100% satisfaction guarantee Immediately available after payment Both online and in PDF No strings attached
logo-home
Previously searched by you
Previously searched by you
logo
NSC 232 Final EKU Questions and Answers(A+ Solution guide) $7.99
Add to cart
Quickly navigate to
Preview
  2.  
  3. NSC 232 EKU
  4.  
  5. NSC 232 EKU

Exam (elaborations)

NSC 232 Final EKU Questions and Answers(A+ Solution guide)
 0 purchase
  • Course
  • NSC 232 EKU
  • Institution
  • NSC 232 EKU

Documentation Guidelines: Accountability - ️️-sign first name, last name, title to each entry -do not use dittos, erasers, correcting fluids, etc. -identify each page record -record is permanent Documentation Guidelines: Content - ️️-complete, accurate, concise, factual -reflecting nu...

[Show more]

Preview 3 out of 17  pages

Document information

  • October 6, 2024
  • 17
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

Subjects

Written for

  • NSC 232 EKU
  • NSC 232 EKU

Seller

avatar-seller
PatrickKaylian

Reviews received

Content preview

NSC 232 Final EKU
Documentation Guidelines: Accountability - ✔️✔️-sign first name, last name, title to
each entry
-do not use dittos, erasers, correcting fluids, etc.
-identify each page record
-record is permanent

Documentation Guidelines: Content - ✔️✔️-complete, accurate, concise, factual
-reflecting nursing process
-record observations, not interpretation
-terminology
-sequencing
-include safety precautions
-medical visits, consultations
-document nursing response to questionable medical orders
-avoid use of stereotypes or derogatory terms

Effective Communication - ✔️✔️-essential to the coordination and continuity of care
-enables personnel to support and compliment one another's services
-avoid duplications and omissions of care

Purposes of Documentation - ✔️✔️-communication
-planning client care
-quality assurance
-research
-education
-reimbursement
-legal documentation

Documentation - ✔️✔️-is written or typed
-a legal record of all pertinent interactions with a patient

Nursing Process - ✔️✔️-assessing
-diagnosing
-planning
-implementing
-evaluating


Documentation Guidelines: Timing - ✔️✔️-timely
-include date and time
-24 hour clock
-do not document before carrying out

,Documentation Guidelines: Format - ✔️✔️-correct chart
-appropriate form
-write legibly
-use standard terminology
-date and time each entry
-chart interventions chronologically
-use consecutive lines, do not skip lines


Documentation Guidelines: Confidentiality - ✔️✔️-patient moral and legal rights
(HIPAA)

Types of Nursing Documentation - ✔️✔️-admission notes
-change of shift notes
-assessment notes
-interval or progress notes
-transfer and discharge notes
-client teaching notes


Documentation Systems - ✔️✔️-narrative charting
-focus charting
-charting by exception (CBE)
-problem oriented medical record (POMR)
-PIE
-flow sheets
-graphic records
-clinical pathways (care maps)

POMR - ✔️✔️subjective, objective, assessment, plan

Vital Signs - ✔️✔️-temperature
-pulse
-respiratory
-blood pressure
-(pain is referred to as the 5th vital sign)

When to Assess Vital Signs - ✔️✔️-upon admission
-change in clients health status
-client reports symptoms such as pain, feeling hot, or faint
-pre and post surgery/invasive procedure
-pre and post medication administration that could affect the cardiovascular system
-pre and post nursing intervention that could affect vital signs

, Thermometers - ✔️✔️electronic: (oral, axillary, rectal)
infrared: (tympanic)
scanning infrared: (temporal artery)
temperature sensitive tape: (forehead)
glass mercury: (oral, axillary, rectal)

Radial Pulse Site - ✔️✔️readily available

Brachial/Femoral Pule Site - ✔️✔️used when radial pulse is not accessible

Carotid Pule Site - ✔️✔️during cardiac arrest/shock in adults to determine the
circulation of the brain

Apical Pule Site - ✔️✔️-used in infants and children up to 3 years of age
-used when there are discrepancies with radial pulse

Popliteal Pulse Site - ✔️✔️circulation to lower leg

Posterior Tibial - ✔️✔️circulation to the foot

Dorsalis Pedis - ✔️✔️circulation to the foot

Tachycardia - ✔️✔️-abnormally rapid pulse rate
-greater than 100 beats per minute

Bradycardia - ✔️✔️-abnormally slow pulse rate
-less than 60 beats per minute

Arrhythmia - ✔️✔️irregular beating of the heart

Inhalation - ✔️✔️-diaphragm contracts (flattens)
-ribs move upward and outward
-sternum moves outward
-enlarging the size of the thorax

Exhalation - ✔️✔️-diaphragm relaxes
-ribs move downward and inward
-sternum moves inward

Eupnea - ✔️✔️normal, quiet breathing

Bradypnea - ✔️✔️abnormally slow respiratory rate
-usually less than 10 respirations per minute

The benefits of buying summaries with Stuvia:

Guaranteed quality through customer reviews

Guaranteed quality through customer reviews

Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.

Quick and easy check-out

Quick and easy check-out

You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.

Focus on what matters

Focus on what matters

Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!

Frequently asked questions

What do I get when I buy this document?

You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.

Satisfaction guarantee: how does it work?

Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.

Who am I buying these notes from?

Stuvia is a marketplace, so you are not buying this document from us, but from seller PatrickKaylian. Stuvia facilitates payment to the seller.

Will I be stuck with a subscription?

No, you only buy these notes for $7.99. You're not tied to anything after your purchase.

Can Stuvia be trusted?

4.6 stars on Google & Trustpilot (+1000 reviews)

69052 documents were sold in the last 30 days

Founded in 2010, the go-to place to buy study notes for 15 years now

Start selling
$7.99
  • (0)
Add to cart
Added