Exam 1 Outline Notes

Chapter 7 Notes- Documentation

Purposes of Documentation- Documentation is a legal record. It can be used as evidence occurred or
treatment given. Documentation provides a written record of the history, treatment given, care, and response of
the patient while under the nursing care. It justifies claims for reimbursement , may be used as evidence in the
court of law, shows the use of the nursing process, and provides data for quality-assurance studies. Each person
who provides care for the patient adds documentation to the Medical record (referred to as the chart). Make sure
your documentation is factual.

The different types of charting- There are 6 main types of documentation.

1. Source Oriented Or Narrative Charting- These records ae organized according to the source of
information. There are separate areas for physicians (focusing on medical problems). Nurses (focusing
on nursing diagnoses). Also, for dieticians and other health care professionals to document their
assessment findings and plan the patients care. Narrative documentation used in source-oriented records
requires documentation of patient care in chronological order. The content is similar to journal entries.
2. Problem Oriented Medical Record- POMR charting focuses on patients status, emphasizes the
problem-solving approach to patient care and providing a method for communicating what, when, and
how thins are to be done to meet the patients needs. The POMR contains five parts. The database, the
problem list, the plan, the progress notes, and the discharge summary.
3. Focus Charting- Focus charting is similar to the POMR system, but it substitutes focus for the problem,
eliminating, the negative connotation attached to “problem”. Focus Charting is directed at a nursing
diagnosis, a patient problem, a concern, a sign, a symptom, or event. The note has three components.
Data, Action, and Response (DAE), or Data, Action, and Evaluation (DAE).
4. Charting By Exception- Charting by Exception is based on the assumption that all standards of practice
are carried out and met with a normal or expected response UNLESS otherwise documented.
5. Computer Assisted Charting- An electronic health record (EHR) is a computerized comprehensive
record of a patients history and care across all facilities and admissions.
6. Computerized Provider Order Entry (CPOE)- provides for efficient workflow because, when orders
are entered into the computer, they are automatically routed to the appropriate clinical areas for action.

Chapter 9 Notes- Patient Education

Nurses teach patients about their disease or disorder, surgery, and self-care. Before discharge the patient
must be taught how to care for himself at home. It is a process that begins at the time of admission. A teaching
moment occurs when the patient is at an optimal level of readiness to learn and apply a piece of information. It
is an ongoing process with opportunities that arise in many situations. When documenting, document what you
taught the patient, the method used, and if the patient effectively learned the skill.
The 3 Different Modes of Learning.
1. Visual Learning- Through what they see, like videos, someone else performing the procedure.
2. Auditory Learning- Through what they hear, like lectures, or someone telling them how to do
something.
3. Kinesthetic Learning- Is learning by doing something hands on.

Learning Categorized by Domains

1. Cognitive Domain- The learner takes in and processes the information by listening to or reading
the material.
2. Affective Domain- The material is presented in a way that is appealing to the learner’s beliefs,
feelings, and values.
3. Psychomotor Domain- The learner processes the information by performing an action or
carrying out a task.
There are other problems that can affect patient learning. Before teaching a patient anything, you must assess
these factors. Conditions that can affect patient education may include, poor vision or hearing, impaired motor
function, illiteracy and impaired cognition. Age may interfere with the strength or dexterity for performing
certain tasks. Personal stress, illness, low literacy and lack of support are other barriers to learning.

Special Considerations When Teaching The Elderly Adult, consider the following
1. Provide good lighting
2. Provide written material
3. Use large type, black ink
4. Be certain the patient is wearing their glasses
5. If the patient wears hearing aids make sure they are turned on and adjusted correctly
6. Use short sentences with frequent pauses to allow for mental processing.
Chapter 27 – Nutritional Therapy and Assisted Feeding

Different Food Modification Levels

1. Puree Diet- The consistency of pudding for when a patient has a hard time swallowing chunks of
food or are at risk for choking.
2. Mechanical Soft- The food is chopped into smaller pieces so the patient has to do less chewing.
3. Liquid Diet- The patient can either be on a full liquid or clear liquid diet, mainy after surgeries.

Preoperative- Before Surgery, patients are usually placed on an NPO diet (Nothing by Mouth) no fluids
or liquids for up to 12 hours before surgery. This decreases the risk of vomiting while under anesthesia,
which could lead to aspiration of stomach contents.
Postoperative- After surgery, healing, and recovery. These patients progress from a clear liquid to full
liquid diet until bowel sounds are heard and they can tolerate solid foods.

Clear Liquids Include Full Liquid Diets

Grape, Apple, and Cranberry Juices Yogurt, Eggnog & Pudding
Vegetable Broth Custard and Ice Cream
Carbonated Clear Water Puree Meat & Veggies in cream soup
Clear fruit flavored drinks Strained Fruit Juice
Sweetened Gelatin and Ices Milk & Milk Beverages
Clear Candies Sweetened Plain Gelatin
Clear Broth Cooked Refined Meats
Popsicles Strained or Blended Gruel
Tea or Coffee All other Beverages
Cream, Margarine, Butter
Sherbet
Popsicles

When a patient is on a prescribed diet they should always have an I&O calculated daily
Ice is considered an input, as it is melted down it is considered water.

NPO- for a post-operative patient is for 12 hours

Difference between Bulimia and Anorexia Nervosa-

Bulimia is an eating disorder characterized by episodic binge eating, followed by behaviors designed to
prevent weight gain, like purging, fasting, using laxatives, and exercising excessively, and vomiting.
Anorexia- is characterized as a psychological disorder by restriction of caloric intake, a very low body
weight for the developmental stage, a pathological fear of becoming fat, and a sever disturbance in body
image. They view themselves obsese despite being extremely underweight.
Three Different Types of Cholesterols – The blood contains three different types of cholesterols.
1. High Density Lipoprotein (HDL)- Known as “Good Cholesterols”, tends to cleanse vessels of fatty
deposits.
2. Low Density Lipoprotein (LDL) – increases fatty deposits on vessels walls.
3. Very Low-Density Lipoprotein (VLDL)- serves as a carrier for triglycerides in the blood (a type of
fat linked to atherosclerosis and coronary artery disease), therefore; levels should be kept low.
Consumption of trans-fats also increases levels of triglycerides.

DASH Diet
Research shows that DASH diets (Dietary Approaches to Stop Hypertension)- include, diets low in
sodium and high in fruits, vegetables, nits, seeds legumes, and low-fat dairy products- can lower blood
pressure in healthy people. This might help prevent hypertension later in life.

Ethics PaperType 1 and Type 2 Diabetes

Type 1- Occurs when the beta cells of the pancreas stop secreting insulin. Type 1 usually develops at an
earlier age.
Type 2- accounts for 90%-95% of all cases of diabetes, it occurs when glucose receptors on the cell
membrane lose their sensitivity to insulin. Usually occurs after age 40, but lately is appearing frequently
in younger people, even children.

Enteral Tubes- Any tubes that is placed into a body to become intestinally absorbed.
Nasogastric Tubes (NG Tubes)- A tube placed through the nose into the stomach.
Gastrostomy Tubes, or Percutaneous Endoscopic Gastrostomy Tubes (PEG)- Placed directly into
the stomach.
Jejunostomy or Duodenal Tubes – Placed directly into the intestines.

Continuous Feeding- is constant feeding 24/7

Intermittent Feeding- is not constant, may only be a few hours at a time.

Words To Know & Facts

 Dysphagia- Difficulty Swallowing
 More then half of patients who aspirate show no obvious signs or symptoms such as coughing.
 Check tube placement at least every shift and before feeding or administering medication.
 Patient death has resulted from misconnected tube misconnections.
 Always keep the patients bed elevated at least 30 degrees if the patient is on continuous feeding,
to facilitate stomach emptying and to prevent aspiration.
 Glycosuria- Glucose in the urine.
 Hyperosmolality- increased concentration of solutes within the fluid.
 Thiamine Deficiency- is often present with alcohol use.
 Atherosclerosis- Accumulation of fatty deposits on the walls of blood vessels.
 Total Parental Nutrition (TPN)- is a method of delivering complete nutrition through a catheter
placed in a large central vein. A large central vein with high blood flow is needed to dilute the
solution rapidly.
 A peripheral inserted central catheter (PICC)- are options used for patients receiving long term
therapy, such as those with massive burns, intestinal obstruction, inflammatory bowel disease,
AIDS, and cancer, or chemotherapy.
 Older adult patients are more at risk for fluid overload when receiving large volumes of
intravenous fluids. Patients should be assessed for fluid overload, and keep a record of intake
and output (I&O).