Which of the following are examples of nursing implementations? (Select All That Apply)

A. History taking: This refers to the process of gathering information about a patient's medical history, including their symptoms, past illnesses, medications, and family history. It involves asking questions and actively listening to the patient's responses.

B. Palpation of an area: Palpation involves using the hands to feel the body's surface, usually to assess the texture, size, consistency, and location of certain organs or structures. For example, a healthcare provider might palpate the abdomen to feel for any abnormalities or tenderness.

C. Communication: Communication is a broad term that encompasses various aspects of interacting with a patient, including asking questions, active listening, providing explanations, and expressing empathy. Effective communication is crucial for building trust, understanding the patient's concerns, and delivering appropriate care.

D. Weighing of a patient: Weighing a patient is a specific measurement and is not a technique used for a physical examination. However, a patient's weight can be an essential piece of information in understanding their overall health and can be considered during the assessment process.

A. The case management system:
Case management involves coordinating comprehensive healthcare services for patients across different settings and healthcare professionals.
This choice doesn't describe the specific style of documentation used in the scenario provided.

B. SOAP Note:
Subjective: Information reported by the patient, like feelings or symptoms.
Objective: Observable and measurable data, such as physical examination findings.
Assessment: The nurse's professional judgment about the patient's condition.
Plan: Interventions and treatments planned for the patient.
In the scenario, the documentation includes subjective information (patient denies itching, happy with improvement), objective data (rash fading, no visible hives), the nurse's assessment (skin integrity improving), and the plan (check rash daily until discharge). This aligns with the structure of a SOAP note.

C. Narrative style:
Narrative charting involves writing out the patient's story in a paragraph form.
While it can contain similar information to a SOAP note, it doesn't follow the structured format of SOAP (Subjective, Objective, Assessment, Plan) and tends to be more detailed and descriptive.

D. Charting by exception:
Charting by exception involves documenting only abnormal findings or significant events.
This method reduces redundant documentation, focusing on deviations from the expected or normal findings.
The scenario provides a mix of both normal (improvement in skin, patient satisfaction) and abnormal (initial rash and hives) findings, so it's not solely charting by exception.