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What is a medical record (chart)?
It's a written account of a person's condition and response to treatment and care. The record is permanent and is a legal document. it can be used as evidence in a court of law of the person's problems. treatment, and care.
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Descrive the care given and the person's response. They are used to record information about special treatments and drugs, teaching and counseling, and procedures performed by the doctor. Nurses chart about a change in the person's condition, unusual events, or problems.
Progress Notes
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Are used to record frequent measurements or observations. They are used for vital signs and daily weight measurements. They are also used for recording intake and output.
Flow Sheets
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A type of flow sheet used to record the person's everyday activities.
Activities-of-daily-living (ADL) flow sheet
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What is the care plan called?
Comprehensive Care Plan
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What is a need?
Something necessary or desired for maintaining life and mental well-being.
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According to Abraham Maslow, a famous psychologist, which needs must be met first?
Lower-level needs must be met before the higher-level needs.
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Basic needs, from the lowest level to the highest level, are:
- 1. Physical needs--Oxygen, food, water, elimination, rest, and shelter are needed for life.
- 2. Safety and security needs--These relater to feeling safe from harm, danger, and fear.
- 3. Love and belonging needs-- These relate to love, closeness, affection, and meaningful relationships.
- 4. Self-estem needs--Self-esteem means to think well of oneself and to see oneself as useful and
- having value.
- 5. Self-actualization needs--Self-actualization means experiencing one's potential. It involves learning,
- understanding, and creating to the limit of a person's capacity.
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The caracteristics of a group of people-- languages, values, beliefs, habits, likes, dislikes, and customs.
Culture
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Listening
Means to focus on verbal and noverbal communication. You use sight, hearing, touch, and smell.
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This type of question focus on certain information.
Direct questions
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This type of question lead or invite the person to share thoughts, feelings, or ideas.
Open-ended questions
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Aphasia
The inability (a) to speak (phasia). Stroke is a common cause.
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Expressive Aphasia
Difficulty expressing or sending out thoughts. Thinking is clear. there are problems speaking, spellijng, counting, gesturing, or writing. The person thinks one thing but says another. For example, the person thinks about food but asks for a book.
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Receptive Aphasia
Relates to difficulty receiving information. The person has trouble understanding what is said or read. People and common objects are not recognized. The person may not know how to use a fork, toilet, cup, TV, phone, or other items.
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Messages are not sent.
Expressive aphasia.
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Messages are not interpreted.
Receptive Aphasia
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Both type of aphasia.
Expressive-receptive aphasia.
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Comatose
People who are unconscious. They cannot respond to others. Often they can hear and feel touch and pain. Assume that a comatose person can hear and understand you. Use touch and give care gently.
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A person is weighed daily. the measurement is recorded on the...
Flow sheet
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Mrs. Jones is blind. You focus on her
- a. As a physical, spsychological, social, and spiritual person.
- b. Care plan
- c. Physical, safety and security, and esteem needs
- d. cultural and religious needs.
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