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What is the purpose for the patient chart?
- provides communication between health care professionals
- legal documentation
- used for financial billing
- used as educational tools
- used for auditing and monitoring
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What is the purpose of the client admission assessment.
admission assessment is to establish a baseline
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What are the guidelines for charting error.
draw a line through the error and initial. Then write "mistaken entry" or "error"
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Charting Guidelines
- Be Factual
- Be Objective
- Do Not write Opinions "seems like" or "appears"
- Use only accepted Abbreviations
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What are the guidelines for a late entry?
put the current date and time then write (late entry for date and time)
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what are the guidelines for writing an incident report?
- Write incident report when something out of the normal happens (needle stick, client fall, med error, injury..)
- Note in the chart that incident reports was written
- Keep incident report separate from the chart
- Write exactly what you saw, if pt tells you something write pt states " "
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Andragogy
Arte and Science of Teaching Adults
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Pedagogy
- Discipline involved with teaching children
- helping children learn
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Geragogy
- the process involved in teaching older adults
- Helping older adults learn
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Behaviorism
a learning theory applied to teaching that states "learning is based on the learners behavior and what is directly observable"
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Cognitivism
- a theory that recognizes the development level of the learner and acknowledge the learners motivation and environment.
- Emphasize the importance of social, environmental and physical contexts
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Humanism
A theory that focuses on the feelings and attitudes of the learner and the importance of learners needs
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What are the 3 domains of learning?
- Cognitive
- Affective
- Psychomotor
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Cognitive Learning
- Intellectual behaviors, requires:
- Thinking
- Knowledge
- Comprehension
- Evaluation
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Affective Learning
- Deals with:
- expression of feelings
- Acceptance of attitudes
- acceptance of values
- acceptance of opinions
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Psychomotor Learning
Acquiring skills that utilize mental and muscular activity
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What are some of the factors that affect learning negatively?
- acute illness
- pain
- emotion-fear,anxiety, depression
- culture/religion
- physical disability
- mental disability
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What are some of the factors that affect learning in a positively?
- active involvement
- motivation
- client readiness
- repetition
- timing
- nonjudgmental support
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How is the nursing process related to education/teaching?
- ADPIE
- Assess
- Diagnose
- Plan
- Implement
- Evaluate
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What are the physical assessment techniques?
(In the order they are performed)
- Physical Readiness
- Emotional Readiness
- Cognitive Readiness
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What is Physical Readiness
- First step in the physical assessment techniques.
- Can the client focus
- Is the client pain free
- Is the client physically ready
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What Emotional Readiness?
- Step 2 in the physical Assessment techniques
- Is the client emotionally ready
- Is the client anxious, depressed, nervous?
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What is Cognitive Readiness?
- Step 3 in the Physical Assessment Techniques
- Can the client think clearly
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