Most documentation systems use nursing process as a foundation and guide. What are the 5 steps of the nursing process?
Assessment Nursing diagnosis Planning Implementation Evaluation or outcomes
How is referent used in a healthcare setting?
Sight sounds, orders, etc. Trigger communication
*What are the 4 phases of the helping relationship?
Pre-interaction phase, orientation phase, working phase, termination phase
Encourages and helps patient to express feelings about their health and to explore own feelings/thoughts. This is part of what phase of the helping relationship?
Working phase
Anticipates health care concerns and issues that may arise. This is part of what phase?
Pre-interaction face
Evaluate goal achievement with patient. Is a part of what phase?
Termination phase
Let patient know when to expect relationship to be terminated. Is a part of what phase?
Orientation phase
When should incident or occurrence reports be made?
Any event that isn’t consistent with the routine, expected care of patient or the standard procedures in place on the health care unit
It’s part of the nursing process would you include emotional status of client
Assessment
Demonstrates client response to interventions, shows an expected responses are reactions, proves follow up on client concerns. This is done during what nursing process?
Evaluation
Measurements and observations, sight and hearing, adverse events, are part of what type of data?
Objective data
Using direct quotes is a part of what type of data?
Subjective
Where possible, is it better to use objective or subjective data?
Objective
What does I-SBAR-R stand for?
Identification - situation – background – assessment -recommendation-repeat back
Describe Duffy’s quality caring model
S - Sit O - Open posture L - lean towards patient E - eye contact R - Relax
