Study Guide for Fundamentals of Nursing The Art and Science of Nursing Care

92 UNIT III THE NURSING PROCESS

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:

DEVELOPING YOUR

KNOWLEDGE BASE

FILL-IN-THE-BLANKS

1.A(n) is a compilation of a

patient’s health information.

2.The usual format for charting is

the unexpected event, the cause of the event,

actions taken in response to the event, and

discharge planning if appropriate.

3. are a key component to facilitate
   data and outcome comparisons. They are spe-
   cific categories of information that use
   uniform definitions to create a common
   language among multiple healthcare data
   users.
   4.The is a group of data elements
   that represent core items of a comprehensive
   assessment for an adult home care patient and
   form the basis for measuring patient outcomes
   for purposes of outcome-based quality
   improvement.
   5.Documentation in long-term care settings is
   specified by the , which helps the
   staff gather definitive information on a
   resident’s strengths and needs and address
   these in an individualized plan of care.
   6.A nurse who communicates oral, written, or
   audiotaped patient data to the nurse replacing
   him/her on the next shift is giving a(n)
   report.
   7.A(n) is a tool used by healthcare
   agencies to document the occurrence of
   anything out of the ordinary that results in, or
   has the potential to result in, harm to a
   patient, employee, or visitor.
   8.A(n) is a meeting of nurses to
   discuss some aspect of a patient’s care.

MATCHING EXERCISES

Match the formats of nursing documentation

listed in Part A with their appropriate example

listed in Part B.

PART A

a.Initial nursing assessment

b.Plan of nursing care

c.Critical/collaborative pathways

d.Progress notes

e.Graphic record

f.24-hour fluid balance record

g.Medication record

h.24-hour nursing care record

i.Discharge and transfer summary

j.Home care documentation

k.Long-term care documentation

PART B

1. The nurse documents the case manage-
   ment plan for a patient population with
   a designated diagnosis, which includes
   expected outcomes, interventions to be
   performed, and the sequence and timing
   of these interventions.


2. The nurse documents a diabetic
   patient’s intake and output of fluids.


3. The nurse summarizes a patient’s reason
   for treatment, significant findings,
   procedures performed and treatment
   rendered, and any specific instructions
   for the patient/family.


4. The nurse uses this form to record a
   patient’s pulse, respiratory rate, blood
   pressure, body temperature, weight, and
   bowel movements.


5. The nurse documents routine aspects of
   care that promote goal achievement,
   safety, and well-being.


6. The nurse records the database obtained
   from the nursing history and physical
   assessment.


7. The nurse documents the
   administration of Cipro IV, 400 mg
   every 12 hours.


8. The nurse documents a patient’s diagno-
   sis of AIDS, expected outcomes, and
   specific nursing interventions.

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