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Chapter 8
client care: planning, processes, reporting, and recording
Question | Answer |
---|---|
Objective data | signs |
Subjective data | symptoms |
process facilities have to follow | assessment, nursing diagnosis, planning, implementation, and evaluation |
basic observations | ability to respond, movement, pain or discomfort, skin, eyes, ears, nose, mouth, respirations, bowels and bladder, appetite, and activities of daily living |
SOAP stands for | subjective data, objective data, assessment, and plan of care |
PIE stands for | Problem, intervention, and evaluation |
assessment involves | collecting information about the client |
the statement, "urinary elimination, impaired" is on a care plan. this statement is a | nursing diagnosis |
if you make an error when recording, you should | draw a single line through the error, and write "error" over it |
in a long- term care facility, who has access to residents charts | it depends on facility policy and procedures |