Foundations of Nursing Test 3

What is the purpose of planning?

To create a client-centered plan of care

Outcomes must be

measurable and client-focused

It is important to avoid

interventions as outcomes

Discharge planning occurs

at admission

If goals are not met

it important to revise the care plan

Initial Planning

developed on admission

Ongoing Planning

updated as client condition changes

Discharge Planning

Begins at admission

Implementation

carry out interventions

For Implementation and Delegation

It is important to follow protocols for routine skills

The RN remains responsible for

delegated tasks

It is important to ask for assistance …

when ambulating post-op patients

It is important to ask the client if 

visitors should stay during procedures

When evaluating it is important to

determine if outcomes were met

If outcomes are achieved

terminate care plan

If outcomes are not achieved

modify the plan

If items are not documented

then it wasn’t done

Correct errors with

Single line, initials, and correction

Primary purpose of record

communication

The S in SOAP means:

S(Subjective)= Client statements/subjective data

In Documentation and Communication, it is important to

use ISBAR when reporting to providers

Source Oriented Records

Progress Note, Narrative notes

SOAP

Subjective, Objective, Assessments, Plan notes

PIE Charting

Problem, Intervention, Evaluation

System Development Lifecycle 

Analyze/Plan 

Design

Test

Train

Erikson

3-6 Yrs; Initiative vs Guilt.

Erikson

Adolescence; Identity vs Role Confusion

Freud

Infant; Oral Stage: mouthing is normal

Piaget

7-11 yrs; Concrete operational— use demonstration. Eg. Teddy bear 

SIDS Prevention

Sleep on back

Suicidal statements

immediate referral

Older adults

allow more response time; coordinate meds to avoid polypharmacy

Ongoing assessment happens..

throughout shift

Palpation

temperature, moisture, turgor

Crackles during physical assessment 

moisture in lungs

Best jaundice check in dark skin would be

sclera

Kyphosis

forward curve of upper back

Guided imagery

visualizing healing

Holistic care

person is a unified whole

While using complementary therapy,

herbs may interact with meds

Therapeutic range

effective dose without toxicity

PRN

given as needed

Always perform

3 checks and rights of administration

If medication error occurs

assess the patient first

If ordered med conflicts with allergy

hold medication and notify provider

Generic meds

same ingredient as brand meds

Alcohol users may require more

anesthesia and postoperative analgesia

Ablative surgery

removes diseased tissue

Regional anesthesia

awake, loss of sensation in area

Support incision with pillow

when coughing post-op

Immediate post-op priority

continuous assessment and safe recovery

Know hospital protocols 

before implementing them

Erikson 

Generativity vs stagnation: raised kids want to find new purpose in life, like a new community base     

Always watch to make sure patient takes

medications

Nutritional and Emotional deprivation

lead to failure to thrive

Time frame

change plan if not adhering to patient

Incorporate everything patient _ in plan

likes

It is important to always look more if the patient

doesn’t want to take medication

Always prevent pain before

it becomes severe, stay on top of pain

3 checks

med room, preventing med, bedside

Vital checks every

10-15 minute post opp.

Correct errors

write that is was a mistake and cross it out.

ISBAR

Intro, Situation, Background, assessment, recommended