Shared Flashcard Set

Details

Aug. 29th
guidelines for recording
46
Nursing
Not Applicable
09/04/2013

Additional Nursing Flashcards

 


 

Cards

Term
t/f enter date and time with each entry
Definition
true
Term
why do we use black ink?
Definition
copying
Term
t/f always document your opinion
Definition
FALSE: factual info only!
Term
SOAPIER
Definition
subjective
objective
assess
plan
intervention
evaluation
revision
Term
PIE
Definition
problem
intervention
evaluation
Term
charting by exception
Definition
only exceptions to norms are documented
Term
purpose of computerised documentation
Definition
large volumes of information
error reduction
accessibility
Term
physical change and increase in size; includes height, weight, bone size and dentition (teeth)
Definition
growth
Term
increase in complexity of function and skill progression; capacity to adapt to an environment
Definition
development
Term
neonate
Definition
birth to day 28; follows objects, closes hands (reflex)
Term
infant
Definition
one month to 1 year; sits, crawls, stands
Term
toddler
Definition
1-3 years; skill with utensils, has daytime bowel/bladder control
Term
preschooler
Definition
3-6 years; climbs, learns letters/numbers, 1000 word vocabulary
Term
school age
Definition
6-12 years; participates in group activities, accomplishes tasks
Term
adolescents
Definition
12-20 years; puberty, peers and independence are important, take risks
Term
young adult
Definition
20-40 years; finds life path, establishes long-term relationships
Term
middle adult
Definition
40-65 years; establishes career, commitment to family
Term
older adult
Definition
"young old" 65-74 years; retirement or semi retirement, new activities
Term
middle-old adult
Definition
75-84 years; adapts to physical and sensory changes
Term
old-old adult
Definition
85 years and older; assistive devices may be needed, may need help with ADLs
Term
two most common responses to hospital admission
Definition
anxiety and fear
Term
dehumanization
Definition
surrender of belongings, privacy, and independence
Term
t/f always address patient by last name unless they say you can call them something else and it has been documented
Definition
true
Term
HIPAA
Definition
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
Term
reasons for transfer
Definition
patient request
condition change
Term
official procedure by which the patient leaves the health care facility for home or other setting
Definition
discharge
Term
patient leaving medical facility without permission of primary care provider
Definition
AMA against medical advice
Term
the exchange of information or thoughts between two or more people
Definition
communication
Term
feedback that both parties understand the message in the same manner
Definition
validation
Term
distance people prefer in interactions with others
Definition
personal space
Term
study of spatial distances between individuals in different cultures and situations
Definition
proxemics
Term
space or things patients consider theirs
Definition
territoriality
Term
exchange of ideas using spoken or writtenword to include electronic communication
Definition
verbal
Term
gestures, facial expression, and touch
Definition
nonverbal
Term
__-__% of communication is nonverbal
Definition
80-90%
Term
patient centered, goal-directed, time-limited communication; used to determine patients' concerns, problems, feelings, or progress
Definition
therapeutic
Term
loss of ability to speak or understand written or verbal language
Definition
aphasia
Term
difficulty articulation words, often a result of stroke
Definition
dysarthria
Term
requires an interpreter
Definition
language barrier
Term
seeking to gain specific information in an interview; closed ended questions
Definition
directive
Term
interview where the patient controls the conversation; open ended statements/questions
Definition
nondirective
Term
3 theories of human learning
Definition
behaviorism
cognitivism
humanism
Term
learning where environment influences behavior
Definition
behaviorism
Term
learning as a complex thinking process
Definition
cognitivism
Term
learning focused on self-development
Definition
humanism
Term
inhibiting factors of patient learning
Definition
emotions, learning plateau, physiological event, terminology
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