Exam I Nursing Study Guide
What is slander?
A quasi-intentional tort consisting of abusive attack on a person's character or good name.
What is libel?
A quasi-intentional tort consisting of false and malicious publication printed for the purpose of defaming a living person.
What is invasion of privacy?
A quasi-intentional tort where a plaintiff is in a place where a reasonable person would have an expectation of privacy.
What is assault?
A tort consisting of a threatened or attempted physical or emotional attack by someone who appears to be able to cause bodily harm if not stopped.
What is battery?
A tort consisting of someone touching someone else without their consent.
What does HIPPA stand for?
Health Insurance Portability and Accountability Act.
What is Assessment?
History and physical assessment of patient. Subjective and objective data. Analyze data, look for trends, etc.
What is an example of situation in SBAR?
I am _____, a nurse at _____. I am calling about (child x) because I am concerned about _____. (BP is high or low, Pulse, early stroke warning)
What is an example of recommendation in SBAR?
I need you to come and see patient _____. is there anything I can do for you in the meantime.
What is an example of assessment in SBAR?
I think the problem is ___. I have _____ OR I am not sure what the problem is but the patient is deteriorating OR I am not sure what is going on but I am concerned
SBAR stands for what?
Situation Background Assessment Recommendation
What is utilitarianism?
The most good for the most people.
What is an example of background in SBAR?
___ was admitted on ___ with ____. They have had _____ (operation, treatment). Child X conditions has changed on _____. The last set of vitals was ___, their normal is _____.
What is SOAP used for?
charting?
What is included in evaluation of SOAPIE?
checking on patient, seeing if status has changed, adjusting the plan of care based on this new information
What is included in the assessment portion of SBAR?
significant findings in head to toe assessment, recent vitals, current treatment measures and diagnosis and pain status
What does SOAP stand for?
subjective objective assessment plan
What does SOAPIE stand for?
subjective, objective, assessment, plan, intervention, evaluation
What is PIE used for?
they are numbered and labeled according to the patients problems, resolved problems are dropped from documentation after the nurses review, continuing problems are documentation daily
What is SBAR used for?
to help reduce sentinel events (which are the worst type of medical errors). related to communication problems during phone conversations. a way to standardize communication of significant events/ changes in a patients conditions and to improve patient safety.
What is included in subjective of SOAP?
verbalization from the patient
What is included in problem of PIE?
what is wrong
What is included in plan in SOAP?
what the caregiver plans to do
What is included in the recommendation portion of SBAR?
your suggestions for the plan of care, and what needs to be addressed.
What is included in objective in SOAP?
data that is measured, and observed
What is included in assessment in SOAP?
diagnosis based on the data
What is an example of plan in SOAP?
explain further preoperative preparations, administer pain medication and check on patient again in 30 mins to see if main is decreased
What is SOAPIE used for?
has a nursing origin whereas SOAP originated from medical records. it simplifies documentation by unifying the care plan and progress notes ?
What is an example of objective in SOAP?
" Asking frequent questions about surgery. Has no previous experience with surgery. Has vitals of ____. Is showing grimacing which is consistent with their report of an 8 on the pain scale"
What is an example of subjective in SOAP?
" I'm worried about what it will be like after the surgery" "I am having pain of an 8 on the pain scale"
What is an example of intervention in PIE?
" explained normal preparations, demonstrated TCDB exercises" " administered pain medication"
What is an example of problem in PIE?
"deficient knowledge regarding surgery related to inexperience" " patient has headache"
What is an example of evaluation of PIE?
"patient is still experiencing headache. i will _____"
How do you process an ethical dilemma?
1. Ask if it is an ethical dilemma. 2. Gather all relevant info. 3. Clarify values. 4. Verbalize the problem. 5. Identify possible courses of action. 6. Negotiate a plan. 7. Evaluate the plan.
What is an example of evaluation of SOAPIE?
????
What is an example of assessment in SOAP?
?????
What is fidelity?
Agreement to keep promises.
What are the steps of the nursing process?
Assess, Diagnose, Plan, Implement, Evaluate.
What is nonmaleficence?
Avoiding harm or hurt.
What is the professional nursing code of ethics?
Basically, the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.
What us deontology?
Defines actions as right or wrong.
What is ethics of care?
Emphasizes the importance of understanding relationships.
What is feminist ethics?
Focuses on gender equality between people.
What is Intervention (or Implementation)?
Making your goals happen. Doing something to improve patient status. Initiation of care plan. Includes documentation. Can be independent or collaborative for a nurse.
What is Planning?
Prioritizing your nursing diagnosis, coming up with goals based on evidence.
What is a Nursing Diagnosis?
Problem, Etiology, and Symptoms of an illness. Problem- Identified from data, given a medical name, NANDA label. Etiology- Case. What it is "related to." Symptoms- How you know what the problem is. "As evidenced by."
What is the purpose of HIPPA?
Protects the privacy of health-realated information of all patients in all hospitals.
What is an example of assessment in SOAPIE?
SAME as in SOAP
What is an example of objective in SOAPIE?
SAME as in SOAP
What is an example of plan in SOAPIE?
SAME as in SOAP
What is an example of subjective in SOAPIE?
SAME as in SOAP
What is included in assessment of SOAPIE?
SAME as in SOAP
What is included in objective of SOAPIE?
SAME as in SOAP
What is included in plan of SOAPIE?
SAME as in SOAP
What is included in subjective of SOAPIE?
SAME as in SOAP
What are the Federal and State Statutory Issues in Nursing?
See "Legal Implications in Nursing Practice" notecards.
What is Evaluation?
Seeing if your care plan worked. Constant evaluation of evidence and outcomes. Re-evaluate patient. Change plan of care as needed. Come up with a new goal or different interventions.
What is beneficence?
Taking positive actions to help others.
What is autonomy?
The commitment to include patients in decisions.
What is ethics?
The philosophical study of moral values and rules
What is an example of intervention of SOAPIE?
administer the pain medication ???
What is included in the situation portion of SBAR?
admitting or secondary diagnosis and the problem your patients is currently having
What is included in intervention of PIE?
how you are going to fix the problem
What is included in the background portion of SBAR?
pertinent medical history, previous medical history, previous lab information (tests and treatment), psychological issues, allergies, current code status
What does PIE stand for?
problem intervention evaluation
What is included in intervention of SOAPIE?
putting your plan into action ????
What is included in evaluation of PIE?
reassessing patient to see if status has changed