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NFDN 1002 MIDTERM UNITS 1-4
NFDN 1002 MIDTERM UNITS 1-4
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NFDN 1002 MIDTERM UNITS 1-4Intrapersonal Communication - ✅✅-communication with oneself
Interpersonal Communication - ✅✅-between two or more people
Transpersonal Communication - ✅✅-interaction that occurs within a person's
spiritual domain
SOAP Charting - ✅✅ -S= Subjective data (how the patient feels)
O= Objective data (results of physical exam, vital signs, etc)
A= Assessment (what is the patient's status)
P= Plan (does the plan stay the same or is change needed?)
SOAPIE Charting - ✅✅ -I= Intervention (what did the nurse do?)
E= Evaluation (what is the patient outcome following the intervention?)
PIE Charting - ✅✅ -P= Patient problems (teaching needs and discharge planning
needs, identified during initial assessment of the patient)
I= Interventions carried out for each specific nursing diagnosis
E= Evaluate the outcomes of the interventions
DAR - ✅✅ -Data: information that supports the focus
Action: the nursing intervention
Response: how the patient responds to the intervention and the outcome
Focus Charting - ✅✅ -Eliminates the word "problem" and uses the term "focus"
Includes patient's condition, nursing diagnosis, s&s, or significant event or change in
condition
Organized using DAR
Source-Oriented Charting - ✅✅ -Most common
Information is organized & presented according to its source
There are separate sections for the doctor's notes, the nurse's notes, the respiratory
therapist notes, etc
Read through all the sections & piece together the data
Charting by Exception - ✅✅ -Chart only when there is a significant change or
finding different from the norm
Otherwise use standardized flow sheets, nursing database, SOAP progress notes
and care plans
CBE use narrative format
Alerts staff to something unusual that has occurred with the patient
, Presumes that unless documented otherwise, all standards have been met with a
normal response
A.C. - ✅✅-before meals
P.C. - ✅✅-after meals
NKA - ✅✅-No known allergies
NPO - ✅✅-Nothing per mouth
HOB - ✅✅-Head of bed
W/C - ✅✅-wheelchair
SOB - ✅✅-Shortness of breath
PRN - ✅✅-As needed
TPR - ✅✅-temperature, pulse, respiration
Written Orders - ✅✅-Physically written by the physician on the chart
Verbal Orders - ✅✅-Given to the nurse while in their presence
Not written on the chart
Telephone Orders - ✅✅-Given to the nurse via telephone
Electronic Orders - ✅✅-Written through the electronic health system of the facility
Processing a Verbal Order - ✅✅-Verify
Clarify
Transcribe
Factors that increase Fall Risk - ✅✅-Age
Fear of falling
Footwear and foot care
Medications
Chronic and acute illnesses
Fall Risk Assessments - ✅✅ -When admitted
Once a year
When there is a change in client condition (e.g. change in mobility status)
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