaviors, requires:
- Deals with:
- expression of feelings
- Acceptance of attitudes
- acceptance of values
- acceptance of opinions
Acquiring skills that utilize mental and muscular activity
What are some of the factors that affect learning negatively?
- acute illness
- emotion-fear,anxiety, depression
- physical disability
- mental disability
What are some of the factors that affect learning in a positively?
- active involvement
- client readiness
- nonjudgmental support
How is the nursing process related to education/teaching?
What are the physical assessment techniques?
(In the order they are performed)
- Physical Readiness
- Emotional Readiness
- Cognitive Readiness
What is Physical Readiness
- First step in the physical assessment techniques.
- Can the client focus
- Is the client pain free
- Is the client physically ready
What Emotional Readiness?
- Step 2 in the physical Assessment techniques
- Is the client emotionally ready
- Is the client anxious, depressed, nervous?
What is Cognitive Readiness?
- Step 3 in the Physical Assessment Techniques
- Can the client think clearly