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Terms in this set (131)
Subjective Data Information from the patient - what they feel or
report. Example: "I feel dizzy and nauseated"
Objective data Data you can observe or measure. Example: BP
88/50, skin pale/clammy
SOAP charting format Subjective, Objective, Assessment, Plan
Example:
S: Incision site hurts
O: Redness, Swelling, 100.9 F temperature
A: Possible wound infection
P: Notify provider, obtain culture, administer
antibiotic as ordered.
PIE charting format Problem, Intervention, Evaluation
Example:
P: Pain 8/10 after surgery
I: Administered prescribed pain medication
E: Pain decreased to 2/10, patient resting comfortably
,DAR charting format Data, Action, Response
Example:
D: Patient reports pain 8/10 in right knee; grimacing
noted, BP 142/88, HR 104
A: Administered prescribed morphine 2 mg IV;
elevated right leg with pillow; applied ice pack
R: Patient states pain decreased to 3/10 after 30
minutes; resting comfortably
Who can access a patients record? Only healthcare providers directly involved in care
and patient.
Which injury results in a loss of Spinal Cord Injury, individuals cannot feel when
sensation to pressure, touch, pressure or heat causes damage.
temperature, and pain perception?
What condition causes a Neuropathy, or more specifically peripheral
burning/tingling sensation? neuropathy that damages peripheral nerves in the
body
How does vision naturally decline with - Lens stiffens: presbyopia (trouble seeing up close)
age? - Pupils smaller, less reactive: decreased
night/peripheral vision
- Decreased tear production: dry, irritated eyes
- Decreased color discrimination esp blue/green
(harder to tell colors apart)
- Weaker eye muscles: slower focus, eye fatigue
, What are some nursing interventions Promote safety & independence:
to maintain/promote independence - Announce presence, explain room layout, call light
with aging vision? location
- Keep environment clutter-free; avoid rugs/cords
- Use grab bars in bathroom
Support daily living:
- Ensure glasses/contacts are available & functional
- Provide large print/magnifiers, adequate lighting
- Describe meals by clock-face method
Prevention:
- Wear safety goggles when needed
- Sunglasses for UV protection
Risks of declining vision Falls, driving/reading difficulty, infection/eye injury
How does hearing naturally decline - Age-related hearing loss (presbycusis) --> gradual
with age? loss of high-frequency sounds and difficulty
understanding speech, especially in noisy areas
- Cerumen (earwax) impaction
- Increased tinnitus
- Inner ear changes --> slower sound transmission
and balance problems
What are some nursing interventions Prevention
to maintain/promote independence - Avoid loud noise; wear ear protection
with aging hearing? - Keep music/TV at safe volume; take breaks from
earbuds
Interventions for loss:
- Face client when speaking; ensure good lighting
- Minimize background noise
- ensure hearing aids are clean/working
- Provide written info or sign language interpreter if
needed
- Teach about OTC hearing aids, cochlear implants
Risks of declining hearing Social isolation, miscommunication, safety alarms
unheard