Nursing Process & SOAP Notes – Flashcards
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The Nursing Process:
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4 original steps: 1. Assessment 2. Planning 3. Implementation 4. Evaluation
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The nursing process defined:
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actual or potential health problems which nurses, by virtue of their education and experience, are capable and licensed to treat
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defined continued:
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a clinical judgement of patients to actual or potential health problems
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Mary Walsh, MSN, RN
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" [the nursing process] it's what nurses do"
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The nursing process
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assists nurses to continually examine: 1. what they are doing 2. how they can do it better
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two popular ways of planning pt. care
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1. nursing process 2. SOAP notes
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Ellen
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High school: B+/A- Senior year: ETOH/alcohol, drugs Currently age 23 Has increased BP Asthma Physical abuse Summary: these are pieces of evidence
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What is evidence-based assessment?
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1. clinical evidence was gathered during Ellen's assessment 2. it was supported by the literature 3. Problems were identified based on the evidence 4. this is evidence-based assessment
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The SOAP note
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a method of documentation employed by health care workers, including nurses, to write out notes in a pt's chart
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S=
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subjective data
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O=
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objective data
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A=
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assessment
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P=
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plan
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subjective data (Ellen)
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Are what the person says about self Estranged from parents sexual abuse from father, age 12-16 no close women friends boyfriend of 2 years is physically abusive to Ellen
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subjective data continued
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heavy ETOH abuse for 3 years cigarette smoking (2 PPD packs per day) for 2 years unemployed for 6 months eats fast food at restaurants, does not consume fruits or vegetables
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objective data:
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defined as what the nurses observe by 1. inspecting 2. percussing 3. palpating 4. auscultation during the health assessment
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objective data (Ellen)
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admitted to substance abuse unit due to drug-related driving offences BP: 142/100 systolic heart murmur moderate exercise wheezing 2-3 cm rt orbital hematoma scar rt lower leg receding gums, missing rt lower molar
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hematoma
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a solid swelling of clotted blood within the tissues
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assessment
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conclusions based on the subjective and objective data, what are the nurse's conclusions about what is wrong with Ellen's health?
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most likely to least likely
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1. addictions to drugs, ETOH and nicotine 2. hypertension 3. asthma 4. sexual, physical and emotional abuse 5. poor nutrition 6. poor dental care
