NUR 2090 EXAM 2 ! QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS VERIFIED LATEST UPDATE
Types of Nursing documentation
◦Admission notes
◦Change-of-shift notes
◦Assessment notes
◦Interval or progress notes
◦Transfer and discharge notes
◦Client teaching notes
Verbal orders
-Spoken to you; often during a client emergency
-Should be made for critical change in patient condition
- closed-loop communication
Critical pathways
frequent occurring conditions with predictable outcomes
PIE charting
problem, intervention, evaluation
FOCUS (DAR)
data, action, response
SOAP notes
subjective, objective, assessment, plan
,TeamSTEPPS
Team Strategies and Tools to Enhance Performance and Patient Safety
SBAR
Situation
Background
Assessment
Recommendation
used for change in patient status and transfer of care report
I PASS the BATON
I-introduction
P-patient
A-assessment
S-situation
S-safety concerns
the
B-background
A-actions
T-timing
O-ownership
N-next
used for transitions
Templates to organize and improve communication
, SBAR
Call-out
Check-back
Handoff
I PASS the BATON
CUS (I'm Concerned, I'm Uncomfortable, this is a Safety issue)
Intravascular fluid (IVF)
fluid inside blood vessels
Sodium
135-145
Potassium
3.5-5.0
Calcium
8.9-10.1
4.3-5.3
Magnesium
1.5-2.5
Chloride
95-108
Bicarbonate
22-26
Phosphate
1.7-2.6
COMPLETE SOLUTIONS VERIFIED LATEST UPDATE
Types of Nursing documentation
◦Admission notes
◦Change-of-shift notes
◦Assessment notes
◦Interval or progress notes
◦Transfer and discharge notes
◦Client teaching notes
Verbal orders
-Spoken to you; often during a client emergency
-Should be made for critical change in patient condition
- closed-loop communication
Critical pathways
frequent occurring conditions with predictable outcomes
PIE charting
problem, intervention, evaluation
FOCUS (DAR)
data, action, response
SOAP notes
subjective, objective, assessment, plan
,TeamSTEPPS
Team Strategies and Tools to Enhance Performance and Patient Safety
SBAR
Situation
Background
Assessment
Recommendation
used for change in patient status and transfer of care report
I PASS the BATON
I-introduction
P-patient
A-assessment
S-situation
S-safety concerns
the
B-background
A-actions
T-timing
O-ownership
N-next
used for transitions
Templates to organize and improve communication
, SBAR
Call-out
Check-back
Handoff
I PASS the BATON
CUS (I'm Concerned, I'm Uncomfortable, this is a Safety issue)
Intravascular fluid (IVF)
fluid inside blood vessels
Sodium
135-145
Potassium
3.5-5.0
Calcium
8.9-10.1
4.3-5.3
Magnesium
1.5-2.5
Chloride
95-108
Bicarbonate
22-26
Phosphate
1.7-2.6
