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What is the best proof of compliance with teaching standards?
To document in the client's record who was taught, what was taught, the teaching method, and the evidencde of learning.
What does "style of learning" refer to?
How a person prefers to acquire knowledge.
- a style of processing information by listening or reading facts and descriptions.
- (auditory or visual)
a style of processing that appeals to a person's feelings, beliefs, or values
- a style of processing that focuses on learning by doing.
4 progressive stages of learning
- 1. recognition (of what's being taught)
- 2. recall (or description of information to others)
- 3. explanation (or application of info)
- 4. independent use of new learning
science of teaching children or those with cognitive ability comparable to children
the principle of teaching adult learners
the techniques that enhance learning among older adults
possess minimal literacy skills
what does formal teaching require?
what is informal teaching?
teaching that is unplanned and occurs spontaneously at the bedside.
what are medical records?
written collections of information about a person's health, the care provided by health practicioners, and the client's progress.
can you use white out on charts?
what is a medical record?
a written, chronological account of a person's illness or injury and the care provided from onset to discharge
why do health care workers share information?
to prevent duplication of care and reduce the chance of error and omission
why does the medical profession promote quality assurance?
to maintain a high level of care and insure compliance with standards of care
how can we make our charting "legally defensible"?
by using correct grammar and spelling and by recording facts, not subjective interpretations
a type of record where the information is organized according to the source of documented information.
problem - oriented record
organized according to the clients health problems. (contains the data base, the problem list, the plan of care, and progress notes)
style of documentation that is generally used in source oriented records that involves writing information about the client and client care in chronological order
- s = subjective data
- 0 = objective data
- a = analysis of the data (assesment)
- p = plan for care
follows the dar model where d = data, a = action, r = response
charting by excepition
documentation method where only abnormal assesment findings or care that deviates from the standard is charted
what is the disadvantage of computerized charting?
password aka hacking
why was hipaa inacted?
to protect the rights of us citezens to retain their health insurance when changing their emploment
where should the light boxes for examining x rays or other diagnostics scans on which the client's name appears?
what do abbreviations do?
shorten the time required for the task
when documenting, nurses must only use what abbreviaions?
those abbreviatinions on the agency approved list
what is the nursing card x?
quick reference for current information about the client and his or her care
what is the change of shift report?
a discussion between nursing spokesperson from the shift that is ending and personel coming on duty
what is the single most important method for identifying the client?
the identification bracelet
making the client feel welcome is one of the most important steps in what?
what is the best thing to do to safe gaurd the clients valuables and clothing?
give to family members to take home
what are the first 2 things that a nurse does when helping the client undress?
- provide privacy
- have the client sit on the edge of bed that has already been lowered
discharge - when does the discharge process begin?
OH HE SAID YO MOMMA
what device do the nurses use to perform oral suction?
yankeur tip or tonsil tip
What rate should the nasal canula be set at?
Where does internal respiration take place?
At the cellular level
How does the nurse physically asses oxygenation?
- 1. observing the breathing pattern and effort
- 2. checking chest symmetry
- 3. auscultating lung sounds
Common signs of inadequate oxygenation
- sitting up to breath
- rapid shallow breathing
What is incentive spirometry?
Deep breathing for inhalation; calibrated device
What is the rate of a simple mask?
Gives us approx. 35-50% oxygenation
oxygenation is approx. 35-60%
disadvantage: requires monitoring to verify that the bag remains inflated at all times
oxygenation is approx. 60-90%
Disadvantage: creates a risk for oxygen toxicity
mixes a precise amount of oxygen and atmosphearic air which ensures that the mask delivers exactly the amount of prescribed oxygen, humidification can be added
more than 50% for longer than 48hrs
- Can be caused by:
- Partial rebreather, rebreather, face tent, trach shit (T piece)
S&S of oxygen toxicity (8)
- 1. Non-productive caugh
- 2. Substernal chest pain
- 3. Nasal stuffiness
- 4. Nausea and vomiting
- 5. Fatigue
- 6. Headache
- 7. Sore throat
- 8. Hypoventilation
Nursing NANDA's for breathing (4)
Innefective breathing pattern
Impaired gas exchange
Risk for injury related to oxygen hazards