COMBO --- 16 (Documentation and Communication)

expected psychosocial development (Erikson: initiative vs guilt): preschooler (3-6 years)

-may take on new experiences despite not having all physical abilities needed to be successful at everything -guilt may occur when unable to accomplish a task and believe they have misbehaved -guiding to attempt activities within their capabilities while setting limits is appropriate

transfer documentation should include:

-med diagnosis and care providers -client demographic info -overview of health status, plan of care, and recent progress -any alterations that may be of immediate concern -notification of any assessments/client care needed within the next few hrs -most recent vital signs and meds (inc PRNs) -allergies -diet and activity orders -presence of/need for special equipment or adaptive devices -advanced directives & emergency code status -family involvement and health care proxy (if applicable)

expected psychosocial development (Erikson-generativity vs stagnation): middle adult (35-65 yrs)

-middle adults strive for generativity -use life as an opportunity for creativity and productivity -have concerns for others -consider parenting an important task -contribute to well-being of the next generation -strive to do well in one's own environment -adjust to changes in physical appearance and abilities

promote healthy lifestyle behaviors by instructing clients to:

-minimize or reduce stress -get adequate sleep/rest - eat a nutritious diet to achieve and maintain a healthy weight -avoid saturated fats -participate in regular physical activity most days of the week -while outdoors, wear protective clothing, use sunscreen, and avoid sun exposure between 10am and 4pm -wear safety gear while participating in physical activity -avoid substances such as tobacco products, alcohol, and illegal drugs -practice safer sex -seek medical care when necessary, and visit provider for routine screenings

expected psychosocial development (body-image changes): preschooler (3-6 years)

-mistaken perceptions of reality coupled with misconceptions in thinking lead to active fantasies and fears -greatest fear is that of bodily harm, thus fear of the dark and animals -sex-role identification is occurring

health promotion (nutrition): young adult (20-35 yrs)

-monitor adequate nutrition and proper physical activity -women: monitor calcium intake

health promotion (injury prevention-substance abuse): adolescent (12-20 yrs)

-monitor for s/s of substance abuse in at-risk children -teach to say "no" to drugs and alcohol -present a no tolerance attitude

Examples of tasks that can be delegated to LPNs

-monitoring client findings -reinforcing client teaching from a standard care plan -trach care -suctioning -checking NG tube patency -admin enteral feedings -inserting urinary cath -admin meds (exc IV in most states)

food poisoning

-most cases caused by bacteria such as E. coli, Listeria monocytogenes, and Salmonella -healthy individuals usually recover in a few days -very young, very old, pregnant, or immunocompromised clients at highest risk for complications -clients who are especially at risk are instructed to follow a low-microbial diet -most cases due to unsanitary food practice -can be prevented by proper hand hygiene, cooking meats/fish to correct temp, handling raw and fresh foods separately to avoid cross-contamination, and proper refrigeration

home safety risks for young and middle age adults include:

-motor vehicle crashes -occupational injury -high alcohol consumption -suicide

home safety risks for adolescents include:

-motor vehicle/injury -burns

nursing responsibilities in regards to isolation/restraints:

-must be identified in the protocol -include how often the client should be: assessed; offered food/fluid; provided for means of hygiene/elimination; monitored for vital signs; offered ROM of extremities

seclusion and restraints

-must be ordered -should be ordered for the shortest duration necessary and only if less restrictive measures are not sufficient -a client may voluntarily request temp seclusion -restraints can be physical or chemical -if used, frequency of client assessments in regards to food, fluid, comfort, and safety should be performed and documented every 15-30 min

restraints should:

-never interfere with treatment -restrict movement as little as is necessary to ensure safety -fit properly -be easily changed to decrease the chance of injury and to provide for the greatest level of dignity

lymph nodes should be ___ & ___; normal nodes are ___ ___

-nonpalpable -nontender -not visible

macule

-nonpalpable, skin color change, <1cm -example: freckle

expected age-appropriate activities: adolescent (12-20 yrs)

-nonviolent video games -nonviolent music -sports -caring for a pet -career-training programs -reading -social events (going to movies or school dances)

standards for emergency preparedness mandated by the Joint Commission require procedures be set for:

-notifying and assisting personnel -notifying external authorities of emergencies -managing space and supplies and providing security -isolating and decontaminating radioactive or chemical agents -evacuating and setting up alternative care site when the environment cannot support adequate client care and treatment -performing triage -managing clients during emergencies -interacting with families and news media -identifying backup resources for utilities and communication -orienting and educating personnel participating in emergency preparedness plan -providing crisis support for health care workers -providing performance monitoring and evaluations related to emergency preparedness -conducting 2 emergency preparedness drills each year

the first number of the recorded visual acuity indicates the ___ ___ ___ from the ___ the client is ___

-number of feet -chart -standing

RNs CANNOT delegate

-nursing process -client education -tasks that require nursing judgment to LPNs or AP

health promotion (nutrition): adolescent (12-20 yrs)

-nutrient deficiencies tend to be: iron, calcium, and vits A & C -eating disorders commonly develop including: anorexia nervosa, bulimia nervosa, obesity -advise parents: ensure balanced diet according to USDA and teach children to make healthy food choices -encourage dental health including: brushing and flossing daily; having regular check-ups and fluoride treatments

health promotion (alterations in health): middle adult (35-65 yrs)

-obesity and type 2 diabetes mellitus -CV disease -cancer -substance abuse (alcoholism) -psychosocial stressors

health promotion (nutrition): middle adult (35-65 yrs)

-obtain adequate protein intake -increase consumption of whole grains -increase consumption of fresh fruits and veggies -limiting fat and cholesterol -increasing vit D and calcium supplementation (esp for women)

The provider's responsibility for informed consent:

-obtain informed consent -must give complete description of treatment/procedure, description of who will be involved in treatment, description of risks, options for other treatments, and the right to refuse -provide clarification if requested

cognitive learning

-obtaining new info, being able to apply the info, and being able to evaluate the info -example: client is taught s/s of hypoglycemia and then can verbalize when to notify provider

supervision:

-occurs after delegation -oversees a staff's performance of delegated activities -determines if: completion of task is on schedule; performance was satisfactory; abnormal/unexpected findings documented & reported; assistance is needed to complete assigned tasks in a timely manner; assignment should be re-evaluated & possibly changed

CN III

-oculomotor -assess corneal light reflex -assess pupillary reaction to light -assess extraocular movements

falls

-older adults at increased risk due to decreased strength, impaired mobility and balance, and endurance limitations combined with decreased sensory perception -other clients at increased risk include those with decreased visual acuity, generalized weakness, urinary frequency, gait and balance problems, and cognitive dysfunction; also side effects of some medications -clients are at greater risk when >1 of the risk factors are present -fall prevention is a major nursing priority

CN I

-olfactory -assess nose for smell

responsibilities of the nurse when transferring/discharging the client:

-on day/time of transfer, confirm they are expecting and have a bed -communicate time client will be arriving -complete documentations -give verbal transfer report in person or over the phone -confirm mode of transportation to complete transfer/discharge -ensure client is dressed appropriately -account for all of client's valuables

CN II

-optic -assess visual acuity -assess visual fields -assess corneal light reflex -assess pupillary reaction to light

expected cognitive development (Piaget: formal operations): young adult (20-35 yrs)

-optimal time for education, both formal and informal -critical thinking skills improve -memory peaks in the 20s -increased ability for creative thought -values/norms of friends (social groups) are relevant

nodule/tumor

-palpable, circumscribed, 0.5cm or > -example: wart

papule

-palpable, circumscribed, <0.5cm -example: elevated nevus

wheal

-palpable, irregular borders, edematous -example: insect bite

in conjunctiva the ___ is pink and the ___ is transparent

-palpebral -bulbar

expected age-appropriate activities: preschooler (3-6 years)

-parallel play shifts to associative play and is not highly organized -appropriate activities include: playing ball, putting puzzles together, riding trike, pretend and dress-up, role play, painting, sewing cards and beads, reading books

Individuals who are authorized to grant consent for another person include:

-parent of a minor -legal guardian -court-specified representative -individual who has durable power of attorney for health care -emancipated minors (for themselves)

expected psychosocial development (Erikson: intimacy vs isolation): young adult (20-35 yrs)

-pass through two stages of development: intimacy vs isolation -may take on more adult commitments and responsibilities -may make occupational choices characterized by: high goals/dreams and exploration/experimentation

additional safety risks in home/community include:

-passive smoking -carbon monoxide poisoning -food poisoning -bioterrorism

-tympanic membranes should be ___ ___ & ___ -light reflex should be ___ and in a ___-___ ___ ___ -___ & ___ landmarks are readily visible -ear canals are ___ with ___ ___

-pearly gray & intact -visible & well-defined cone shape -umbo & manubrium -pink w/fine hairs

expected psychosocial development (social development): school-age (6-12 yrs)

-peer groups play an important part in social development -peer pressure begins to take effect -same-gender friendships begin to form; this is time period when clubs and best friends are popular -children prefer company of same-gender companions -most relationships come from school associations -at this age, may rival same-sex parent -conformity becomes evident

expected psychosocial development (social development): adolescent (12-20 yrs)

-peer relationships develop -these relationships act as support system for the child -best friend relationships are more stable and long-lasting in comparison to previous years -parent-child relationships change to allow a greater source of independence

factors that enhance learning:

-perceived benefit -cognitive and physical ability -health and cultural beliefs -active participation -age/educational level-appropriate methods

sterile procedure steps

-perform hand hygiene -open packaging, slipping package onto center of workspace with top flap opening away from the body -reach around to open top flap -open side flaps, using left hand for left flap and right hand for right flap -grasp last flap and turn it down toward the body -open additional sterile packages and add contents directly to sterile field by dropping contents into place -pour sterile solutions -don sterile gloves

Items to be transferred/discharged with the client include:

-personal belongings at the bedside -valuables from the safe -medications -assistive devices -medical records or transfer form

home safety risks for older adults include:

-physical, cognitive and sensory changes -changes in musculoskeletal and logical systems -impaired vision and/or hearing -nocturia and incontinence

health promotion (nutrition): toddler (1-3 yrs)

-picky eaters; repeated requests for favorite foods -consume 24-30 oz of milk/day; may switch from whole milk to 2% at age 2 -limit juice to 4-6 oz/day -food serving size is 1 tbsp for each yr of age -exposure to new food may take 8-15 times before acceptance -if there is a family history of an allergy to a certain food, gradually introduce while monitoring for reactions -finger foods may be preferred due to increasing autonomy -regular meal times and nutritious snacks best meet nutrient needs -avoid snacks/desserts high in sugar, fat, sodium -avoid foods that are potential choking hazards -always provide supervision during snack/mealtimes -cut small bite-size pieces to make them easier to swallow and prevent choking -do not allow drinking/eating during play or while lying down -suggest parents follow USDA nutrition guidelines

expected physical development (size): infant (birth-1 yr)

-posterior fontanel closes by 2-3 months -anterior fontanel closes by 12-18 months -weight: gains 150-210 g (5-7 oz) per month for 1st 6 months; birth weight should double by 4-6 months and triple by the end of the 1st year -height: grows about 2.5 cm (1 in) per month for 1st 6 months; then about 1.25 (0.5 in) per month til the end of 1st yr -head circumference: increases about 1.25 cm (0.5 in) per month for 1st 6 months; then about 0.5 cm (0.2 in)between 6-12 months)

complete documentation of isolation/restraint use includes a description of:

-precipitating events and behavior prior to seclusion/restraints -alternative actions taken to avoid seclusion/restraint -time restraints applied and removed (if discontinued) -type of restraint and location -client's behavior while restrained -type and frequency of care -client's response when restraint removed -meds administered

expected cognitive development (Piaget: still in preoperational phase>preconceptual though to intuitive thought): preschooler (3-6 years)

-preconceptual thought (2-4 year): make judgments based on visual apperances; misconceptions in thinking include artificialism (everything is made by humans), animism (inanimate objects are alive), and imminent justice (a universal code exists that determines law and order) -intuitive thought (4-7 year): can classify information and become aware of cause-and-effect relationships

Prior to delegating client care, the nurse should consider:

-predictability of outcome -potential for harm -complexity of care -need for problem solving and innovation -level of interaction with the client

expected psychosocial development (self-concept development): toddler (1-3 yrs)

-progressively see themselves as separate from their parents and increase their exploration away from them

droplet precautions

-protect against droplets larger than 5 mcg (streptococcal phryngitis or pnemonia, scarlet fever, rubella, pertussis, mumps, mycoplasma, pneumonia, meningococcal pneumonia/sepsis, pneumonic plague) -require a private room or room with clients with the same infectious disease and masks for providers and visitors

Civil law:

-protect the individual rights of people -one type that relates to the provision of nursing care is tort law

contact precautions

-protect visitors and caregivers against direct client/environmental contact infections (respiratory syncytial virus, shigella, enteric diseases caused by micro-organisms, wound infections, herpes simplex, scabies, multidrug-resistant organisms) -require a private room or a room with other clients with the same infection, gloves and gowns worn by caregivers and visitors, and disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag

health promotion (injury prevention-pregnancy prevention): adolescent (12-20 yrs)

-provide education

health promotion (injury prevention-STDs): adolescent (12-20 yrs)

-provide education and resources for treatment

health promotion (injury prevention-drowning): school-age (6-12 yrs)

-provide supervision when around pool/near body of water -teach to swim

Nursing role in advanced directives

-provide written information regarding advanced directives -document the client's advanced directives status -ensure that the advanced directives reflect the client's current decisions -inform all members of the health care team of the client's advance directives

baseline data

-provided by the admissions assessment -compared with future assessments to monitor client status and response to treatment

purposes of client teaching include:

-providing clients with info and skills to maintain and promote health, and prevent illness (immunizations, lifestyle change, prenatal care) -providing clients with info about how to restore health (teaching how to admin insulin) -providing clients with info about how to adapt to permanent illness or injury (ostomy care, learning swallowing techniques, speech therapy)

ecchymosis

-purple fading to green or yellow over time -variable in size -flat

pustule

-puss-filled -example: acne

hematoma

-raised ecchymosis

steps of mobility assessment

-range of motion -moving from supine to sitting on side of bed -gait -exercise tolerance

cherry angioma

-red -1-3 cm -round -can be raised

spider angioma

-red center with radiating red legs -up to 2 cm -can be raised

s/s during 1st stage of the inflammatory response (local infection):

-redness (from dilation of arterioles bringing blood to the area) -warmth of the area on palpation -edema -pain or tenderness -loss of use of the affected part

erythema

-redness: best noted in face, trauma and pressure sore areas -indication of inflammation

prevention education for risk of burns in preschoolers and school-age children:

-reduce setting on water heater to no higher than 120 deg F -teach dangers of playing with matches, fireworks, fire arms, etc -teach school-aged children how to use microwave and other cooking instruments

State laws

-regulate the core of nursing practice -each state has enacted statutes defining parameters of practice and gives authority to regulate to the state board of nursing

expected psychosocial development (moral development): middle adult (35-65 yrs)

-religious maturity -spiritual beliefs and religion may take on added importance -may become more secure in convictions -often have advanced moral development

safety prevention education for young and middle age adults includes:

-remind clients to drive defensively and not to drive after drinking -reinforce teaching about long term effects of high alcohol consumption -monitor for s/s of depression/suicide and refer as appropriate -encourage clients to be proactive about safety in workplace -ensure understanding of hazards of excessive sun exposure and the need to use sun block and protective clothing

expected cognitive development (language development): infant (birth-1 yr)

-responds to noises -vocalizes with "ooos" and "aahs" -laughs and squeals -turns head to sound of a rattle -pronounces single-syllable words -begins speaking two and then three-word phrases

health promotion (injury prevention-MVA): school-age (6-12 yrs)

-restrained in car seat or booster seat until adult seat belt fits correctly (laws vary from state to state) -under 13 are safest in back seat

The nurse is working on a unit that uses nursing assessment flow sheets. Which statement best describes this form of charting? Nursing assessment flow sheets 1) Are comprehensive charting forms that integrate assessments and nursing actions 2) Contain only graphic information, such as I&O, vital signs, and medication administration 3) Are used to record routine aspects of care; they do not contain assessment data 4) Contain vital data collected upon admission, which can be compared with newly collected data

1) Are comprehensive charting forms that integrate assessments and nursing actions

discharge instructions should include:

-step-by-step for procedures done at home -precautions to take when performing home procedures and with meds -s/s of complications that should be reported -names and numbers of providers and community services contacts -plans for follow-up care and therapies

expected psychosocial development (self-concept development): school-age (6-12 yrs)

-strive to develop healthy self-respect by finding out in what areas they excel -parents need to encourage regarding educational or extracurricular success

health promotion (alterations in health): young adult (20-35 yrs)

-substance abuse -periodontal disease due to poor oral hygiene -unplanned pregnancies (a source of high stress) -STDs -infertility -work-related injuries or exposures

hazardous material incidents

-take measures to protect self and avoid contact -approach scene cautiously -try to identify the material and have knowledge of where MSDS manual is located -try to contain material to one area as much as possible until haz-mat team arrives -if individuals are contaminated, decontaminate as much as possible at the scene or as close to the scene as possible

biological incidents

-take measures to protect self and others -recognize s/s of infection/poisoning and appropriate treatments -incidents include: inhalational anthrax, botulism, smallpox, and ebola

chemical incidents

-take measures to protect yourself and to avoid contact -assess and intervene to maintain the client's ABCs and admin first aid as needed -effectively remove the offending chemical/decontaminate -gather specific history of the injury, if possible -in the event of chemical warfare, have knowledge of which facilities are open to exposed clients and which are open to unexposed clients only -follow facility's emergency ops plans

prevention education for risk of poison in preschoolers and school-age children:

-teach about hazards of alcohol, prescription, non-prescription, and illegal drugs -keep potentially dangerous substances out of reach

health promotion (injury prevention-burns): adolescent (12-20 yrs)

-teach fire safety -use sunscreen when outside

health promotion (injury prevention-burns): school-age (6-12 yrs)

-teach fire safety and potential burn hazards -have working smoke and carbon monoxide detectors in the home -use sunscreen when outdoors

health promotion (injury prevention-drowning): adolescent (12-20 yrs)

-teach to swim -teach not to swim alone

prevention education for risk of burns in adolescents

-teach to use sunblock and protective clothing -teach dangers of sun bathing and tanning beds -educate on hazards of smoking

prevention education for risk of burns in infants and toddlers:

-test temp of formula and bath water -place pots on back burner and turn handle away from front of stove -supervise use of faucets

Entities with codes of ethics that may be used to guide nursing practice include:

-the American Nurses Association (ANA) -the International Council of Nurses (ICN) -the National Association for Practical Nurse Education and Services, Inc.

asepsis

-the absence of illness-producing micro-organisms -maintained through the use of aseptic technique with hand hygiene as the primary associated behavior

bioterrorism

-the dissemination of harmful toxins, bacteria, viruses, and pathogens for the purpose of causing illness or death -examples include anthrax, variola, Clostridium botulism, and Yersinia pestis

complex critical thinking

-the nurse begins to express autonomy by analyzing and examining data to determine the best alternative -results from increased nursing knowledge, experience, intuition, and more flexible attitudes

commitment

-the nurse expects to have to make more choices without help from others and fully assumes the responsibility for those choices -results from an expert level of knowledge, experience, developed intuition, and reflective, flexible attitudes

basic critical thinking

-the nurse trusts the experts and thinks concretely based on the "rules." -results from limited nursing knowledge and experience, as well as inadequate critical thinking experience

only sterile items may be in a sterile field

-the outer wrapping and 1 inch edges are non-sterile -touch sterile materials only with sterile gloves -any object held below the waist or above the chest is considered contaminated -sterile materials may only tough other sterile materials/surfaces; contact with nonsterile materials at any time renders a sterile area contaminated, no matter how short the contact

therapeutic communication is

-the purposeful use of communication to build and maintain helping relationships with the client, families, and significant others -client centered: not social or reciprocal -purposeful, planned, and goal-directed

Consent considered informed when the client has been provided and understands:

-the reason the treatment or procedure is needed -how the treatment or procedure will benefit the client -risk involved if treatment or procedure is chosen -other options to treat the problem (including no action)

adequate fluid intake/hydration prevents:

-the stasis of urine by flushing the urinary tract and decreasing the growth of micro-organisms -the skin from breaking down which will help prevent micro-organisms from entering the body

health promotion (psychosocial interventions to improve self-concept & alleviate social isolation): older adult (65+ yrs)

-therapeutic communication -touch -reality orientation -validation therapy -reminiscence therapy -attending to physical appearance -assistive devices (canes, walkers, hearing aids)

LOC: coma

-there is no response to repeated stimuli -abnormal posturing (decorticate or decerebrate rigidity)

individuals with compromised health or defenses against infection include:

-those who are immunocompromised -those who have had surgery -those with indwelling devices -a break in the skin -those with poor oxygenation -those with impaired circulation -those who have chronic or acute disease

CN V

-trigeminal -assess the face for strength and sensation

CN IV

-trochlear -assess extraocular movements

health promotion (injury prevention-burns): preschooler (3-6 yrs)

-turn down thermostat on hot water heater -have working smoke detectors in the home -use sunscreen while outside

discharge documentation should include

-type of discharge -date/time of discharge, how the client was transported out and with who -where discharged to -summary of condition upon discharge -description of any unresolved difficulties and procedures for follow up -deposition of valuables and meds -copy of discharge instructions

passive smoking

-unintentional inhalation of tobacco smoke -exposure can put one at risk for numerous diseases including: cancer, heart disease, and lung infections -low-birth weight, prematurity, stillbirths, and SIDS have been associated with maternal smoking -smoking in presence of children is associated with development of bronchitis, pneumonia, middle ear infections, and an increase in frequency/severity of asthma attacks

health promotion (injury prevention-MVA): infant (birth-1 yr)

-use approved rear-facing car seat in the back seat (pref in middle) -infants in rear facing for 1st year until weighing 9.1 kg (20 lbs) rear-facing recommended till child reaches weight limit -in addition, a 5point harness or T-shield should be a part of the convertible restraint

prevention education for risk of motor vehicle/injury in infants and toddlers:

-use backward facing car seat until yr old and weighs at least 20 lbs -all car seats should be federally approved and be placed in the back seat

prevention education for risk of motor vehicle/injury in preschoolers and school-age children:

-use booster seats for children < 4'9" and <40 lbs -use seat belts properly after booster seats no longer necessary -use protective equipment when participating in sports or riding/passenger on a bike -supervise and teach safe use of equipment -teach to play in safe areas, rules of the road, and what to do if approached by a stranger -begin sex education for school-ages children

oxygen safety measures:

-use/store according to manufacture's recommendations -place a NO SMOKING sign near front door of home and on door of client's bedroom -inform client and family of smoking in presence of oxygen and that smokers should smoke outdoors -ensure electrical equipment is in good repair and well grounded -replace bedding that can generate static electricity (wool, nylon, synthetics) with cotton -keep flammable items (such as heating oil and nail polish remover) away from client when O2 in use -follow general safety measures for fire safety

health promotion (injury prevention-MVA): toddler (1-3 yrs)

-used approved car seat in back seat away from airbags -should be rear facing till reaches 9.1 kg (20 lbs) and is 1 yr old; then can use forward facing seat in back seat-usually until 4 yo old 40 lbs -children who meet weight but not age requirement of 1 yr should remain rear facing and a 5 point harness or T-shield should be a part of convertible harness

airborne precautions

-used to protect against droplet infections smaller than 5mcg (measles, varicella, pulmonary or laryngeal TB) -require a private room, masks/respiratory devices for caregivers and visitors (N95 or HEPA respirator for known/suspected TB), and negative pressure airflow exchange room of at least 6 exchanges per hr

Telephone report

-useful when contacting provider or other members of the interdisciplinary team -important to have all data prepared before calling; use professional demeanor; use exact, relevant, and accurate info; document name of person called, time, content of message, and instructions or information received

CN X

-vagus -assess mouth for movement of soft palate and the gag reflex -assess swallowing and speech

heart sounds: S3

-ventricular gallop -produced by rapid ventricular filling -can be a normal finding in children and young adults -best heard with bell of steth

health promotion (health screenings): preschooler (3-6 yrs)

-vision: myopia and amblyopia can be detected and treated before poor visual acuity impairs the learning environment

expected cognitive development (language): preschooler (3-6 years)

-vocabulary continues to increase -can now speak sentences, is able to identify colors, enjoys talking

expected psychosocial development : adolescent (12-20 yrs)

-vocationally: work habits begin to solidify; plan for future college and career -sexually: increased interest in opposite gender -health perceptions: may view themselves as invincible to bad outcomes of risky behaviors

expected physical development (size): preschooler (3-6 yrs)

-weight: should gain about 2-3 kg (4.5-6.5 lbs) per year -height: should grow about 6.2-7.5 cm (2.5-3 in) per year

expected physical development (size/growth): school-age (6-12 yrs)

-weight: will gain about 2-4 kg (4.4-8.8 lb) per year -height: will grow about 5 cm (2 in) per year -puberty changes (male): enlargement of testicles with changes in scrotum; appearance of pubic hair -puberty changes (female): budding breasts; appearance of pubic hair; menarche -permanent teeth erupt -visual acuity improves to 20/20 -auditory acuity and sense of touch is fully developed -fine and gross motor skills: coordination continues to develop

5 rights of delegation help decide:

-what task should be delegated (right task) -under what circumstances (right circumstance) -to whom (right person) -what info should be communicated (right direction/communication) -how to supervise/evaluate (right supervision /evaluation)

bomb threat

-when a phone call is received: >lengthen conversation as much as possible >listen for distinctive background noise >be alert for distinguishing voice characteristics >ask where the bomb will explode and at what time >note if the caller indicates knowledge of the facility by his description of the location -if what appears to be a bomb is found, don't touch, clear the area, isolate it, and obtain professional assistance -notify authorities and key personnel -cooperate with police and others -keep elevators available for authorities -remain calm and alert and try not to alarm clients

Examples of questions to use to determine need for problem solving and innovation:

-will a judgment need to be made while performing the task? -does it require nursing assessment skills?

Examples of questions to use to determine predictability of care:

-will the completion of the task have a predictable outcome? -is it a routine treatment? -is it a new treatment?

steps to donning sterile gloves:

-with cuff side pointing toward the body, use non-dominate had to pick up dominate glove -while picking up edge of the cuff, pull the dominate glove onto the hand -with sterile dominate hand gloved, place fingers of dominate hand inside cuff of left hand, lifting it off the wrapper and put non-dominate hand into it -when both hands are gloved, adjust fingers as needed -during this time, only sterile gloved hand can touch the other sterile gloved hand

The nurse's responsibility for informed consent:

-witness informed consent -must ensure provider provided necessary information, ensure the client understood and is competent to give consent, have the client sign informed consent document, notify provider if more information or clarification needed/requested by client, and document client questions and that the provider was notified (also if interpreter was used)

expected psychosocial development (body-image changes): middle adult (35-65 yrs)

-women: symptoms of menopause may represent loss of reproductive role or femininity and/or new interest in intimacy -men: decreasing strength may be frustrating or frightening -decreased sex drive may occur as a result of declining hormones, chronic disease, or meds -changes in physical appearance may raise concerns about desirability

jaundice

-yellow: orange of skin, sclera, and mucous membranes -indication of liver dysfunction, red blood-cell destruction

adherence

...

The nurse is orienting a new nurse to the unit and reviews source-oriented charting. Which statement by the nurse best describes source-oriented charting? Source-oriented charting 1) Separates the health record according to discipline 2) Organizes documentation around the patient's problems 3) Highlights the patient's concerns, problems, and strengths 4) Is designed to streamline documentation

1) Separates the health record according to discipline

5 elements necessary to prove negligence

1) duty to provide care as defined by a standard 2) breach of duty by failure to meet standard 3) foreseeability of harm 4) breach of duty has potential to cause harm (combines 2&3) 5) harm occurs

steps to assessing orthostatic BP changes

1) take client's BP and HR in the supine position 2) have client change to sitting or standing position 3) wait 1-5 mins 4) reassess BP and HR 5) client is experiencing orthostatic hypotension if SBP decreases >20 mm Hg and/or DBP decreases >10 mm Hg with a 10%-20% increase in HR

grading of pitting edema: 1+: 2+: 3+: 4+:

1+: 2mm/trace, rapid return 2+: 4mm/mild, 10-15 second return 3+: 6mm/moderate, 1-2 min return 4+: 8+mm/severe, 2-5+ min return

Five common issues in malpractice caused by inadequate or incorrect documentation

1. Failing to document the correct times of events 2. Failing to record verbal orders or to have them signed 3. Charting actions in advance to save time 4. Documenting incorrect data 5. Failing to give a report or giving an incomplete report to an oncoming shift

expected rectal temperatures are usually:

0.5* C (0.9* F) higher than oral temps

expected axillary and tympanic temperatures are usually:

0.5* C (0.9* F) lower than oral temps

nursing roles in ethical decision making

1. an agent for the client facing an ethical decision. ex. caring for an adolescent client who has to decide whether to undergo an abortion even though her parents think its wrong, discussing options with a parent who has to decide whether to consent to a blood transfusion for a child when his religion prohibits such tx. 2. a decision maker for health care delivery. ex. assigning staff nurses a higher client load than recommended because administration has cut the number of nurses per shift, witnessing a surgeon discuss only surgical options with a client without informing the client about more conservative measures available.

A group of nurses is discussing the advantages of using computerized provider order entry (CPOE). Which of the following statements indicates that the nurses understand the major advantage of using CPOE? A) "CPOE reduces transcription errors." B) "CPOE reduces the time necessary for health care providers to write orders." C) "Health care providers can write orders from any computer that has Internet access." D) "CPOE reduces the time nurses use to communicate with health care providers."

A

Define Client record: A) A confidential, permanent legal documentation of information relevant to a client's health care. B) Name, address, phone number, insurance information. C) List of medications. D) Temporary notes made pertaining to the clients current visit made on the nurses pocket notepad.

A

Define reports: A) Oral, written, or audiotaped exchanges between caregivers. B) Summary of xrays, MRI and Sonograms done on patient. C) Documentation of all activity patient has had previously for current condition. D) Review of all patients for cause trending.

A

Describe what Critical Pathways are. A) Multidisciplinary care plans that include client problems, key interventions, and expected outcomes. Involves all of health care team for a particular patient. B) Emergency Room proticol C) Critical Care Crash Team D) Steps to take when patient is critical and not expected to survive.

A

Documentation is: A) Anything written or printed that you rely on as record or proof for authorized persons. B) Lab results for a patient you are taking care of. C) Admission paperwork for billing purposes. D) Instructions from the attending doctor.

A

What does being "Complete" mean? A) Documentation containing appropriate and essential information B) A list of patients food likes and dislikes. C) A full narrative of how the patient was cared for.

A

What is Auditing? A) Objective, ongoing review of records to determine the degree to which quality improvement standards are met. B) Investigation by TJC for fraud C) Employee performance evaluations D) Research on "Never Events".

A

What is a Kardex? A) Has activity, treatment, nursing care plan sections that organize information for quick reference. Older method, not used so much any more. B) A medication for the lips. C) Roledex of contact information for Physicians and other healthcare professionals. D) Charts kept at the end of the patients bed that provides all of their medical information.

A

What is research? A) Gathering of statistical data of clinical disorders, complications, therapies, recovery and deaths B) Studies by nurses who are back in school for their masters degree. C) Scientific study of a specific illness conducted by scientists and doctors to create new medications.

A

You are supervising a beginning nursing student who is documenting patient care. Which of the following actions requires you to intervene? The nursing student: A) Documented medication given by another nursing student. B) Included the date and time of all entries in the chart. C) Stood with his back against the wall while documenting on the computer. D) Signed all documentation electronically.

A

Long-term care documenting

A summary of the client's condition; an evaluation of the client's ability to perform ADLs; the client's level of consciousness and mood; hydration and nutrition status; response to medications; any treatments provided; safety measures (bed rails, bed alarm, wander guard)

Charting by exception (CBE)

A system of charting in which only significant findings or exceptions to standards and norms of care are charted. To use effectively, you must know and adhere to professional, legal, and organizational guidelines for nursing assessments and interventions. CBE uses preprinted flow sheets to document most aspects of care. CBE assumes that unless separate entry is made, all standards have been met and patient has responded normally.

Documentation and Reporting

A way to communicate with other staff members as well as health care team

Documentation of nursing care for home health patients requires which of the following? Choose all that are correct. A. Certification of homebound status B. Use of the OASIS data set C. A weekly summary describing the patient's status and ongoing needs D. Ongoing assessment of need for skilled nursing care

A, B, D

You are giving a hand-off report to another nurse who will be caring for your patient at the end of your shift. Which of the following pieces of information do you include in the report? (Select all that apply.) A) The patient's name, age, and admitting diagnosis B) Allergies to food and medications C) Your evaluation that the patient is "needy" D) How much the patient ate for breakfast E) That the patient's pain rating went from 8 to 2 on a scale of 1 to 10 after receiving 650 mg of Tylenol

A, B, E

What information should be included in a transfer report? (Select all that apply) A) Client's name B) Age C) Marital Status D) Employer E) Primary physician F) Medical diagnosis G) Summary of progress H) Current health status I) Insurance J) Allergies K) Need for additional equipment

A, B, E, F, G, H, J, K

PIE--nursing based charting. (Select all that apply). A) Problem B) Assessment C) Intervention D) Evaluation E) Expectations

A, C, D

Which of the following are examples of events that would be recorded by an incident or occurrence report? (Select all that apply). A) Patient fall B) MRI machine not working C) Needle stick D) Medication error E) Ambulance arrival in the ER

A, C, D

List major areas to include in a change of shift report. (Select all that apply). A) Date & Time. B) Census count C) Essential background information. D) Client's nursing diagnosis or health care problems and their related causes. E) Length of time you have cared for patient. F) Description of objective measurements or observations G) Significant information about family members. H) Discharge plan. I) List of patients belongings. J) Significant changes in the way therapies are to be given. K) Any patient education completed. L) Evaluation of nursing care to date M) Priorities

A, C, D, F, G, H, J, K, L, M

SOAP--medical records based includes what type of information? A) Subjective B) Organized C) Objective D) Analytical E) Assessment F) Plan

A, C, E, F

List the information that needs to be documented with telephone reports. (Select all that apply). A) Date & TIme of call B) Diagnosis C) Physicans name D) Who was called E) Why they were called (info they were given and info that was received from them)

A, D, E

A typical source-oriented record includes the following:

Admission data Advance directives History and physical Physician's orders Progress notes Diagnostic studies Laboratory data Nursing notes Graphic data-numerical data recorded over time and displayed visually to see trends. Rehabilitation and therapy notes Discharge planning

Computer Assisted Medical Chartingaka EHR (Electronic Health Record)

Advantages -Data legible -Quick access -Easily retrievable -Confidentiality- restricted access -minimizes repetition and redundancy -Bedside computers increase accuracy and speed of charting -Meets JCAHO standards -Increase speed and completeness of reimbursement CALLED WOW -WORK STATION ON WHEELS

SOAP

Advantages: All charting focused around client problems, Interdisciplinary, everyone charts on same notes, Easy to track progress Disadvantages: Difficult to master, Specific focus-difficult to chart general info without identifying problem, Lengthy and time consuming

FOCUS/DAR

Advantages: Broad view-can chart on any significant area, Concise, Flexible, Works well in long-term or ambulatory care or mental health settings Disadvantages: Not multidisciplinary, Difficult to identify chronological order, Progress note may not relate to plan of care

Narrative Charting

Advantages: Easy to learn, Easy to adjust, Can explain in detail Disadvantages: Time consuming, Difficult to retrieve information, Irrelevant information often included, Possibly unfocused or disorganized

Charting by Exception

Advantages: Efficient, Use of flow sheets permit rapid detection of changes, Can take place of care plan Disadvantages: Expensive to institute-must in-service staff, Not prevention focused, Not appropriate for long-term or ambulatory care Examples: Client refuses medication, Lung sounds are abnormal, Client's oxygenation status is deteriorating

PIE

Advantages: Plan of care incorporated in progress notes, Outcomes included, Daily review to determine progress, Less redundancy, Easily adaptable to automated charting Disadvantages: Must read progress notes to determine plan of care, If problem not ID'd, difficult to chart, Not multidisciplinary

What should you document after administering a prn medication?

After administering a PRN medication, document the time and date the medication was given and the location of administration if the medication was injected on the medication administration record (MAR). In the nurses' notes, state the reason for administering the medicine, the amount given, and the patient's response to the medication.

When should you document?

After care or assessment Beginning of shift Chronologically, to communicate changing status (document times in order) Never chart ahead (before performing an intervention) Avoid "block" charting (ex.from 1300 to 1500) Late entries, paper. (add late entries to first avail. line. Record date and time you are charting, but in the body, clearly designate that it is a late entry.) Late entries, EHR. (Open appropriate form and change the auto. generated date and time then sign)

ETOH

Alcohol

Therapeutic Communication - Using Silence:

Allows client to think things through

How is documentation on paper different than documentation in an EHR or on an electronic digital form?

Although the same principles apply, there are some differences. When you document electronically, the information is immediately available to other care providers in other settings. You do not have to wait for another provider to finish with the chart, so you can chart almost immediately after patient contact. Usually, you will not type in a narrative note but will enter a phrase or click to bring up a screen. After that, you check or indicate certain words or fields that then bring up other screens and other choices. You will struggle less with phrasing and terminology because the computer provides lists from which you choose those applicable to your patient and your interventions.

Amb

Ambulation, ambulatory

Charting by exception (CBE)

Amis to eliminate redundancy Emphasizes abnormal findings Identifies trends

What is the purpose of an occurrence report?

An occurrence report is a formal record of an unusual occurrence or accident. This is an agency report and is not part of the patient's chart. An occurrence report is filed in many circumstances. Examples of reportable events include falls or other patient injury, loss of patient belongings, or administration of the wrong medicine. Occurrence forms are used to track problems and identify areas for quality improvement.

What should you do when your handoff report is finished?

Ask the receiving nurse if he has any questions. Get the nurse's full name, and then record it plus the transfer date and time in your transfer documentation.

Barriers to therapeutic communication:

Asking too many questions, asking why, changing the subject inappropriately, failing to probe, expressing approval or disapproval, offering advice, providing false reassurance, stereotyping, using patronizing language

Delegating

Assess and diagnose; Plan goals and interventions; Implement; Evaluate

Using the nursing process to promote health

Assessment - settling in, attuning, acceptance, enjoying Analysis/nursing diagnosis - anxiety, caregiver role strain, deficient knowledge and spiritual distress Planning outcomes/evaluation - both realistic and valued by the patient and family Planning interventions/implementation - draw on patient and family strengths to help achieve the desired outcomes

What does the Home healthcare documentation include?

Assessment highlighting changes in the client's condition Interventions performed The client's response to interventions Any interaction or teaching that you conducted with caregivers Any interaction with the patient's primary care provider

The Joint Commission requires

Assessment of physical, self-care, environmental, patient education, and discharge planning needs Documentation and evidence

Skilled home nursing care has six categories of practice

Assessment, diagnosis, outcomes identification, planning, implementation, evaluation of care plan

Current

At the time of occurrence

A new graduate nurse is providing a telephone report to a patient's health care provider and accepting telephone orders from the provider. Which of the following actions requires the new nurse's preceptor to intervene? The new nurse: A) Uses SBAR (Situation-Background-Assessment-Recommendation) as a format when providing the report. B) Gives a newly ordered medication before entering the order in the patient's medical record. C) Reads the orders back to the health care provider after receiving them and verifies their accuracy. D) Asks the preceptor to listen in on the phone conversation.

B

A patient asks for a copy of her medical record. The best response by the nurse is to: A) State that only her family may read the record. B) Indicate that she has the right to read her record. C) Tell her that she is not allowed to read her record. D) Explain that only health care workers have access to her record.

B

Define Referrals: A) A physicians order for lab work B) An arrangement for services by another care provider C) Any physicians order that requires a authorization from the insurance company. D) Treatment options the physician discusses with the patient.

B

During a change-of-shift report: A) Two or more nurses always visit all patients to review their plan of care. B) The nurse should identify nursing diagnoses and clarify patient priorities. C) Nurses should exchange judgments they have made about patient attitudes. D) Patient information is communcated from a nurse on a sending unit to a nurse on a receiving unit.

B

Explain what "Current" means. A) The direction the patient is laying when they are on a bed. B) Timely entries; immediate documentation of information as it is collected from the client. C) Patient's ability to tell you the date and time. D) Patient's health history as it relates to their recent issues.

B

How is Charting by exception different than other charting methods? A) It focuses on only one diagnosis. B) Focuses on deviation from the established norm or abnormal findings, highlights trends or changes. If no new notes, then no new changes or findings. If nothing is there, it doesn't mean the nurse forgot it, it means there's nothing new. C) Charting done for patients who are in critical care and have multiple healthcare issues.

B

On the nursing unit you are able to access a patient's medical record and review the education that other nurses provided to the patient during an initial hospitalization and three subsequent clinic visits. This type of feature is most common in what type of record system? A) Information technology. B) Electronic health record. C) Personal health information. D) Administrative information system.

B

What are standardized care plans? A) Computer generated care plans based on patients age, weight, and height. B) Preprinted, set guidelines used to care for the client. C) Care plans dictated by TJC. D) Plans of care that work 100% of the time and require no deviation ever.

B

What does it meant to be accurate? A) Only having to check the vitals one time during a shift. B) The use of accepted abbreviations, symbols, and system of measures that are clear and easy to understand C) The weight of a patient in ounces. D) Spelling things correctly when writing notes.

B

While reviewing the pulmonary section of a patient's electronic chart, the physician notices blank spaces since the initial assessment the previous day when the nurse documented that the lung assessment was within normal limits. There also are no progress notes about the patient's respiratory status in the nurse's notes. The most likely reason for this is because: A) The nurses forgot to document on the pulmonary system. B) The nurses were charting by exception. C) The computer is not working correctly. D) The physician does not have authorization to view the nursing assessment.

B

You are helping to design a new patient discharge teaching sheet that will go home with patients who are discharged to home from your unit. Which of the following do you need to remember when designing the teaching sheet? A) The new federal laws require that teaching sheets be e-mailed to patients after they are discharged. B) You need to use words the patients can understand when writing the directions. C) The form needs to be given to patients in a sealed envelope to protect their health information. D) The names of everyone who cared for the patient in the hospital need to be included on the form in case the patient has questions at home.

B

Requirements for documentation in long-term care settings:

Based on professional standards, federal and state regulations, policies of health care agency

What to Chart

Basic assessment data In-depth assessment of any abnormalities Nursing actions taken Patient Response to these actions Patient Progress towards goals of plan of care Education Provided Discharge needs/care/instructions

Managing the Communication Process

Be aware of what is motivating you & your values/beliefs and perceptions; Think about what may be the perceptions of the receiver; Consider the verbal & non-verbal aspects of the communication; Use as many different channels as possible; Solicit feedback; Actively listen; Manage the environment

Telephone reports

Be concise and accurate, have chart ready to give any further information needed, and document date, time, and content of the call

Clarity and Brevity

Be simple, brief and direct; Which is better?: "Please describe for me the correct technique for performing a subcutaneous injection on yourself", "How do you give yourself a shot?"; Can use examples to clarify

Nontherapeutic Communication - Changing the subject:

Blocks further communication

A nurse caring for a patient on a ventilator electronically documents the head of bed elevated at 20 degrees. Suddenly an alert warning appears on the screen warning the nurse that this patient is at a high risk for aspiration because the head of the bed is not elevated high enough. This warning is known as what type of system? A) Electronic health record B) Clinical documentation C) Clinical decision support system D) Computerized physician order entry

C

Accreditation is: A) Certification by the ANA. B) Medicare approval. C) Joint Commission specifies guidelines for documentation. D) Passing the NCLEX.

C

An incident report is: A) A legal claim against a nurse for negligent nursing care. B) A summary report of all falls occurring on a nursing unit. C) A report of an event inconsistent with the routine care of a patient. D) A report of a nurse's behavior submitted to the hospital administration.

C

Case Management documenting is: A) Referral of patient to another provider. B) Interaction with Social Services to support patients needs away from healthcare facility. C) Incorporates a multidisciplinary approach to documenting care. D) Involvement of Qualtiy Assurance in the care of patients.

C

Define "Education". A) Nursing giving a patient a pamplet about various health conditions. B) Smoking cessation classes C) Learning the nature of an illness and the individual client's responses D) Nursing care in local schools with school aged children.

C

Define consultations: A) Lab results B) End of shift transition to next shift C) Form of discussion whereby one professional caregiver gives formal advice about the level of care of a client to another caregiver. D) Indication by billing on patients ability to pay.

C

What does it meant to be organized with documentation? A) Have everything in one folder so it can be found. B) Color code information from various departments to make it easier to identify that information. C) Communicate information in a logical order. D) Write legibily.

C

What does the admission nursing history form provide? A) Insurance B) DPOA information C) Baseline data to compare with changes in the clients condition. D) Risk factors

C

What is an appropriate way for a nurse to dispose of printed patient information? A) Rip several times and place in a standard trash can B) Place in the patient's paper-based chart C) Place in a secure canister marked for shredding D) Burn the documents

C

You are reviewing Health Insurance Portability and Accountability Act (HIPAA) regulations with your patient during the admission process. The patient states, "I've heard a lot about these HIPAA regulations in the news lately. How will they affect my care?" Which of the following is the best response? A) HIPAA allows all hospital staff access to your medical record. B) HIPAA limits the information that is documented in your medical record. C) HIPAA provides you with greater control over your personal health care information. D) HIPAA enables health care institutions to release all of your personal information to improve continuity of care.

C

expected psychosocial development (social development): middle adult (35-65 yrs)

-a need to maintain and strengthen intimacy -provide assistance to aging parents, adult children, and grandchildren

expected psychosocial development (Erikson: industry vs inferiority): school-age (6-12 yrs)

-a sense of industry is achieved through advances in learning -motivated by tasks that increase self-worth -fears of ridicule by peer and teachers over school-related issues are common -some manifest nervous behaviors to deal with stress such as nail biting

CN VI

-abducens -assess extraocular movements

clubbing of the fingernail

-abnormal curvature of the nail with an angle >160* -can be result of chronic low SaO2, emphysema, chronic bronchitis

Mandatory reporting

-abuse: child or elder abuse, domestic violence -communicable diseases (according to CDC) such as hepatitis and TB

CN VIII

-acoustic -assess ears for hearing

primary prevention

-addresses the needs of healthy clients to promote health and prevent disease with specific precautions -examples: immunizations programs; child car seat education; nutrition and fitness activities; health education in schools

expected psychosocial development (body-image changes): older adult (65+ yrs)

-adjustments to decreases in physical strength and endurance may be difficult, esp for older adults who are cognitively active and engaged -many feel frustrated that their bodies are limiting what they desire to do

factors that affect the client's ability to protect himself include:

-age, with young and old at greatest risk -mobility cognitive -sensory awareness -emotional state -lifestyle -safety awareness

Nurse's roles in ethical decision making include:

-agent for client facing an ethical decision: adolescent child debating on abortion; parent contemplating blood transfusion even when against religious beliefs -decision maker in regard to nursing practice: increasing staff load due to shift cuts; witnessing a surgeon discussion only surgical options without informing client of more conservative options

tertiary prevention

-aims to prevent the long-term consequences of a chronic illness or disability and to support optimal functioning -examples: prevention of pressure ulcers as complication of a spinal cord injury; promoting independence for the client who has traumatic brain injury

transmission precautions (tier 2) include:

-airborne precautions -droplet precautions -contact precautions

medical asepsis

-aka "clean technique" -the use of precise practices to reduce the number, growth, and spread of micro-organisms from an object, person, or area -used for administering oral meds, managing NG tubes, providing personal hygiene, and many other common nursing tasks

surgical asepsis

-aka "sterile technique" -the use of precise practices to eliminate all micro-organisms from an object or area -used for parenteral med administration, insertion of urinary catheters, surgical procedures, sterile dressing changes, and many other common nursing procedures

the following must occur in order for seclusion or restraint to be used:

-all other less restrictive means have to be exhausted -the treatment must be prescribed by provider in writing based on a face-to-face assessment of the client (exception is in emergency situation where client is a danger to himself or others and providers order must be written asap) -rx must include reason, type, location, how long it may be used, and type of behavior that warranted the restraint -provider must rewrite the rx every 24hrs or as specified by the facility -PRN rx is not allowed

other responsibilities of health care providers when dealing with isolation/restraints include:

-always explain need to client and family -obtain signed consent from client or guardian, if required -review manuf. instructions for correct application -remove or replace restraints frequently to ensure good circulation and full ROM of restricted limb -pad bony prominences -use quick-release knot to tie restraints to bed frame -ensure restraint is loose enough for ROM and 2 fingers can fit between device and the client -regularly assess need for continued need -never leave client unattended w/o the restraint

guidelines for cleaning contaminated equipment

-always wear gloves -rinse 1st in cold water -wash the article in hot water with soap -use a brush or abrasive to clean corners or hard-to-reach areas -rinse well in warm or hot water -clean the equipment used in cleaning and the sink (still considered dirty unless a disinfectant is used) -remove gloves and perform hand hygiene

criteria to follow when identifying clients who can be safely discharged in an emergency situation

-ambulatory clients requiring minimal care should be discharged or relocated first -clients requiring assistance should be next and arrangements made for continuation of their care -clients who are unstable and/or require nursing care should not be discharged or relocated unless they are in imminent danger

radiological incidents

-amount of exposure is related to time exposed, distance from source, and amount of shielding -facility treating victims should activate interventions to prevent exposure to treatment areas -staff should wear water-resistant gowns, double glove, and fully cover bodies with caps/shoe covers/masks/goggles -staff should wear radiation or dosimetry badges to monitor amount of exposure -clients should be initially surveyed with radiation meter to determine amount of contamination -decontamination should occur prior to entering the hospital with soap, water, and disposable towels -after decontamination, client should be resurveyed and washed until free of all contamination

Nurses should be aware that security measures include:

-an identification system that identifies authorized personnel -electronic security systems in high-risk areas

health promotion (injury prevention-poisoning): preschooler (3-6 yrs)

-avoid exposure to lead paint -keep plants out of reach -place safety locks on cabinets with cleaners and other chemicals -keep poison control number near phone -keep meds in childproof containers and out of reach -have working carbon monoxide detector in home

health promotion (injury prevention-poisoning): toddler (1-3 yrs)

-avoid exposure to lead paint -place safety locks on cabinets with household cleaners/chemicals -keep plants out of reach -keep poison control number by phone -keep meds in childproof container and out of reach -have working carbon monoxide detector in home

health promotion (injury prevention-suffocation): toddler (1-3 yrs)

-avoid plastic bags -be sure crib mattress fits tightly -ensure crib slats no further apart than 6 cm (2.4 in) -keep pillows out of crib -remove drawstrings from jackets and other clothing

health promotion (injury prevention-suffocation): infant (birth-1 yr)

-avoid plastic bags -keep balloons out of reach -ensure crib mattress fits snugly -ensure crib slats are no more than 6 cm (2.4 in) apart -remove crib mobiles and gyms by 4-5 months -do not use pillows in crib -place infant on back for sleep -keep toys with small parts out of reach -remove drawstrings from jackets and other clothing

health promotion (injury prevention-aspiration of foreign objects): infant (birth-1 yr)

-avoid small objects (such as grapes, coins and candy) that can become lodged in throat -provide age-appropriate toys -check clothing for safety hazards (loose buttons)

health promotion (injury prevention-aspiration of foreign objects): toddler (1-3 yrs)

-avoid small objects that can become lodged in throat -keep toys with small parts out of reach -provide age-appropriate toys -check clothes for choking hazards -keep balloons out of reach

Levels of critical thinking

-basic critical thinking -complex critical thinking -commitment

discharge education should:

-be clear and concise and also print ed for client to take home -identify safety concerns at home -review s/s of potential complications and when to contact provider -include provider phone number -provide names and numbers of community resources -instructions for continuing treatments -dietary restrictions and guidelines -amount and frequency of therapies -directions and information on medications

The client has the right to:

-be informed about the aspects of care in order to be active in the decision making process -accept, refuse, or request modification to the plan of care -receive care that is delivered by competent individuals who treat the client with respect

prone position

-client lies flat on abdomen with head to one side -position promotes drainage from the mouth of clients following throat or oral surgery, but inhibits chest expansion

supine or dorsal recumbent position

-client lies on his back with head and shoulders elevated on a pillow; client's forearms may be placed on pillows or placed at side; foot support prevents footdrop and maintains proper alignmentl

sims' or semi-prone position

-client lies on side halfway between lateral and prone positions; weight is on anterior ileum, humerus, and clavicle; lower arm behind client while upper arm is in front; both legs flexed but upper at greater anger than lower at hip and knee -this is a comfortable sleeping position for many clients and promotes oral drainage

lateral or side-laying position

-client lies on side with most of weight on the dependent hip and shoulder; arms should be flexed in front of the body; pillow placed under head & neck, the upper arm, and under the leg & thigh to maintain body alignment -this is a good sleeping position but the client must be turned regularly to prevent development of pressure ulcers on dependent areas; 30 degree lateral position is recommended for clients at risk for pressure ulcers

semi-fowler's position

-client lies supine with head of bed elevated approx 30 degrees and knees may be slightly elevated (about 15 degrees) -position frequently used to prevent regurgitation of tube feedings and aspiration in clients with difficulty swallowing

fowler's position

-client lies supine with head of bed elevated approx 45 degrees and knees may be slightly elevated (about 15 degrees) -position frequently used during procedures such as NG tube insertion and suctioning; also allows for better chest expansion & ventilation, as well as better dependent drainage, after abdominal surgeries

high-fowler's position

-client lies supine with head of bed elevated approx 90 degrees, and knees may or may not be elevated -position promotes lung expansion by lowering the diaphragm and used for clients experiencing severe dyspnea

LOC: obtundation

-client needs to be lightly shaken to respond, but may be confused and slow to respond

LOC: stupor

-client requires painful stimuli (pinching a tendon or rubbing sternum) to achieve a brief response -client may not be able to respond verbally

orthpneic position

-client sits in the bed or at bedside; pillow placed on over-bed table, which is placed over client's lap; client rests arms on the over-bed table -position allows for chest expansion and is especially beneficial to clients with COPD

Nurse's role in client rights includes:

-client understands their rights -protecting rights of clients under their care

Transfer reports should include

-client's demographic information -client's medical diagnosis and providers -and overview of the client's health status (physical and psychosocial), plan of care, and recent progress -any alterations that might become urgent or emergent situations -directives for assessments or client care essential w/in next few hours -most recent vital signs -meds prescribed and last doses administered (inc PRN) -allergies -diet & activity orders -presence of or need for special equipment or adaptive devices -advance directives and resuscitation status -family involvements in care & health care proxy, if applicable

indications for transfer and discharge

-client's level of care has changed -another setting is required to provide necessary client care -facility does not offer type of care now required -client no longer needs inpatient care and is ready to return home

expected psychosocial development (moral development): toddler (1-3 yrs)

-closely associated with cognitive development -egocentric: unable to see another's perspective; can only view things from their POV -punishment and obedience orientation begins with sense that good behavior is rewarded and bad behavior is punished

Nurses should be aware that all health care institutions have color-codes designated for emergencies: some examples include:

-code red (fire) -code pink (newborn abduction) -code orange (chemical spill) -code blue (mass casualty incident) -code gray (tornado) **may vary by institution**

Advanced directives

-communicate client's end-of-life care wishes for them if they become unable to -PSDA requires all clients be asked if they have advanced directives upon admission -clients with out advanced directives must be provided with written information about their health care rights and how to formulate advanced directives -a health care rep should be available to help with the process

expected age-appropriate activities: school-age (6-12 yrs)

-competitive and cooperative play is predominant -activities for 6-9: simple board and number games, hopscotch, jump rope, collections, riding bike, building simple models, joining organized sports (skill building) -activities for 9-12: making crafts, building models, collections/hobbies, jigsaw puzzles, board and card games, organized competitive sports

normal spine curvatures: -cervical spine: ___ -thoracic spine: ___ -lumbar spine: ___

-concave -convex -concave

expected cognitive development (Piaget: sensorimotor transitions to preoperational): toddler (1-3 yrs)

-concept of object permanence is developed fully -have and demonstrate memories of events that relate to them -domestic mimicry is evident (playing house) -preoperational thought does not allow to understand other viewpoints, but does allow to symbolize objects and people in order to imitate activities seen previously

health promotion (nutrition): preschooler (3-6 yrs)

-consumes about 1/2 the cals of an adult (19800 kcal) -picky eating remains a problem for some, but often by 5 they become more willing to sample different foods -need 13-19 g/day of complete protein in addition to adequate calcium, iron, folate, and vitamins A&C -parents need to ensure child receiving balanced nutrition as outlined by USDA

expected psychosocial development (moral development): preschooler (3-6 years)

-continues in the good-bad orientation of toddler years but begins to understand behaviors in terms of what is socially acceptable

seclusion and/or restraint must never be used for:

-convenience of the staff -punishment for the client -clients who are extremely physically or mentally unstable -clients who cannot tolerate the decreased stimulation of a seclusion room

expected psychosocial development (moral development): adolescent (12-20 yrs)

-conventional law and order: rules are not seen as absolutes; each situation needs to be looked at and maybe rules adjusted -not all adolescents attain this level during these years

prolonged exposure to airborne micro-organisms can make sterile items nonsterile. Avoid:

-coughing, sneezing, and talking directly over a sterile field -air movement should be controlled by special ventilation

components of hygiene/cough etiquette that applies to anyone entering a health care setting includes:

-covering the mouth and nose when coughing and sneezing -using facial tissues to contain respiratory secretions, and disposing of them promptly into a hands-free receptacle -wear surgical mask when coughing to minimize contamination of the surrounding environment -turning head when coughing and staying a min of 3' away from others, especially in common waiting areas -performing hand hygiene after contact with respiratory secretions

implementation related to client education includes:

-create an environment conducive to learning (reduce distractions and interruptions, provide privacy) -use therapeutic communication to develop a trusting relationship that allows client to express concern -review previous knowledge and experiences -explain the therapeutic regimen or procedure -present steps building to more complex tasks -demonstrate psychomotor skills -allow time for return demonstration -provide positive reinforcement

-pain in the chest wall may ___ respiration depth -onset of acute pain may ___ respiration rate -anxiety ___ respiration rate and depth -smoking causes resting respiration rate to ___ -neuro injury to the brainstem ___ respiratory rate and depth

-decrease -increase -increases -increase -decreases

A problem is an ethical dilemma if:

-it cannot be solved solely by a review of scientific data -it involves a conflict between two moral imperatives -the answer will have a profound effect on the situation/client

sterile fields and moisture

-keep all areas dry -discard any sterile packages that become wet

health promotion (injury prevention-substance abuse/poisoning): school-age (6-12 yrs)

-keep cleaners or chemicals in locked cabinet and out of reach -teach to say "no" to illegal drugs and alcohol

prevention education for risk of falls in infants and toddlers:

-keep crib and playpen rails up -never leave unattended on changing table or other high surface -restrain while in high chair, swing, stroller, etc -place in low bed when toddler starts to climb

health promotion (injury prevention-falls): infant (birth-1 yr)

-keep crib mattress in lowest position with rails all the way up -use restraints in infant seats -place infant seat on ground/floor if used outside of car and do not leave on elevated surfaces unattended -use safety gates across stairs

health promotion (injury prevention-falls): toddler (1-3 yrs)

-keep doors and windows locked -keep crib mattress in lowest position with rails all the way up -use safety gates across stairs

health promotion (injury prevention-bodily harm): school-age (6-12 yrs)

-keep firearms in a locked cabinet or box -assist with identifying "safe" play areas -teach stranger safety -teach to wear helmets and pads when needed

health promotion (injury prevention-bodily harm): adolescent (12-20 yrs)

-keep firearms in locked cabinet or box -teach proper use of sporting equipment prior to use -insist on helmet and/or pads when appropriate -avoid trampolines -be aware of changes in mood and monitor for self-harm in at-risk children (poor school performance, lack of interest in things once interested in, social isolation, disturbances in sleep patterns or appetite, expression of suicidal thoughts)

health promotion (injury prevention-bodily harm): preschooler (3-6 yrs)

-keep firearms in locked cabinet/container -teach stranger safety -wear helmets when riding bike/helmet and pads when participating in physical activity

prevention education for risk of poisoning in infants and toddlers:

-keep house plants and cleaning agents out of reach -place poisons, paint, and gas in locked cabinets -keep medication in child-proof containers and locked up -dispose of meds which are no longer used or out of date

prevention education for risk of suffocation in infants and toddlers:

-keep plastic bags out of reach -ensure crib mattress fits snugly and no more than 2 2/3 inches between crib slats -never leave alone in bathtub -remove crib toys, including mobiles, as soon as infant begins to push up -keep latex balloons out of reach -fence swimming pools and use locked gate -begin swimming lessons as soon as developmental status allows -keep toilet lids down and bathroom doors shut

health promotion (injury prevention-bodily harm): toddler (1-3 yrs)

-keep sharp objects out of reach -keep firearms in locked box/cabinet -do not leave unattended with animals -teach stranger safety

health promotion (injury prevention-bodily harm): infant (birth-1 yr)

-keep sharp objects out of reach -keep infant away from heavy objects that can be pulled down onto her -do not leave alone with animals -monitor for shaken baby syndrome

prevention education for risk of aspiration in infants and toddlers:

-keep small objects out of reach -check toys for loose parts -do not feed infant hard candy, peanuts, popcorn, or whole/sliced pieces of hot dog -do not place infant in supine position while feeding or prop the bottle -pacifiers should be constructed of one piece -provide information on prevention of lead poisoning

components of critical thinking

-knowledge -experience -competence -attitudes -standards

expected cognitive development (language development): toddler (1-3 yrs)

-language increases to about 400 words with toddlers speaking in 2-3 word phrases

before beginning any task or procedure that requires aseptic technique, health care team members must check for:

-latex allergies (client and team members) -if there is a known allergy, latex-free gloves, equipment, and supplies must be used

psychomotor learning

-learning how to complete a physical activity or motor skill -example: client practices preparing insulin injections

Client's rights

-legal guarantees that clients have with regard to their health care -situations where nurses have opportunity to protect client's rights include: informed consent, refusal of treatment, advanced directives, confidentiality, and information security

lab results indicating infection include:

-leukocytosis (WBCs > 10,000/uL -increases in the specific types of WBCs on differential (left shift = increase in neutrophils) -elevated erythrocyte sedimentation rate (ESR) -presence of micro-organisms on culture of the specific fluid/area

fissure

-linear crack -example: tinea pedis

all staff must be instructed in fire response procedures including:

-location of exits, fire extinguishers, and O2 shut-off valves -evacuation plan for the unit and facility

factors leading to bradycardia include:

-long-term physical fitness -hypothermia -medications -changing position from standing/sitting to lying down -chronic pain -hypothyroidism

pallor

-loss of color: best noted in face, conjunctivae, nail beds, palms -indication of anemia or lack of blood flow

internal emergencies include:

-loss of electric power or potable water and -severe damage or casualties w/in the facility related to fire, weather, an explosion, or terrorist act

ulcer

-loss of epidermis and dermis with possible bleeding and scarring -example: venous stasis ulcer or pressure ulcers

erosion

-lost epidermis, moist surface, no bleeding -example: ruptured vesicle

infants have a ___ BP that gradually ___ with age

-low -increases

circadian (diurnal) rhythms affect BP, with BP usually ___ in the early morning hours and ___ during the later part of the afternoon/evening

-lowest -peaking

feedback

-may be verbal and/or nonverbal, positive and/or negative -the message returned to the sender by the receiver that indicates the message was received -an essential component of ongoing communication

expected psychosocial development (social changes): young adult (20-35 yrs)

-may leave home early and establish independent living situation -may establish close friendships (intimacy) -may transition from being single to being member of new family -may question their ability to parent -may experience increased anxiety and/or depression, esp. after the birth of a child

expected psychosocial development (moral development): young adult (20-35 yrs)

-may personalize values and beliefs -reasoning may be based on ethical fairness principles, such as justice

Admission Nursing Assessment

Comprehensive admission assessment when client first admitted to nursing unit

Kardex

Concise method of organizing & recording data - Consists of a series of cards in a portable index file or on computer-generated forms - Pertinent info about the pt - Allergies - List of meds including IV fluids - List of daily treatments and procedures - List of diagnostic procedures - Physical needs that are to be met - Stated goals

What are the 6 guidelines for documentation?

Confidential, Complete, Current, Factual, Accurate, Organized

PIE

Consists of documentation; client assessment flow sheet & progress notes - acronym for *P*roblem *I*nterventions, and *E*valuation of nursing care - *P*roblem statement is labeled "P" & referred to by number (e.g., P #5) - *I*nterventions employed to manage the problem are labeled "I" and numbered according to the problem (e.g., I #5) - *E*valuation of the effectiveness of the interventions is also labeled and numbered according to the problem (e.g., E #5)

Electronic medical record

Contains patient data gathered in a health care setting at a specific time and place and is part of the electronic health record

C in Pace. What should be included?

Continuing needs and potential changes include the following: Patient care and treatments that must be monitored on other shifts Changes in the patient's condition or the care plan, recent or anticipated

case management plan

Coordinates services, promotes collaboration communication Multidisciplinary approach

What do EHR's (electronic health records) promote, improve, or help do?

EHR's promote efficient use of nurses' time, improve interdisciplinary collaboration, streamline processes, make procedures more accurate and efficient, and ensure improved patient safety and care outcomes.

A manager who is reviewing the nurses' notes in a patient's medical record finds the following entry, "Patient is difficult to care for, refuses suggestion for improving appetite." Which of the following directions does the manager give to the staff nurse who entered the note? A) Avoid rushing when charting an entry. B) Use correction fluid to remove the entry. C) Draw a single line through the statement and initial it. D) Enter only objective and factual information about the patient.

D

As you enter the patient's room, you notice that he is anxious to say something. He quickly states, "I don't know what's going on; I can't get an explanation from my doctor about my test results. I want something done about this." Which of the following is the most appropriate documentation of the patient's emotional status? A) The patient has a defiant attitude and is demanding his test results. B) The patient appears to be upset with his nurse because he wants his test results immediately. C) The patient is demanding and complains frequently about his doctor. D) The patient stated that he felt frustrated by the lack of information he received regarding his tests.

D

Discharge summary forms tell you what? A) Diagnosis of patient B) Total charges of visit C) Allergies D) Emphasize previous learning by the client and the care that should be continued.

D

Source record charting provides what? A) Reference information on where to find all resources. B) Key Code to help decifer physician notes C) Information of the source or cause of the patients illness. D) Separate section for each discipline

D

The primary purpose of a patient's medical record is to: A) Provide validation for hospital charges. B) Satisfy requirements of accreditation agencies. C) Provide the nurse with a defense against malpractice. D) Communication accurate, timely information about the patient.

D

The standards of documentation by the Joint Commission require: A) Narrative on how patient was cared for. B) Patient's vital signs every 4 hours. C) A resolution date for all planned outcomes. D) Documentation within the context of the nursing process, as well as evidence of client and family teaching and discharge planning.

D

What are Acuity records used for? A) Helps billing determine what to charge for a type of service. B) Sharpness; acuteness; keenness of patient C) The global standard for payment efficiency D) Records that assist a nurse manager in planning staffing requirements for the future.

D

What does "Factual" mean? A) Giving the patients point of view to understand how they feel. B) Your opion of the patients condition or behavior. C) Emotional and psychological assessment of the patient. D) Descriptive, objective information about what a nurse sees, hears, feels, and smells.

D

Which of the following charting entries is most accurate? A) Patient walked up and down hallway with assistance, tolerated well. B) Patient up, out of bed, walked down hallway and back to room, tolerated well. C) Patient up, walked 50 feet and back down hallway with assistance from nurse. Spouse also accompanied patient during the walk. D) Patient walked 50 feet and back down hallway with assistance from nurse; HR 88 and regular before exercise, 94 and regular following exercise.

D

Which of the following is correctly charted according to the six guidelines for quality recording? A) "Was depressed today." B) "Respirations rapid; lung sounds clear." C) "Had a good day. Up and about in room." D) "Crying. States she doesn't want visitors to see her like this."

D

registered nurse (RN)

Edu. Prep: must meet the state board of nursing's requirements for licensure, requires completion of diploma prog, an associate degree, or baccalaureate degree in nursing prior to taking the licensure exam. Roles/Responsibilities: function legally under state nurse practice acts, perform assessments, establish nursing diagnoses, goals, and interventions; and conduct ongoing client evaluations, participate in developing interprofessional plans for client care, share appropriate info among team members; initiate referrals for client assistance, including health edu; and identify community resources.

What influences your choice of format?

Depending on the documentation model your organization selects, you may use one or more of the following charting formats. Also influenced by whether your nursing documentation is written on paper, captured and stored electronically, or in a blend of the two. In all formats, you must learn to use abbreviations appropriately.

DM

Diabetes mellitus

D&C

Dilation and curettage

Types of interviews

Directive interviewing - obtain factual, easily categorized information, or in an emergency situation Closed questions - yes or no answers Nondirective interviewing - promote communication, build rapport, or help the patient to express feelings Open-ended questions - specify a topic to be explored

When an incident happens, what do you write in the patient's medical record?

Do not mention the incident report in the patient's medical record. Instead I document an objective description of what happened, what I observed, and the follow-up actions taken in the patient's medical record. Evaluate and document the patient's response to the error or incident.

If I question an order must I record it? If so, how?

Do not record "physician made error". Instead chart that "Dr. Smith was called to clarify order for analgesic"

Guidelines for documenting care:

Document accurately, and use nonjudgemental language; konw the requirements of reimbursement; provide details about the client's condition; document immediately; never chart ahead; if you chart a symptom, also chart your interventions; chart chronologically to communicate the changing status of the patient; date and time all your documentation

What should you document?

Document condition of patient, assessments and interventions performed, any abnormalities, the patient response to interventions towards goal.

Block Charting

Document in paragraph form everything that happened for entire shift; Focus on important aspects of care, but can easily omit important information; Inadequate when describing event that require timing (i.e. care of unstable patient)

What is required if a patient is receiving Medicare-reimbursed services?

Documentation is required during each shift and a summary written by nurse is needed weekly.

charting by exception (CBE)

Documentation of abnormal or significant findings - Agencies develop standards of nursing practice - Exceptions to standards described in narrative form on nurses notes *3 Key Elements:* - *Flow sheets* (Ex: graphic record, fluid balance record, daily nursing assessments record, client teaching record, client discharge record, and skin assessment record) - *Standards of nursing care:* Documentation by reference to the agency's printed standards of nursing practice (Ex: The nurse must ensure that the unconscious client has oral care at least q4h) - *Bedside chart forms:* All flow sheets are kept at the client's bedside to allow immediate recording

What is unique about documentation in long-term care?

Documentation requirements for long-term care depend on the level of care the client requires. All facilities must have a comprehensive assessment done on each patient within 14 days of admission (federal law). MDS must be updated every 3 months. Legal requirements mandate that you report changes in a client's condition to primary care provider and the family.

Nontherapeutic Communication - Arguing:

Don't challenge your client's perceptions

Nontherapeutic Communication - Defensive responses:

Don't ignore criticisms; Criticisms can promote discovery

Nontherapeutic Communication - Approval or disapproval:

Don't impose your own attitudes or beliefs

licensed practical nurse (LPN)

Edu. Prep: must meet the state board of nursing's requirements, requires vocational or community college education prior to taking the licensure exam. Roles/Responsibilities: work under the supervision of RN, collaborate within the nursing process, coordinate the plan of care, consult with other team members, and recognize the needs for referrals to assist with actual or potential problems, possess technical knowledge and skills, and participate in delivery of nursing care, using the nursing process as framework.

unlicensed and licensed assistive personnel

Edu. Prep: must meet the state's formal or informal training requirements. requirement by most states for training and examination to attain CNA status. Roles/Responsibilities: work under the direct supervision of an RN or LPN. position description in the employing facility outlines specific tasks. tasks may include feeding, preparing nutritional supplements, lifting, basic care, measuring and recording vitals, and ambulating clients.

What does effective documentation enable use of?

Effective documentation enables use of current and consistent data, problem statements, diagnoses, goals, and strategies to support continuity of care.

EEG

Electroencephalogram

ED/ER

Emergency department, emergency room

Five key characteristics to therapeutic communication:

Empathy - desire to understand and be sensitive to the feelings, beliefs, and situation of another person Respect Genuineness - ability to respond honestly Concreteness - process recording (two people converse while a third records the conversation; used to improve communication skills) Confrontation

Therapeutic Communication - Sharing Hope:

Encouragement and positive feedback

Advantages of Electronic Records System

Enhanced communication and collaboration among healthcare providers Improved access to information: people can access info at same time. Authorized persons can access information remotely, and integrate client information between multiple departments so that one area can immediately see information from another. Time Savings: spend up to 25% less time documenting Improved quality of care: can use protocols to automatically enter orders based on client's conditions. Embedded protocols enhance caregiver knowledge and the ability to follow clinical practice guidelines. Medical errors minimized by alerts. Data can be analyzed when collected, EHRs facilitate evidence-based practice. Information is private and safe: permanently stored, confidentiality is enhanced in several ways: tracking everyone who accesses chart, proper security clearances, unique passwords, restricted access, and using screen protectors.

Advantages to electronic health records:

Enhanced communication and collaboration, improved access to information, time savings, improved quality of care, information is private and safe

Nursing Documentation

Ensures continuity of care Provides legal evidence Records evaluation of patient outcomes

Factors that affect communication

Environment Developmental variations Gender Personal space - intimate distance (within 18 inches); personal distance (18 to 4 feet); social distance (4 to 12 feet); public distance (beyond 12 feet) Territoriality Sociocultural factors Roles and relationships

Charting Difficulties

Error correction: Draw single line through it; Write "mistaken entry"; Initial, date, and time

Why should I correct all errors promptly?

Errors in recording can lead to errors in treatment or may imply an attempt to mislead or hide evidence. I should avoid rushing to complete charting and make sure the information is accurate and complete

dsg or drsg

Dressing

EBL

Estimated blood loss

E in Pace. What should be included?

Evaluation of responses to nursing and medical interventions, progress toward, goals, and effectiveness of the plan

Joint Commission requires clinical record to include:

Evidence of client assessment Nursing diagnosis Nursing interventions Client outcomes Current nursing care plans

Accurate

Exact measurements No unnecessary words Accepted abbreviations only Entries documented correctly

Disadvantages of Electronic Health Records

Expense Downtime: downtime processes must be in place for times when parts of EHR are not available Difficulties associated with change: can be challenging and time consuming. Some healthcare providers see no reason to change and resist changing to EHR. Not always easy to capture narrative nursing content from paper into electronic format. Some EHRs not user friendly. Some systems do not control redundancy Lack of Integration: Most EHRs not integrated across diff. departments. Sometimes a person cannot see part of chart from their location.

Disadvantages to electronic health records:

Expense, downtime, difficulties associated change, lack of integration

Right communication

Explain exactly what the task is; Include specific times and methods for reporting; Explain the purpose or objective of the task; Describe the expected results or potential complications to expect; Be specific in your instructions

Interpersonal Variables:

Factors that influence communication; Perception, values and beliefs

Guidlines for quality documentation

Factural Accurate Complete Concise Current Organized

Advantages to paper health records:

Familiar, no downtime for system changes or weather, inexpensive

FBS

Fasting blood sugar

Consider the person's perspective on environmental control

Find out what the client's health traditions and practices are Know whether the person believes she has any ability to "change things" Know the general influence of the culture on perception and tolerance of pain Know what foods are forbidden, what foods may or may not be eaten together, and what and how utensils are used

What does Focus Charting consist of and look like?

First column is time and date. Second column identifies the focus or problem addressed in the note. Third column contains charting in a DAR format.

Parts of focus charting:

First column: time and date; second column: identifies the focus or problem addressed in the note; third column: charting in DAR (data, action, response) format

When documenting a significant change that appears on a flow sheet, what must I do?

First complete a focus assessment. Record the assessment and the action taken in the progress notes.

What should be done when writing a telephone or verbal order onto a paper order?

First document the date and time, Next write the text of the order. Following the text of the order, depending on how you received the order write "TO" (telephone order) or "VO" (verbal order), followed by the ordering provider's name and then your name.

When does Focus Charting work well?

Focus charting works well in acute care setting s and in areas in which the same care and procedures are repeated frequently.

Focus Charting

Focus on client concerns and strengths; progress notes organized into DAR format (data, action, response); holistic perspective of client needs; nursing process framework for progress notes

Benefits include

Higher-quality documentation Etiology-specific interventions Nursing-specific patient outcomes

H&P

History and physical

Channels:

How the message is communicated; Different techniques; The more channels the better

Charting Principles

How to chart; What to chart; What not to chart; When to chart; Who should chart

HTN

Hypertension

I have made a mistake on a patient record. What do I do and why?

I do not erase, apply correction fluid, or scratch out errors made while recording because the charting becomes illegible. It may also appear as if I was trying to hide information or deface record. I must draw a single line through the error, write the work "error" above it, and sign my name or initials. Then record note correctly

Client records: health care analysis

Identify agency needs such as overutilized and underutilized hospital services

Conflict

Identify the problem or issue; Generate possible solutions; Evaluate suggested solutions; Choose the best solution; Implement the solution chosen; Evaluate - Is the problem resolved?

How should you start each part of SBAR?

Identify yourself, the patient, and the agency. Situation-"Here's the situation.." Background- "The support background information is..." Assessment-"My assessment of the situation is that..." Recommendation- "I recommend that you..."

I should never chart for someone else except...

If the caregiver has left the unit for the day and calls with information that needs to be documented. I must include the name of the source of the information in the entry and that the information was provided via telephone.

Why must I use black ink and write legibly?

Illegible entries can be misinterpreted causing errors and lawsuits; black ink is more legible when photocopied or scanned

When recording a medication administration in a report, what criteria do I record?

Immediately document after administration: time medication given, dose, route, any preliminary assessment (e.g. pain level, vital signs), patient response or effect of medication.

Therapeutic Communication - Confronting:

Improves client self-awareness

Electronic Health Records (EHR)

Improves patient care Patient centered Timely Provides continuity of care over multiple visits

Therapeutic Communication - Sharing Humor:

Improves patient outcomes; Helps nurses with stress

Source Record

In a source record the patient's chart is organized so that each discipline has a separate section in which to record data

Verbal Orders

In person: Doctor should write order on chart, Repeat order back to doctor, Ask for any clarification immediately Over the telephone: Repeat order back to doctor, Doctor should sign-off on order when on unit

Nurses record discussions, consultations, and referrals where?

In the patient's permanent record

CBE Disadvantages

Inadvertent omissions are the main problem. Critics say CBE requires nurses to be overly familiar with the organizations documentation standards and policies Makes it difficult to capture the skilled judgement of nurses Reduces care to such rote repetitions that you may forget to chart an exception to the established standards. Documentation can be time-sensitive and under CBE false documentation can be created by assuming that care has been done when it has not.

P in Pace. What should be included?

Include patient's name, room number, diagnosis, reason for admission, and recent procedures. State the present problem. Briefly summarize medical history relevant to current problem.

FACT System

Incorporates many CBE principles and includes four key elements: Flow sheets individualized to specific services Assessment features standardized to baseline parameters Concise, integrated progress notes and flow sheets documenting client's condition and responses Timely entries documented when care is given. Includes only exceptions to the norm or significant information about the patient.

I PASS the BATON (handoff communication tool)

Introduction Patient Assessment Situation Safety Concerns Background Actions Timing Ownership Next

Right task

Is repetitive, requires little supervision, and is relatively noninvasive for a certain client

Explain the purpose of Documentation.

It is an act of making it a written record. Records patient status and care.

When is intermediate-care services provided in a long-term care facility and what will be needed for these clients?

It is provided when a client needs assistance with medications, nutrition, and ADLs. These clients require a nursing care summary every 2 weeks.

Physical Therapist

Job: assess and plan for client to increase musculoskeletal functions, esp of lower extremities, to maintain mobility; direct care of physical therapy assistants Refer to when: ex- following a hip replacement, a client requires assistance learning to ambulate and regain strength

Occupational therapist

Job: assess and plan for the client to regain ADLs, esp motor skills of the upper extremities; direct care of occupational therapy assistants Refer to when: ex- client has difficulties using an eating utensil with dominate hand following a stroke

Provider

Job: assess, diagnose, and treat cllient for disease and/or injury; includes MDs, DOs, APNs, and PAs Refer to when: ex- client experiences change in vital signs

Registered dietitian

Job: assess, plan for, and educate the client reg. nutritional needs; direct care of nutritional aids Refer to when: ex- the client has low nutrient levels and/or experienced a recent unexplained weight loss

Speech therapist

Job: evaluate and make recommendations regarding the functions of speech, language, and swallowing impacted by various client disorders or injuries; teach client techniques and exercises to improve function when possible Refer to when: ex- a client is having difficulty swallowing a regular diet after trauma to the head and neck

Respiratory therapist

Job: evaluate resp status and provide prescribed resp treatments including O2 therapy, chest physiotherapy, inhalation therapy, and artificial mechanical ventilation Refer to when: ex- client with resp disease experiences SOB and requests nebulizer treatment that is ordered PRN

Lab tech

Job: obtain specimens of the client's body fluids and perform the necessary diagnostic tests Refer to when: ex- the provider orders a CBC to be performed immediately

Rad Tech

Job: position client and perform x-rays and other imaging procedures for providers to review for diagnosis of disorders of various body parts Refer to when: ex- provider orders x-ray of client's hip after a fall

Pharmacist

Job: provide & monitor meds for the client as prescribed by the provider; supervises pharm techs in states in which the practice is allowed Refer to when: client concerns over meds; dosage concerns; etc

Clergy

Job: provide spiritual care to client (pastors, rabbis, priests) Refer to when: the client requests communication or the family asks for prayer prior to client undergoing a procedure

Social Worker

Job: work with client and client's family by coordinating inpatient and community resources to meet psychosocial and environmental needs that are necessary for recovery and/or discharge Refer to when: ex- client dying of cancer wishes to go home but is unable to perform ADLs; the spouse needs med equipment in the home to care for client

What does the Joint Commission recommend with handoff report method?

Joint Commission recommends using a method that allows for questioning between the giver and receiver of the information.

Non-Therapeutic Communication - JAWS

Judgment; Argumentative; Why?; Sympathy

Kardex or Patient Care Summary

Kardex is a special paper form or folding card that briefly summarizes a patient's status and plan of care. Paper Kardex and electronic patient care summaries typically pull patient data from multiple areas of the health record. Paper Kardex are usually kept together in a portable file in a central location in the nurses station to allow all team members access to patients' summary information.

Consider the person's need for personal space

Know the person's cultural and religious customs regarding touching and contact Know the usual comfortable distance for conversing in the client's culture

Legal Issues

Know what order to question: Any order patient questions, Any order if the patient's condition has changed, Standing orders if inexperienced & have questions, Ambiguous order, You can clarify/discuss an order with your supervisor, Gut feelings

Consider social organization

Know which person in the family is the leader or decision maker Know what dates are important and whether gifts are expected or not Know how special events, such as births and funerals, are celebrated, whether certain colors have meaning, and what the expected rituals are

Consider verbal and nonverbal communication

Know, or find out, whether touch (e.g., a handshake) is expected or prohibited. Know, or find out, whether eye contact is expected or avoided. Avoiding eye contact, for some, is a sign or respect. Ask the client how he wishes to be addressed. Know, or find out, the ways people welcome each other.

Assessing a client's ability to receive, process, or transmit information:

Language barrier, cognitive skills, sensory perceptual alterations, physiological barriers

Organized

Logical order

Therapeutic Communication - Active Listening:

Maintain eye contact; Use a relaxed posture; Lean forward; Nods in acknowledgment

Do's of charting:

Make sure patient's correct name and current date on chart; Write legibly: Black ink, Spell correctly, Use proper terms and grammar; If you finish entry and line is only partially full, draw horizontal line through it and sign at end; Use hospital approved abbreviations; Documenting potentially serious situations: Record facts & specific times, Include objective observations, Report to physician and supervisor, Document all actions taken, Add quotes or paraphrase specific communications

Source-Oriented system Disadvantages

May be fragmented and scattered throughout clients record. Difficult to find treatment and outcomes associated with particular problem. Need to look in multiple sections.

Nontherapeutic Communication - False Reassurance:

May have good intentions; Can block further communication/trust

When recording discharge planning in a report, what criteria do I record?

Measurable patient goals or expected outcomes, progress toward goals, need for referrals

MD

Medical doctor

Source Oriented Record

Members of each discipline and/or the interdisciplinary team record their findings

os

Mouth, opening

Client records: planning client care

Nurses use baseline and ongoing data to evaluate effectiveness of the care plan.

NIC

Nursing Interventions Classifications

NOC

Nursing Outcomes Classifications

Forms nurses use to document nursing care:

Nursing admission data forma, discharge summary, flowsheets and graphic records (checklists and intake and output records), medication administration records (MARs), Kardex (special paper form or folding card that briefly summarized a patient's status and plan of care) or patient care summary, integrated plan of care (IPOCs) (combined charting and care plan form), occurence reports or incident report

A in Pace. What should be included?

Nursing assessments and interventions directed to the problem, including teaching done and status of discharge planning.

Factual

Objective Subjective

OB

Obstetrics

Some Communication Principles

One cannot not communicate; Communication functions to meet basic interpersonal needs; As anxiety increases, effective communication decreases; Communication occurs on different levels; The Message sent is not always the message received; "Actions speak louder than words"

Disadvantages of Paper Health Record

Only one care provider can access the record at a time. Retrieving information may be slow: may need to search through multiple pages to find information. Documentation is time consuming: handwriting slower, often redundant and repetitive, paper records require manual audit of many charts to create reports and collect client date. High risk for patient care error: writing hard to read, papers can be lost or damaged. Storage of paper records is expensive. Confidentiality is difficult to protect.

When documenting objective information in a report, what information should be recorded?

Onset, location, description of condition

OR

Operating room

Reports are

Oral Written Audiotaped

Reports

Oral, written, or audiotaped exchanges of information between caregivers

Report

Oral, written, or computer-based communication intended to convey information to others (ex. at end of shifts)

Problem-Oriented Record Systems and its parts

Organized around patient's problems. Consist of four parts: Data, problem list, plan of care, and progress notes.

Problem-Intervention-Evaluation (PIE)

Organizes information according to the patient's problems and requires keeping a daily assessment record and progress notes. This eliminates the need for seperate care plan and provides a nursing-focused rather than medical focused record.

LPNs may delegate to

Other LPNs and AP

RNs may delegate to

Other RNs, LPNs, and AP

OPD

Outpatient department

PIE

P-problem. I-intervention. E-evaluation.

PIE

P-roblem I-ntervention E-valuation

PIE stands for

P: Problem or nursing diagnosis for the patient I: Interventions or actions taken E: Evaluation of the outcomes of nursing interventions

to use a fire extinguisher:

PASS -pull the pin -aim at the base of the fire -squeeze the levers -sweep back and forth over the fire

Problem-Oriented Record Systems Disadvantages

POR system requires a cooperation between health care providers and diligence in maintaining a current database and problem list.

What info is in the patient record?

PPPPMMDDTRAINSC Patient education Patient info & demographic data Progress notes Physical exam notes Medical history Medical diagnosis Discharge planning Diagnostic study results Therapeutic orders Record of nursing care treatment and evaluation Admission nursing history or data Informed consent for treatment and procedures Nursing dx & problems Summary of operative procedures Care Plan

Components of Health Care Systems

Participants, settings, regulatory agencies, and health care financing mechanisms.

Five-P's (handoff communication)

Patient Plan Purpose Problem Precautions Physician (assigned to coordinate)

Charting examples:

Patient has chest pain if she lays on her left side for more than a year.; The patient refused an autopsy.; The patient has no past history of suicides.; Patient has left his white blood cells at another hospital.; I saw your patient today who is still under our car for physical therapy.; The skin was moist and dry.; Healthy appearing decrepit 69-year-old male, mentally alert but forgetful.; She is numb from her toes down

PACE (handoff communication)

Patient/Problem Assessment/Action Continuing(treatment)/Changes Evaluation

Nonverbal Communication

Personal Appearance; Posture and Gait; Facial Expression; Eye Contact; Gestures; Sounds; Territoriality and Personal Space

How do healthcare providers use documentation?

Planning and evaluation of a patient's care. Communication and continuity of care. Legal documentation. Quality improvement. Professional standards of care. Documents: relevant data, diagnoses, expected outcomes, the plan of care, implementation, the coordination of the care, the results of the evaluation, referrals, communicates effectively, creates a documented plan. Reimbursement and utilization review. Education. Research.

Stages of Helping Relationship

Pre orientation Phase: Be prepared, ask questions Orientation Phase: Establish helping relationship; Address who you are; what you will do; when you will leave Working Phase Termination Phase

Helping Relationships

Prerequisites: Open, honest congruent communication; Empathy (vs sympathy); Respect: No judgmentalness, Believe in patient strengths, Actively listen, Be consistent in verbal & non-verbal communication, Pacing, Offer assistance as needed

nursing personnel

RNs, LPNs, Unlicensed assistive personnel (UAP), certified nursing assistants (CNA), certified medical assistants (CMA), and non-nursing personnel such as dialysis techs, monitor techs, and phlebotomists. They work together to advocate for and meet needs of the clients within HC delivery system. RN is the lead member, soliciting input from all nursing team members, setting priorities, sharing info with other disciplines, and coordinating client care.

Home healthcare documenting

Require certification of home-bound status, a plan of care, and ongoing assessment of the need for skilled care Most commonly used form: OASIS - outcome and assessment information set Include: Your assessment highlighting changes in the client's condition; interventions performed (wound care, dressing changes, teaching, and so on); the client's response to interventions; any interaction or teaching that you conducted with caregivers; any interaction with the patient's primary care provider

Therapeutic Communication - Self-Disclosing:

Revealing personal experiences with the intent of helping the client

SBAR tool

S- situation B- background A- assessment R- recommendation

SOAP

S-subjective data. O-objective data. A-assessment. P-plan

SOAPIE

S-ubjective O-bjective A-ssessment (inc nursing diagnosis) P-lan I-ntervention E-valuation

What factors does description of condition include?

S.D.F.-P.A.R.=severity; duration; frequency; precipitating, aggravating, and relieving factors

SBAR stands for

S: Situation B: Background A: Assessment R: Recommendation

SOAP(IE) stands for

S: Subjective Data O: Objective Data A: Assessment/ Analysis (conclusion based on subjective and objective data) P: Plan I: Intervention E: Evaluation

What is the SBAR?

SBAR- Situation-Background-Assessment-Recommendation. An easy to remember, concrete acronym useful for framing conversations, especially interdisciplinary communication. Allows for an easy and focused way to set expectations for what will be communicated and how between members of team.

Reporting to Medical Staff

SBAR: -Communication among HC team. -Provides for patient safety and continuity of care Situation: What is happening at the present time? Background: What are the circumstances that led up to the situation? Assessment: What do I think the problem is? Recommendation: What should we do to correct the problem? -PROVIDES PATIENT SAFETY AND CONTINUITY OF CARE FROM SHIFT TO SHIFT

Problem-oriented Medical Record (POMR)

SOAP or SOAPIE -Data organized based on problems -Documents one problem at a time. Each member of the health team documents on the same problem -The overall picture can be seen easily

MAR orders:

Scheduled medications - given on a regular scheduled basis Unscheduled medications - given on call at the appropriate time Continuous infusions - IV fluids that are running consistently unless stopped for a blood transfusion or to give an IV medication that is not compatible with the IV fluid running PRN - as needed, given only when the patient meets certain conditions set when the prn medication is ordered Stat - given immediately and only once Single-order - given once at a specified time, not necessarily immediately Also on the MAR: Injections, assessment required before administration, drug allergies, patient refusal, omitted medication or delayed administration

Problem List

Section of Problem-Oriented Medical Records that develops after a patient database is analyzed. The list includes all the patients needs. Problems are listed in chronological order to serve as an organizing guide for patient care.

Nursing Care Plan

Section of Problem-Oriented Medical Records where all disciplines involved in a patient's care contribute to the development of a plan of care for a specific problem

Patient Database

Section of Problem-Oriented Medical Records. Contains all available assessment information pertaining to the patient.

Progress Notes

Section of Problem-Oriented Medical Records. Progress notes are used by healthcare team members to monitor and record the progress of a patients problem. Narrative notes, flow sheets, and discharge summaries are formats used to document patient progress.

Kardexes

Series of cards kept in a portable index file or on computer-generated form that makes information quickly accessible

Don't's of charting:

Share your password with anyone; Correct mistaken entry: By erasing, With white-out, Crossing it out (X), Scribbling it out; Use negative language or include inappropriate information in patient record: Use labels to describe patient, be objective, Don't record staffing problems, Don't record staff conflicts, Don't mention incident reports, Don't use words associated with errors, Don't name a second patient, Don't chart casual conversations with co-workers

What does an oral report provide?

The oral report provides an opportunity for professional communication that assists in organizing your work and also for learning, building team relationships, and collaborating to improve patient care.

Health records system

The overall process by which all patient records are created, stored, and retrieved in an organization. Each healthcare agency determines the health record system that is used. Nursing leaders in each organization usually determines the documentation forms that nurses will use within the records system.

Always contact _________ whenever an incident happens

The patients health care provider

Sender:

The person who encodes and sends the message

Receiver:

The person who receives and decodes the message

Reporting

The purpose is to communicate specific info to a person or group of people

What is the purpose of a handoff (also called change-of-shift or handover) report?

The purpose of a hand off report is to alert the next caregiver about the client's status or recent changes in the client's condition and to discuss planned activities, tests, procedures, or concerns that require follow-up.

What is the purpose of giving an oral report?

The purpose of giving an oral report is to maintain continuity of care.

What does the quality of a report influence?

The quality of the report you give or receive influences how you and others plan the day or night's work

What could be in Occurrence report?

Should clearly identify the client, date, time, and location. Briefly describe the incident in objective terms.

Eye Contact

Should you maintain eye contact when communicating with your clients?; How might a client interpret your message if you don't establish eye contact with them?

Therapeutic Communication - SCORE

Silence; Clarify; Open Ended; Reflection; Empathy

SBAR documentation

Situation Background Assessment Recommendation

Pacing

Speak at the right pace; Not to fast or too slow

Communicating with clients who have special needs

Speaking difficulties; Hearing deficits; Cognitive impairment; Unresponsive clients; Non English speaking

Client information is considered confidential unless

Staff members are directly involved in the patient's care and need to know in order to care for the patient

Why are standardized nursing languages important?

Standardized nursing terminology helps measure nursing contribution to care and demonstrate the value of nursing by making nursing care and its effect on patient outcomes more visible in patient records. Allows researchers to retrieve nursing data for aggregation and analysis. With the use of nursing language in nursing documentation, evidence-based nursing care delivery has now been established. Standardized languages are important in EHR systems because computers require standardized information that can be converted into numerical code.

SOAP documentation

Subjective Objective Assessment/Analysis Plan

How and when should I validate data?

Subjective and objective data do not agree, or do not make sense together. The patient's statements differ at different times in the interview. The data fall far outside normal range. Factors are present that interfere with accurate measurement.

Explain what SOAP(IER) stands for?

Subjective data Objective data Assessment- usually patient problem or nursing diagnoses. Plan: Short term and long term goals and strategies that will be used. Interventions Evaluation:effectiveness of interventions Revision: Changes made to original care plan

SOAP ,SOAPIE, SOAPIER

Subjective: What the patient says (i.e. "My pain is 8/10") Objective: Pt is grimacing BP 150/88 Pulse 100 R- 24 Assessment: Pt. is having incisional pain Plan: Relieve patient from 8 to 4/10 Implementation: Reposition, backrub, medicate with Morphine 2 mg IVP Evaluation: Did it work? Pt. stated pain is 4/10 1 hour post pain medication

Assessment

Systematic collection of information

TO

Telephone order

Consider time orientation

Tell clients when you are coming, and be on time Avoid surprise visits Share your own expectations about time Ask clients what they expect regarding time, appointments, and so on Be sure you know the times for and meanings of the client's religious and ethnic holidays

TPR

Temperature, pulse, respirations

What type of terms should I avoid in a report and why?

Terms like appears, seems, or apparently. These terms are often subject to interpretation and suggest that I am stating an opinion.

What is unique about documentation in Home Healthcare?

The Centers for Medicare & Medicaid Services (CMS) guidelines govern home healthcare documentation. Requirements for care are: certification of homebound status a plan of care and ongoing assessment of the need for skilled care.

How do I receive and document verbal and telephone orders?

The Joint Commission says that to best avoid the dangers you should "verify the complete order and test result by having the person receiving the information record and 'read-back' the complete order or test result".

SOAP/SOAPIE/SOAPIER

The SOAP format is often used to write nursing and other progress notes. Can be used in source-oriented, problem-oriented, and electronic health records.

Diagnosis Related Groups (DRGs)

The basis for establishing reimbursement for patient care. A DRG is a classification based on patient's medical diagnoses. Hospitals are reimbursed a predetermined dollar amount by medicare for each DRG.

Therapeutic Communication - Open Ended:

Those which require more thought and more than a simple one-word answer

Can I delegate charting?

Though NAP's can chart ADLs, activity, and I&O on a graphic chart, you are responsible for charting any nursing actions you provide. Never chart the actions of others as though you performed them.

When recording a treatment in a report, what criteria do I record?

Time administered, equiptment used (if appropriate), patient's response (objective and subjective changes) compared to previous treatment,

What is the purpose of the hand-off report?

To permit the new nurse an opportunity to ask questions about the patient.

Intonation

Tone of voice; Can interfere or conflict with content of message; Listen to client's tone

Referent:

What motivates someone to communicate; What might motivate a nurse to communicate with a patient.

Document the following activities or findings at the time of occurrence:

Vital Signs Pain assessment Administration of medications and treatments Preparation for diagnostic tests or surgery, including preoperative checklist Change in patient's status and who was notified Treatment for sudden change in patient's status Patient's response to intervention or treatment Admission, transfer, death, or discharge of a patient

Verbal Communication

Vocabulary; Pacing; Intonation; Clarity and Brevity; Congruent with Non-Verbal

What data should be included in a handoff report?

Will always include: Client progress made during your shift, therapies and treatments administered, teaching done, consultations done or planned with other disciplines, status of identified desired outcomes, any changes in client status, progress made on discharge planning

What is the only subjective data included in a report? What should I add to the subjective data?

Words that the patient actually verbalizes. Make sure I write in quotation marks. Include objective data to support subjective data so my charting is as descriptive as possible.

Traditional care plans vs. Standardized care plans

Written for each client vs. Based on institutions standards of practice

Do clients have the right to review their record?

Yes

How does POR format relate to SOAP format?

You will refer to and use the four parts of POR (database-not for SOAP-, problem list, initial plan, progress notes and discharge summary) when charting in SOAP format.

Medical abbreviations

abbreviations commonly utilized in medical documentation that is standardized and usually identified by each facility as acceptable for use in practice

virulence

ability of a pathogen to invade and injure a host.

Autonomy

ability of client to make personal decisions, even when those decisions may not be in the client's best interest

Accountability

ability to answer for one's own actions

accountability

ability to answer for one's own actions.

tachycardia is

above expected range or faster than 100 bpm

AKA

above knee amputation

supraclavicular nodes located

above the clavicles

antipyretics

acetaminophen and aspirin. used for fever and discomfort as prescribed. considerations: monitor fever to determine effectiveness of medication, graph the pt temp fluctuations on the medical record for trending.

humility

acknowledges weaknesses

Documentation

act of recording patient status and care in written or electronic form, or in a combination of the two forms

Process

act of sending, receiving, interpreting, and reacting to a message

isolation guidelines

actions that include hand hygiene and the use of barrier precautions, which intend to reduce the transmission of infectious organisms. precautions apply to every pt, regardless of diagnosis, and implementation of them must occur whenever there's anticipation of coming into contact with a potentially infectious material. change PPE after contact with each pt, and between procedures with the same pt if in contact with large amounts of blood and body fluids. assist pt and their family to understand the reason for isolation and provide sensory stimulation. standard precautions: tier one, transmission precautions: tier two, droplet precautions, contact precautions.

Working phase

active part of the relationship

Ongoing groups

address issues that are recurrent

Continuing HC

addresses long-term or chronic health care needs. ex. end-of-life care, palliative care, hospice, adult day care, and in-home respite care.

transpersonal communication

addresses spiritual needs and provides interventions to meet those needs

responsibility

adheres to standards of practice

certified registered nurse anesthetist (CRNA)

administers anesthesia and provides care during procedures under the supervision of an anesthesiologist.

expanded nursing roles

advanced practice nurse (APN), clinical nurse specialist (CNS), nurse practitioner (NP), certified registered nurse anesthetist (CRNA), certified nurse-midwife (CNM), nurse educator, nurse administrator, nurse researcher.

electronic health records

advantages include standardization, accuracy, confidentiality, easy access for multiple users, and rapid acquisition and transfer of client's info. challenges include learning the system, knowing how to correct errors, and maintaining security.

basic principles of ethics

advocacy, responsibility, accountability, and confidentiality.

P, p

after

Documentation and the nursing process - Diagnosis/Analysis:

after analyzing assessment data, document your clinical nursing judgement about the client's response to actual or potential health conditions or needs

capillary refill

after blanching nail bed, color should return to normal withing <3 secs

pc

after meals

Documentation and the nursing process - Implementation:

after putting the plan of care into effect, document the specific interventions that were used

Beneficence

agreement that the care given is in the best interest of the client; taking positive actions to help others

Fidelity

agreement to keep one's promise to the client about care that was offered

fidelity

agreement to keep promises

expected findings for the Rinne test

air conduction (AC) greater than bone conduction (BC); 2:1 ration

Problem-oriented record (POR)

aka Problem-oriented medical record

report and document ___ incidents per facility policy

all

Nurse licensure compact

allows licensed nurses who reside in a compact state to practice in other compact states under a multi-state license; must provide care in accordance to statutes and rules in state care is being provided

specific adaptive immunity

allows the body to make antibodies in response to a foreign organisms. this reaction directs against an identifiable microorganism. requires time to react to antigen, provides permanent immunity, involves B and T lymphocytes, produces specific antibodies against specific antigens; called immunoglobulins, IgA, IgD, IgE, IgG, IgM.

submandibular lymph node located

along base of mandible

anterior cervical lymph node located

along the sternocleidomastoid muscle

Flow sheet

also called abbreviated progress notes; have vertical or horizontal columns for recording dates, times and nursing interventions

Occurrence Reports

also called incident report, is a format record of an unusual occurrence or accident. Not part of the clients health record. Both used to track problems and identify areas for quality improvement and to create safe processes and procedures for clients and staff. You should report all errors, even if there was no adverse impact on the client.

guidelines for cleaning contaminated equipment

always wear gloves and protective eyewear. rinse first with cold water, wash the article with warm water with soap. use a brush or abrasive to clean corners or hard-to-reach areas, rinse well in warm water, dry the article. clean the equipment used in cleaning and the sink. remove gloves and perform hand hygiene.

percussion of the thorax resulting in dullness is

an abnormal finding and caused by fluid or solid tissue; can indicate pneumonia or a tumor

percussion of the thorax resulting in hyperresonance is

an abnormal finding and caused by the presence of air; can indicate pneumothorax or emphysema

hyperthermia is

an abnormally elevated body temp

hypothermia is

an abnormally low body temp; a body temp below 35* C (below 95* F)

pulse deficit is

an apical rate faster than the radial rate; with dysrhythmias, the heart may contract ineffectively, resulting in a beat heard at the apical site with no pulsation felt at the radial pulse point

Referrals

an arrangement for services by another care provider

Nursing Minimum Data Set (NMDS)

an effort to establish uniform definitions and categories (e.g., nursing diagnoses) for collecting, essential nursing data for inclusion in computer databases

Electronic health record

an electronic record of patient health information generated whenever a patient accesses medical care in any health care delivery setting.

hypertrophy

an enlargement of muscle due to strengthening

What is the PACE format?

an example of a standardized approach. Stands for Patient/Problem, Assessment/Actions, Continuing/Changes. and Evaluation.

The foundation of ethics is based on:

an expected behavior of a certain group in relation to what is considered right and wrong; it is the study of conduct and character

Goal

an expected or desired outcome

extension

an extension of the angle

hyperextension

an extreme extension

discussion

an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem

intuition

an inner sensing that facts dont currently support something. should spark the nurse to search the data to confirm or disprove the feeling.

Intuition

an inner sensing that something is not currently supported with fact. Intuition should spark the nurse to search the data to confirm or disprove the "feeling." The nurse should ponder the following: -"Did the vital signs reflect any changes that would account for the client's present status?" -"When the client's status changed in this way last month, there was a specific reason for it. Is that what is happening here?"

discharge planning

an interprofessional process that starts at admission

dysrhythmia is

an irregular heart rhythm often noted as an irregular radial pulse

Liability

an obligation that legally binds an individual or company to settle a debt

Quality assurance (QA)

an ongoing systematic process designed to evaluate and promote excellence in the health care provided to pt's

during palpation, the fingers and thumb are used to grab:

an organ or mass

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

an organization that accredits acute care health facilities

independence

analyzes ideas for logical reasoning

tonsillar lymph node located

angle of mandible

vector borne

animals or insects as intermediaries.

Symptoms

any phenomenon or circumstance accompanying something and serving as evidence of it

competence

cognitive processes a nurse uses to make a nursing judgement. general critical thinking including scientific method, problem solving, decision making, diagnostic reasoning and inference, and clinical decision making-collaboration. specific critical thinking in nursing includes the nursing process.

Competence

cognitive processes a nurse uses to make nursing judgments, such as: -general critical thinking: scientific method; problem-solving; decision-making; diagnostic reasoning and inference; clinical decision-making - collaboration -specific critical thinking in nursing: the nursing process

the 3 domains of learning are:

cognitive, affective, and psychomotor

certified nurse-midwife (CNM)

collaborates with one or more providers to deliver care to maternal-newborn clients and their families.

nurse practitioner (NP)

collaborates with one or more providers to deliver nonemergency primary health care in a variety of settings.

subjective data

collected during a nursing hx. include client's feelings, perceptions, and description of health status. client's are the only ones who can describe and verify their own symptoms.

Data

collected during the assessment phase; observations and data from flow sheet

Medical record or chart

collection of documentation, orders, and other care information for a patient Present emphasis on health, now commonly referred to as Health record

right direction/communication

communicate in writing, orally, or both. data to collect, method and timeline for reporting, including when to report concerns and assessments findings, specific task(s) to perform; client--specific instructions, expected results, timelines, and expectations for follow-up communication.

right direction/communication

communicate verbally or in writing: -data to collect -method and timeline for reporting -specific tasks to be completed; client specific instructions -expected results, timelines, and expectations for follow-up communication

interpersonal communication

communication between two people

public communication

communication that occurs within large groups of people; community settings

small group communication

communication w/in a group of people

Correct spelling increases accuracy as well as gives the reader an idea regarding

competency of the nurse and attention to detail

c/o

complaint of

Managed Care Organizations (MCOs)

comprehensive care is overseen by a primary care provider & focuses on prevention and health promotion

Medication Administration Records (MAR)

comprehensive list of all ordered meds, info on allergies, document scheduled/routine, PRN, STAT, or omitted doses on patients

Clinical decision support systems

computerized programs used within the health care setting to support decision making.

Problem List

concise listing of problems that have been identified from the database

Termination phase

conclusion of the relationship

nurse researcher

conducts research primarily to improve the quality of client care.

Intrapersonal communication

conscious internal dialogue, sometimes known as self-talk

delegatee factors

consider education, training, experience, knowledge, skill to perform the task, level of critical thinking required to complete the task, ability to communicate with others as it pertains to the task, demonstrated competence, facility policies and procedures, licensing legislation.

task factors

consider the predictability of outcome, potential for harm, complexity of care, need for problem solving and innovation, level of interaction with the client.

problem-oriented medical records

consist of a database, problem list, care plan, and progress notes.

Electronic health record systems (EHR)

consists of record that are entered via computer

Electronic Health Record (EHR) Systems

consists of records that are entered via computer. Typically combine source-oriented and problem-oriented record styles, although Source-oriented is most common.

Participants

consumers (patients), providers (licensed providers such as RN, LPN, advanced practice nurses, medical doctors, pharmacists, dentists, dietitians, PT, resp., and occupational therapists. also unlicensed providers such as assistive personnel).

mode of transmission

contact, droplet, airborne, vector borne.

purulent

contains leukocytes and bacteria

sanguineous

contains red blood cells

perseverance

continues to work at a problem until theres a resolution

adaptation

coping behavior that describes how an individual handles demands imposed by the environment

Kardex

a "flip-over" file kept at the nurses station that provides information for daily patient care needs. It has an activity and treatment section and a nursing care plan section.

progress note

a chart entry made by all health professionals involved in a client's care; numbered to correspond to the problems on the problem list (SOAPIER)

Charting by Exception

a charting system that involves completing a flow sheet that incorporates standard assessment and intervention criteria by placing a check mark in the appropriate standard box on the flow sheet to indicate normal finding and routine interventions. You write a narrative nurse's note only when there is an exception to the established standard or abnormal data are present.

Medical Records

a chronological written account of a patients examination and treatment that includes the patients medical history and complaints, the physicians physical findings, the results of diagnostic test and procedures, and medications

postural (orthostatic) hypotension is a BP that falls when

a client changes position from lying to sitting or standing; may be caused by peripheral vasodilation, medication side effects, fluid depletion, anemia, prolonged bedrest

libel

a damaging statement that has be written and read by others

Problem-orientated medical records consist of:

a database, problem list, care plan, and progress notes; examples include SOAPIE, PIE, and DAR

atrophy

a decrease in muscle size due to disuse

flexion

a decrease of the angle

durable power of attorney

a document in which client's designate a health care proxy to make health care decisions for them if they are unable to do so. they proxy may be any competent adult they chose.

Medication Administration Record (MAR)

a form that health care facilities utilize to document the administration of medications

chart

a formal, legal document that provides evidence of a client's care

NANDA (North American Nursing Associations)

a group of professional nurses that develop the widely accepted taxonomy

Nursing Diagnosis

a health problem that can be prevented, reduced, or resolved through independent nursing measures

Case managament

a method of delivering health care that controls cost while still ensuring quality care

pulse oximetry is

a noninvasive, indirect measurement of oxygen saturation of the blood (SaO2)

malpractice

a nurse administers a large dose of meds due to a calculation error. the client has cardiac arrest and dies.

negligence

a nurse fails to implement safety measures for a client at risk of falls.

breach of confidentiality

a nurse releases a client's medical diagnosis to a member of the press.

defamation of character

a nurse tells a coworker that she believes the client has been unfaithful to her spouse.

impaired coworkers

a nurse who suspects a coworker of any behavior that jeopardizes client care or could indicate substance use disorder has a duty to report the coworker to the appropriate manger. each state has laws and regulations that govern the disposition of nurses who have substance use disorders. criminal charges could apply.

thrills are:

a palpable vibration that may be present with murmurs or cardiac malformation

Face sheet

a part of the patients chart that contains name, address, insurance and contact information, place of employment

false imprisonment

a person is confined or restrained against his will. ex. a nurse uses restraints on a competent client to prevent his leaving the health care facility.

external emergency readiness includes:

a plan for participation in community-wide emergencies and disasters

ethical decision making

a process that requires striking a balance between science and morality. steps: 1. identify whether the issue is indeed an ethical dilemma. 2. state the ethical dilemma, including all surrounding issues and individuals involved. 3. list and analyze all possible options for resolving the dilemma, and review implications of each option. 4. select the option that is in concert with the ethical principle that applies to this situation, the decision maker's values and beliefs, and the profession's values for client care. 5. apply this decision to the dilemma, and evaluate the outcomes.

problem as an ethical dilemma

a review of scientific data is not enough to solve it. it involves a conflict between two moral imperatives. the answer will have a profound effect on the situation and the client.

equipment should only be used by the nurse after:

a safety inspection and instruction

Narrative documentation records information as

a sequence of events

Nursing informatics

a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice.

Narrative charting

a style of documentation generally used in source-oriented records

criminal laws

a subsection of public law and relates to the relationship of an individual with the government. A nurse who falsifies a record to cover up a serious mistake may be guilty of breaking a this.

physical assessment

a systematic assessment of the body structures

Incident/Variance report

a written account of an unusual event involving a patient, employee, or visitor that has the potential for being injurious, or litigious

History and Physical

a written synopsis that provides the history of the patient, including their physical assessment, medication, allergies, and combined diagnoses

respiratory hygiene and cough etiquette

covering mouth and nose when coughing and sneezing, using facial tissues to contain respiratory secretions, and disposing of them promptly into a hands-free receptacle. wearing a surgical mask when coughing to minimize contaminaiton of the surrounding environment. turning the head when coughing and staying a minimum of 3 ft away from others, especially in common waiting areas, performing hand hygiene after contact with respiratory secretions.

ptosis

covering of the pupil by the upper eyelid

CCU

critical care unit or coronary care unit

strabismus

crossed eyes

nursing process

cyclical, critical thinking process that consists of five steps to follow in a purposeful, goal-directed, systematic way to achieve optimal client outcomes. its a variation of scientific reasoning that helps nurses organize nursing care and apply the optimal available evidence to care delivery. its dynamic, continuous, client-centered, problem solving and decision making framework that is foundational for practice. provides a framework throughout which nurses can apply knowledge, experience, judgement, and skills as well as established standards of practice to the formulation of a plan of care. 5 steps that are sequential but overlapping include, assessment/ data collection, analysis/data collection, planning, implementation, and evaluation. each step depends on satisfactory completion of the preceding step(s). use of this results in a comprehensive, individualized, client-centered plan of care that nurses can deliver in a timely and reasonable manner. this helps nurses integrate critical thinking creatively to base nursing judgements on reason. promotes the professionalism of nursing while differentiating the practice of nursing from the practice of medicine and that of other health care professionals.

during the 3rd stage of infection, ___ ___ is replaced by ___ ___.

damaged tissue is replaced by scar tissue

Problem-oriented medical record (POMR)

data are arranged to the problems the client has rather than the source of the information; consists of a database, problem list, plan of care, progress notes (flow sheets and discharge notes are added as needed)

problem-oriented medical record (POMR)

data arranged according to the pt's problems, rather than according to the source of the info. - health team contributes to the problem list, plan of care, and progress notes - Encourages collaboration - Easier to track status of problems - Vigilance required to maintain problem list - Less efficient bc assessments & interventions must be repeated for more than one problem *Four Basic Components* - *Database* (includes assessment, primary care provider's history, social and family data, and the results of the physical exam & baseline diagnostic tests) - *Problem list* (usually kept at the front of the chart and serves as an index to the numbered entries in the progress notes; all caregivers may contribute to the problem list) - *Plan of care* (care plans are generated by the person who lists the problem) - *Progress notes* +Uses SOAP, SOAPIE, SOAPIER documentation

Experience

decision-making ability derived from opportunities to observe, sense, and interact with clients followed by active reflection. The nurse: demonstrates an understanding of clinical situations; recognizes and analyzes cues for relevance; incorporates experience into intuition.

experience

decision-making ability derived from opportunities to observe, sense, and interact with clients followed by active reflection. a nurse demonstrates an understanding of clinical situations, recognizes and analyzes cues for relevance, and incorporates experience into intuition.

good oral hygiene and infection

decreases PRO which attracts organisms in the oral cavity, which thereby decreases the growth of organisms that can migrate through breaks in oral mucosa.

good pulmonary hygiene and infection

decreases the growth of organisms and the development of pneumonia by preventing stasis of pulmonary excretions, stimulating ciliary movements and clearance and expanding lungs. exercises include turning, coughing, deep breathing, incentive spirometry.

Database

demographic data, the history and physical, nursing assessment data, and family and social history; as the patient's condition changes, the database is updated to reflect the patient's current status

Content

describes the actual subject matter, words, gestures, and substance of he message

A factual record contains

descriptive, objective information about what a nurse sees, hears, feels, and smells.

Continuing health care

designed to address long-term or chronic health care needs. examples include hospice, adult day care, and in-home respite care

Evaluation

determining whether expected outcomes were met, measuring effectiveness of nursing care, medical care, and forms of health care by other providers

Task groups

developed to address a task or need; short-term groups - dissolve once the task is completed

Electronic Medical Record

developed to manage volume of info - Use of computers to store the pt's database, new data, create & revise care plans & doc pt's progress - Info easily retrieved - Speech-recognition technology - Possible to transmit info from one care setting to another - aka Electronic Health Records

Computerized Documention (EHRs)

developed to manage volume of information; used to store client's database, input new data, create and revise care plans, and document client's progress

discipline

develops a systematic approach to thinking

DRG

diagnosis-related group

expected psychosocial development (self-concept development): older adult (65+ yrs)

difficulties including: -seeing oneself as an aging person -finding ways to maintain a good quality of life -becoming more dependent on others for ADLs

contact

direct physical contact, indirect contact with an inanimate object, fecal-oral transmission.

Subjective data can be documented as:

direct quote, within quotation marks, or summarized and identified as the client's statement

discharge education

discuss discharge instructions and provide a copy to client, instructions should be clear, concise language that the client will understand.

Change of shift report

discussion between a nurse from the shift that is ending and the personnel coming on duty

alchol-based product hand washing

dispense 3-5mL in palm of hand. rub vigorously, covering all areas of both hands and fingers. continue to rub until completely dry.

heat loss- convection is:

dispersion of heat by air currents (wind blowing across exposed skin)

heat loss- evaporation is:

dispersion of heat through water vapor (sweating and diaphoresis)

Documentation and the nursing process - Outcomes/Planning:

document a measurable and achievable short-term and long-term plan of acre with goals directed at preventing, minimizing, or resolving identified client problems or issues

Documentation and the nursing process - Evaluation:

document client responses to nursing care; document whether the plan of care was effective in preventing, minimizing or resolving the identified problems; and then modify the plan as needed

Documentation and the nursing process - Assessment:

document signs and symptoms that may indicate actual or potential client problems

Durable power of attorney for health care

document that designates a health care proxy, who is authorized make health care decisions for a client who is unable

SOAP documentation

documentation style more likely to be used in a problem-oriented record

incident report

does not go in to chart

gtt(s)

drops

Communication

dynamic , reciprocal process of sending and receiving messages

state laws

each state has enacted statutes that define the parameters of nursing practice and gives the authority to regulate the practice of nursing to its state board of nursing. board of nursing has the authority to adopt rules and regulations that further regulate practice. boards have the authority to issue and revoke a nursing licensure, they also set standards for nursing programs and further delineate the scope of practice for RNs, LPNs, and APN.

ROM head: lateral flexion

ear to shoulder bilaterally

fever is the body's response to infectious and/or inflammatory processes but may be blunted in the ___ population

elderly (geriatric)

Primary health care

emphasizes health promotion, and includes prenatal and well-baby care, nutrition counseling, and disease control. is based on a sustained partnership between client and provider. examples include office or clinic visits and scheduled school/work centered screenings (vision, hearing, obesity)

Primary HC

emphasizes health promotion, and includes prenatal and well-baby care, nutrition counseling, and disease control. this level is sustained partnership between pt and providers. ex. office or clinic visits and scheduled school-or-work-centered screenings.

Case Management Model

emphasizes quality, cost-effective care delivered within an established length of stay; uses multidisciplinary approach to planning and documenting client care, using critical pathways, CBE

prevention education for risk of motor vehicle/injury in adolescents

ensure teen has completed driver's ed -set rules on # of people in car, seat belt use, and to call for ride home if driver is impaired -reinforce teaching on proper use of protective equipment used in sports -be alert to signs of depression -teach about hazards and safety precautions of firearms -teach to check water depth before diving

Effective documentation

ensures continuity of care, maintains standards, and reduces errors

speech-language pathologist

evaluates and makes recommendations regarding the impact of disorders or injuries on speech, language, and swallowing. teaches techniques and exercises to improve function. Ex. of when to refer: a client is having difficulty swallowing a regular diet after trauma to the head and neck.

resp. therapist

evaluates resp. status and provides resp. tx. including oxygen therapy, chest physiotherapy, inhalation therapy, and mechanical ventilation. ex. of when to refer: a pt who has resp. disease is SOB and requests a nebulizer tx.

Response

evaluation phase; client's response to nursing and medical care

q

every

qh

every hour

qam

every morning

scoliosis

exaggerated lateral curvature

ethical theory

examines principles, ideas, systems, and philosophies that affect judgements about what is right and wrong, and good and bad. Two common types are utilitarianism and deontology.

Malpractice (professional negligence)

example: a nurse administers a large dose of medication due to a calculation error; the client has a cardiac arrest and dies

Breach of confidentiality

example: a nurse releases the medical diagnosis of a client to a member of the press

Defamation of character

example: a nurse tells a coworker that she believes the client has been unfaithful to her spouse

Negligence

example: a nurse who fails to implement safety measures for a client who has been identified as at risk for falls

False imprisonment

example: a person is confined or restrained against his will (using restraints on a competent client to prevent his leaving the health care facility)

Battery

example: intentional and wrongful physical contact with a person that involves and injury or offensive contact (restraining a client and administering an injection against her wishes)

Assault

example: the conduct of one person makes another person fearful and apprehensive (threatening to place a nasogastric tube in a client who is refusing to eat).

nursing roles with delegating

licensed nurses are responsible for providing clear directions when delegating a task initially and for periodic reassessment and evaluation of the outcome of the task. RNs can delegate to other RNs, LPNs, and AP. They must delegate tasks so that they can complete higher-level tasks that only RNs can perform. LPNs can delegate to other LPNs and APs.

information security protocols

log off computer before leaving the workstation to ensure that others cant view protected health information on the monitor. never share a user ID or password with anyone. Never leave a medical record or other printed or written PHI where others can access it. shred any printed or written client information for reporting or client care after use.

auscultation of the lungs (expected sound): bronchial

loud, high-pitched, expiration heard longer than inspiration over the trachea

Oral reporting

maintain continuity of care

information security

mandatory adherence with HIPAA helps to ensure the confidentiality of health information. a major component of HIPAA, the privacy rule, promotes the use of standard methods of maintaining the privacy of protected health info. (PHI). among HC agencies. essential for nurses to be aware of client's rights to privacy and confidentiality. Privacy rule requires that nurses protect all written and verbal communication about clients.

expected psychosocial development (self-concept): middle adult (35-65 yrs)

may experience issues related to: -menopause -sexuality -depression -irritability -difficulty with sexual identity -job performance and ability to provide support -marital changes with death of a spouse or divorce

Face-to-face report

may involve outgoing and oncoming nurse or entire oncoming shift. Time efficient and allows interaction among nurses.

Hospital's ethics committee

may meet to discuss/resolve unusual or complex ethical issues; not a legal entity

therapeutic interventions

measures nurses take to minimize risk and to respond to unplanned events, such as an observation of unsafe practice, a change in a status, or the emergency of a life-threatening situation.

transfer documentation

medical diagnosis and care providers, demographic info, overview of health status, plan of care and recent progress, any alterations that may precipitate an immediate concern, notification of any assessment or care essential within the next few hours, most recent vitals and medications including PRN, allergies, diet and activity orders, special equip or adaptive devices, advance directives and emergency code status, family involvement in care and health care proxy, if applicable.

auscultation of the lungs (expected sound): bronchovesicular

medium pitch and intensity, equal inspiration and expiration, and heard over the larger airways

Channel

medium used to send the message

Source-oriented records

members of each discipline record their findings in a separately labeled section of the chart Typical source-oriented record includes: admission data, advance directive, history and physical, physician's orders, progress notes, diagnostic studies, laboratory data, nurses' notes, graphic data, rehabilitation and therapy notes, discharge planning

Source-Oriented system

members of each discipline record their findings in separately labeled section of the chart.

channel

method of transmitting and receiving a message (received via sight, hearing, and/or touch)

pathogens

micro-organisms or microbes that cause infection

submental lymph node located

midline under the chin

MN

midnight

Attitudes

mindsets that affect how a nurse approaches a problem. Attitudes of critical thinkers include: confidence, independence, fairness, responsibility, risk taking, discipline, perseverance, creativity, curiosity, integrity, humility

attitudes

mindsets that affect how a nurse approaches a problem. attitudes of critical thinkers include confidence, independence, fairness, responsibility, risk taking, discipline, perseverance, creativity, curiosity, integrity, humility.

Standards

model to which care is compared to determine acceptability, excellence, and appropriateness -intellectual standards ensure the through application of critical thinking. -professional standards include: nursing judgment based on ethical criteria; evaluation that relies on evidence-based practice; demonstration of professional responsibility

standards

models for comparing care to determine acceptability, excellence, and appropriateness. intellectual standards ensure the thorough application of critical thinking, professional standards include nursing judgement based on ethical criteria, evaluation that relies on evidence-based practice, demonstration of professional responsibility.

fungi

molds and yeasts. candida albicans, aspergillus

commitment

nurse expects to make choices without help from others and fully assumes the responsibility for those choices. results from an expert level of knowledge, experience, developed intuition, and reflective, flexible attitudes. ex. a nurse increases the rate of an IV fluid infusion when the pt blood pressure indicates hypovolemic shock 24 hr after surgery.

Warning by HIPPA about speech-recognition technology:

nurse must be alert and aware of others who might hear the dictation

basic critical thinking

nurse trusts the experts and thinks concretely based on the rules. results from limited nursing knowledge and experience as well as inadequate critical thinking experience. ex. pt reports pain 1 hr after receiving pain med. instead of reassessing pt pain, nurse tells client he must wait 2 more hrs before he can get another dose.

implementation

nurses base care they provide on assessment data, analyses, and the plan of care they developed in the previous steps. must use problem-solving, clinical judgment, and critical thinking to select and implement appropriate therapeutic interventions using nursing knowledge, priorities of care, and planned goals or outcomes to promote, maintain, or restore health. also use interpersonal skills, and technical skills . during this step nurses perform nursing actions, delegate tasks, supervise over health care staff and document the care and client's response.

delegation factors

nurses can delegate only tasks appropriate for the skill and education level of the nurse who is receiving the assignment. RNs cant delegate the nursing process,client education, or tasks that require nursing judgement to LPNs or AP.

information technology

nurses document the care they provided and it should reflect the nursing process. purpose for medical records include communication, legal documentation, financial billing, education, research, and auditing. purpose of reporting is to provide continuity of care among all team members who provide care to the same clients.

evaluation

nurses evaluate client's response to nursing interventions and form a clinical judgement about the extent to which clients have met the goals and outcomes. this determines whether or not to modify the plan of care. client outcomes in specific, measurable terms are easier to evaluate. factors that can lead to lack of goal achievement include an incomplete database, unrealistic client outcomes, nonspecific nursing interventions, and inadequate time for the client to achieve the outcome.

change-of-shift reports

nurses give this report at the conclusion of each shift to the nurse assuming responsibility for the clients. formats include face to face, audiotaping, or presentation during walking rounds in each client's room. report should include significant objective information about client's health problems, proceed in logical sequence, include no grasp or personal opinion, relate recent changes in medications, treatments, procedures, and the discharge plan.

licensure

nurses must a current one of these in every state they practice in. the state have adopted the nurse licensure compact are exceptions, this allows nurses who reside in a compact state to practice in other compact states under a multistate license. within the compact nurses must practice in accordance with the statutes and rules of the state in which they provide care.

objective data

nurses observe and measure these during a physical exam. they feel, see, hear, and smell them through observation or physical exam of a client.

Receiver

observer, listener, and interpreter of the message

laboratory technician

obtains specimen of body fluids, and performs diagnostic tests. ex. of when to refer: a provider needs to see a pts CBC results STAT.

supervision

occurs after delegation, oversees staff's performance of delegated tasks, determine whether completion of tasks is on schedule, performance was at a satisfactory level, delegatee documented and reported unexpected findings, delegatee needed assistance to complete assigned tasks in a timely manner, supervising nurse should reevaluate and possibly change the assignment.

Pre-interaction phase

occurs before you meet the client; involves gathering information about the client

Interpersonal communication

occurs between two or more people; face-to-face conversation between two people is the most frequent form of interpersonal communication

Ambiguous terms

occurs when an abbreviation can stand for more than one term leading to misinterpretation

infection

occurs when the presence of a pathogen leads to a chain of events. all components of the chain must be present and intact for this to occur.

expected psychosocial development (Erikson-integrity vs despair): older adult (65+ yrs)

older adults may need to: -adjust to lifestyle changes related to retirement (decreased income, living situation, loss of work role) -adapt to changes in family structure (may be role reversal in later years) -deal with multiple losses (death of a spouse, friends, siblings) -face death

transferring/discharging a client

on day of transfer confirm that the receiving facility of unit is expecting client, and that the room or bed is available. communicate the time the client will transfer to receiving facility or unit. complete documentation, give verbal transfer report in person or via telephone, confirm the mode of transport the client will use to complete the transfer or discharge, make sure the client is dressed appropriately if going outside the facility, account for all the client's belongings.

ss

one-half

components of the Privacy Rule

only HC team members directly responsible for a client's care may access that client's record. Nurses may not share info with other clients or staff not caring for the client. clients have a right to read and obtain a copy of their medical records. nurses may not photocopy any part of the medical record except for authorized exchange of documents between facilities and providers. staff must keep medical records in a secure area to prevent inappropriate access to the info. they may not use public display boards to list client's names and diagnoses. electronic records are password protected. nurse must not disclose client's info to unauthorized individuals or family members who request it in person or by telephone or email. communication about a client should only take place in a private setting where unauthorized individuals cant overhear it.

Charting by Exception

only abnormal or significant findings or exceptions to norms are recorded; flow sheets, standards of nursing care, bedside access to chart forms (eliminates lengthy, repetitive notes and makes client changes in condition more obvious)

When documenting patient behavior in a report, what information should be recorded?

onset, behaviors exhibited, precipitating factors, patient's verbal behavior

Reporting

oral communication about a patient's status

Reporting

oral communication about the patients status

viruses

organisms that use the host's genetic machinery to reproduce. HIV, hepatitis, herpes zoster, herpes simplex.

Progress Notes

organized according to the problem list, each disciple charts on shared notes, charting is labeled according to problem number

Problem-oriented records (PORs)

organized around the patient's problems; consists of database, problem list, plan of care and progress notes

ortho

orthopedics

OOB

out of bed

tympany from percussion is expected to be found:

over a gastric bubble

flat percussion sounds are expected to be found:

over muscles

dull percussion sounds are expected to be found:

over the liver

resonance from percussion is expected to be found:

over the lungs

postauricular lymph node located

over the mastoid

Health records system

overall process by which all patient records are created, stored, and retrieved in an organization

hemiplegia

paralysis of the left side of the body

people allow to consent for others

parent of a minor, legal guardian, court-specified representative, an individual who has durable power of attorney authority for health care, emancipated minors for themselves.

discharge summaries

part of discharge planning for optimal patient outcomes

Nursing Progress Notes

part of the medical record that nursing staff document patient care, condition, communication information

PCA

patient controlled analgesia

problem-oriented medical records

patient database problem list nursing care plan progress note

indirect percussion involves:

placing a hand flatly on the body, as the striking surface, for sound production

Action

planning and implementing phase; immediate and future nursing actions

Standards of Care

policies that ensure quality of patient care

radiologic technician

positions pt and performs xrays and other imaging procedures for providers to review for diagnosis of disorders of various body parts. ex. of when to refer: a pt reports severe pain in his hip after a fall, and the provider prescribes an xray of the pt hip.

beneficence

positive actions to help others.

posterior cervical lymph node located

posterior to the sternocleidomastoid muscle

complications of shingles

postherpetic neuralgia. tricyclic antidepressants sometimes prescribed. common in adults older than 60.

PPBS

postprandial blood sugar

integrity

practices truthfully and ethically

Language

precise, clear language demonstrating focused thinking and communicating unambiguous messages and expectations to both the client and other health care team members. The nurse should consider the following: -"Did I use language appropriate for the client?" -"Did I communicate the message clearly to the provider?"

language

precise, clear language demonstrating focused thinking and communicating unambiguous messages and expectations to clients and other health care team members.

Discharge Plans

predetermining a patients post-discharge needs and coordinating the use of appropriate community resources to provide a continuum of care

Objective Language

presented w/facts and does not have a judgment about the facts

maxillary sinuses are palpated by

pressing upward at the skin crevices that run from the sides of the nose to the corner of the mouth

frontal sinuses are palpated by

pressing upward with the thumbs from just below the eyebrows on either side of the bridge of the nose

Client records: communication

prevents fragmentation, repetition, and delays in client care

adequate intake of fluids and infection

prevents the stasis of urine by flushing the urinary tract and decreasing growth of organisms, keeps skin from breaking down.

Medical record or chart

previous term for the collection of documentation, orders, and other care information for a patient

Plan of Care

primary care provider's orders and the nursing care plan for addressing the identified problems

admission process

prior to arrival bring necessary equip into the room. procedure: introduce yourself, explain the roles of other care delivery staff, if in a semiprivate room, introduce the client to his roommate, provide hospital attire and assist as necessary, position the client comfortably, apply the ID bracelet and allergy band if necessary, provide facility-specific brochures and informational material, provide info about advance directives, document the clients advance directives status in medical records. place a copy in there if available. assess and collect data.

Ethical dilemmas are:

problems about which more than one choice can be made and the choice made is influenced by the values and beliefs of the decision makers

ethical dilemmas

problems that involve more than one choice and stem from the different values and beliefs of the decision makers.

supervising

process of directing, monitoring, and evaluating the performance of tasks by another member of the health care team. RNs are responsible for the supervision of client care tasks delegated to assistive personnel and licensed practical nurses.

charting

process of making an entry on a client record

documenting

process of making an entry on a client record

recording

process of making an entry on a pt medical record

delegating

process of transferring the authority and responsibility to another member of the health care team to complete a task while retaining the accountability.

heart sounds: S4

produced by a strong atrial contraction -can be normal finding in older and athletic adults and children -best heard with bell of steth

bruits are:

produced by an obstructed peripheral blood flow and are heard as a blowing or swishing sound with the bell of the steth

droplet precautions

protect against droplets larger than 5 mcg and travel 3-6 ft from the pt. (streptococcal pharyngitis or pneumonia, haemophilus influenzae type B, scarlet fever, rubella, pertussis, mumps, mycoplasma pneumonia, meningococcal pneumonia and sepsis, pneumonic plague). precautions require: private room or a room with other clients with the same infectious disease, ensuring each client have their own equipment. masks for providers and visitors.

civil laws

protect individual rights. one example is that it relates to the provision of nursing care is a tort law.

contact precautions

protect visitors and caregivers when they are within 3 ft of the client against direct client and environmental contact infections (respiratory syncytial virus, shigella, enteric diseases caused by organisms, wound infections, herpes simplex, impetigo, scabies, multidrug-resistant organisms. precautions require: private room or a room with other pt with same infection, gloves and gown worn by the caregivers and visitors, disposal of infectious dressing material into a single, nonporous bag without touching the outside of thee bag.

PHI

protected health information

confidentiality

protection of privacy without diminishing access to high-quality care.

Confidentiality

protection of privacy without diminishing access to quality care

prions

protein particles. new variant Creutzfeldt-Jakob disease.

parasites

protozoa. malaria, toxoplasmosis. and helminths. worms, flukes.

admission assessments

provide baseline data to use in the development of the nursing care plan.

nursing roles in advance directives

provide written info about advance directives, document the client's advance directive status, ensure that the advance directive reflect the client's current decision, inform all members of the health care team of the client's advance directives.

it is the ___'s ___ to assess, report, and document client allergies and to provide client care that avoids exposure to allergens

provider's responsibility

pharmacists

provides and monitors meds. supervises pharmacy techs in states that allow practice. ex. of when to refer: a pt is concerned about a new meds interaction with any of his other meds.

Long-Term Care Insurance

provides for long-term care expenses not covered by Medicare

nurse administrator

provides leadership to nursing departments within a health care facility.

spiritual support staff

provides spiritual care, pastors, rabbis, priests, ex. of when to refer: a pt requests communion or the family ask for prayer prior to the pt undergoing a procedure.

Commission requires

pt. record documentation to be timely, complete, accurate, confidential, and specific to the pt.

Health Care Financing mechanisms

public federally funded programs (medicare-care for the old,medicaid-aid the poor). private plans (traditional insurance reimburses for services on a fee-for-service basis, managed care org., preferred provider org., exclusive provider org., long-term care insurance.).

to assess inner ear in children <2 years

pull auricle down and back

to assess the inner ear of adults and children >2 years

pull auricle up and back

during palpation, the fingertips detect:

pulsation, position, texture, size, and consistency

advance directives

purpose is to communicate a client's wishes regarding end-of-life care should the client become unable to do so. PSDA requires asking clients upon admission to facility whether they have these. types of these: living will, durable power of attorney for health care, and provider's orders.

inspection

purposeful observation

reflection

purposefully thinking back or recalling a situation to discover its meaning and gain insight into the event.

Reflection

purposefully thinking back or recalling a situation to discover its meaning and gain insight into the event. -"Why did I say this or do that?" -"Did the original plan of care achieve optimal client outcomes?"

the International Association for Healthcare Security & Safety (IAHSS) provides:

recommendations for the development of security plans

narrative documentation

records information as a sequence of events in a story like manner

Source-oriented Narrative Record

records organized according to the source of information, e.g. a patients chart will be organized into physicians orders, progress notes, laboratory findings, x-rays, respiratory findings, the history and physical, face sheet, ect.

signs and symptoms of local infection

redness from dilation of arterioles bringing blood to area, warmth of the area on palpation, edema, pain or tenderness, loss of use of the affected part.

expected pulse oximetry ranges are

reference range: 95%-100% acceptable for some clients: 91%-100% some illnesses allow for: 85%-89% abnormal: <85%

pulse rhythm can be

regular or irregular; a premature or late heartbeat can result in an irregular interval and can indicate abnormal electrical activity of the heart

Traditional Insurance

reimburses for services on fee-for-service basis.

Decoding

relating the message to your past experiences to determine the sender's meaning; uses visual auditory, and tactile senses to decode the message

reporting communicable diseases

reporting allows officials to: -ensure appropriate medical treatment of diseases (TB) -monitor for common-source outbreaks (foodborne - Hep A) -plan and evaluate control and prevention plans (immunizations for preventable diseases) -identify outbreaks and epidemics -determine public

Minimum Data Set (MDS)

required for reimbursement from Medicare and Medicaid

curiosity

requires more information about clients and problems

Omnibus Budget Reconciliation Act (OBRA)

requires that (a) a comprehensive assessment [MDS] be performed within 4 days of admission to long-term care, (b) plan of care created within 7 days, (c) assessment and care screening process reviewed every 3 months

normal percussion of the thorax should result in

resonance

portal of exits

respiratory tract (droplet, airborne)-mycobacterium tuberculosis and streptococcus pneumoniae. gastrointestinal tract-shigella, salmonella enteritidis, salmonella typhi, hepatitis A. genitourinary tract-escherichia coli, hepatitis A, herpes simplex virus (type 1), HIV. skin, mucous membranes-herpes simplex virus and varicella. blood/body fluids-HIV and hepatitis B and C.

procedure

responsibilities of the nurse, transfer documentation, discharge documentation, discharge instructions.

5 Rights of Medication Administration

right patient, the right drug, the right dose, the right route, and the right time

Confidentiality

safe-guarding a patients health information from public disclosure

atypical symptoms of infection

seen in some older adults; agitation, confusion, incontinence.

nursing interventions for asepsis

select clean area above waist level in the client's environment to set up. check that all sterile packages are dry and have a future expiration date. any chemical tape must show the appropriate color. make sure an appropriate waste receptacle is near by. wash hands, open covering of package per directions, slipping package onto the center of workspace with top flap opening away from the body. grasp tip of top flap, and with arm positioned away from sterile field unfold flap from body. open side flaps using the right hand for right flap and etc. grasp left flap and turn it down toward body. additional sterile packages open next to sterile field by holding the bottom edge with one hand and pulling back on sterile field and open these first. add them directly to field, lift package from dry surface, holding at 6 in above the field, pulling the two surfaces apart, dropping it onto field. pour sterile solutions by removing bottle cap, placing cap face up on clean nonsterile surface, holding bottle with label in palm so solution doesn't run down the label, first pour a small amount of solution in an available receptacle. pouring solution onto the dressing or site without touching the bottle to the site. once sterile field is set up don sterile gloves.

SCD

sequential compression device

exudate types

serous, sanguineous, purulent

do not ___ linens because do can spread micro-organisms in the air

shake

SOB

short of breath

Telephone orders (TO) or verbal orders (VO)

should be avoided but may be necessary during emergencies and at unusual times

discharge planning

should begin at admission unless at long term care. assess whether or not the pt will be able to return to his previous residence, determine whether or not the pt will need adaptions or specific equip. make a referral to the social worker to arrange for community services, communicate health status and needs to community service providers. provider documents that the client may be discharged. nurse has pt sign the proper papers and provides discharge teaching.

transfer reports

should include demographic information, medical diagnosis, providers, an overview of health status (physical, psychosocial), plan of care, recent progress, any alterations that might become an urgent or emergent situation, directives for any assessments or client care essential within the next few hrs, most recent vital signs, medications and last doses, allergies, diet, activity, special equipment or adaptive devices, advance directives and resuscitation status, and family involvement in care and health care proxy.

flow charts

show trends in vitals, blood glucose levels, pain level, and other frequent assessments.

risk taking

takes calculated chances in finding better solutions to problems

five rights of delegation

task to delegate (right task), under what circumstance (right circumstance), to whom (right person), what info to communicate (right direction/communication), how to supervise/evaluate (right supervision/evaluation)

care after discharge

teach the client about any infection control measures at home, self-administration of medication therapy. complications that need to be needs to immediately.

nurse educator

teaches in schools of nursing, staff development departments in health care facilities, or client education departments.

___ is an interactive process driven by specific client goals

teaching

during palpation, the dorsal surface of the hand detects:

temperature

Ishihara test

tests for color vision

for Documenting Times

the 24-hr Cycle Military Clock

indication for transfer and discharge

the level of care has changed. another setting is required to provide necessary care, the facility doesn't offer the type of care a client now requires, the client no longer need inpt care and is ready to return home.

provider's orders

unless provider writes a DNR or "allow natural death" (AND) prescription in the client's medical record, the nurse initiates CPR when the client has no pulse or respiration.

complete a fall-risk assessment ___ ___ & at ___ ___ to limit risk of falls

upon admission & at regular intervals

Assertive communication

expression of a wide range of positive and negative thoughts and feelings in a style that is direct, open, honest, spontaneous, responsible, and nonjudgmental; recognizes your rights while still respecting the rights of others How to: Question care decisions openly and honestly. Use "I" statements. Focus on the issue, not the participants. Use effective nonverbal language. Don't invite negative responses. Use "fogging" to help you accept criticism without becoming anxious and defensive. Use negative inquiry. Strive for a workable compromise.

EENT

eyes, ears, nose, throat

How can hand-off reports be given?

face to face, in writing, or verbally such as over the telephone or via audiorecording

Parts of verbal communication:

facial expression, posture and gait, personal appearance, gestures, touch

health promotion (nutrition): older adult (65+ yrs)

factors that influence nutrition include: -GI alterations -difficulty getting to and from supermarket to shop for food -low income -impaired mobility -depression or dementia -social isolation (preparing meals for 1 and eating alone) -meds that alter taste or appetite -prescribed diets that are unappealing -incontinence that may cause a person to limit fluid intake -constipation -metabolic rates decline so caloric intake should decline and be pf good nutritional value -nutritional recommendations include: increasing intake of vit D, B6 and calcium; increasing fluid intake to minimize dehydration and prevent constipation; take low-dose multivitamin along with mineral supplementation; follow provider;s recommendation for sodium intake

documentation

factual-subjective and objective data. subjective data should be reported as direct quotes within quotation marks, or summarize and identify the information as the client's statement. objective data should be descriptive and should include what the nurse sees, hears, feels, and smells. document without derogatory words, judgements, or opinions. document client's behavior accurately. ex. "client is agitated." NO write this! "client paced back and forth in room, yelling loudly." accurate and concise. complete and current-never prechart an assessment, intervention or evaluation. organized.

negligence issues that cause malpractice

failure to follow professional and facility-established standards of care, use of equipment in a responsible and knowledge manner, communicate effectively and thoroughly with clients, and document care the nurse provided.

Justice

fair treatment in matters related to physical and psychosocial care and use of resources

justice

fairness in care delivery and use of resources.

sources of laws

federal regulations such as Health Insurance Portability and Accountability Act (HIPAA), Americans with Disabilities Act (ADA), Mental Health Party Act (MHPA), Patient Self-Determination Act (PSDA), and criminal and civil laws

confidence

feels sure of abilities

signs and symptoms of infections

fever, chills which happen when temp rises, diaphoresis which happens when temp is decreasing, increased pulse and respirations, malaise, fatigue, anorexia, nausea, and vomiting, abdominal cramping, diarrhea, enlarged lymph nodes.

auscultation of the lungs (abnormal or adventitious sound): crackles or rales

fine to coarse popping heard as air passes through fluid or re-expands collapsed small airways

decorticate rigidity

flexion and internal rotation of upper extremity joints and legs

documentation formats

flow charts, narrative documentation, charting by exception, problem-oriented medical records, SOAP, PIE, DAR.

Focused charting

focus on pt concerns & strengths - 3 columns of recording used: *D*ate and *T*ime, *F*ocus, and *P*rogress notes - Focus: condition, a nursing diagnosis, behavior, S/S, acute change in the pt's condition, or a pt strength - Progress notes organized by D.A.R. - Holistic perspective of client and client's needs

Preventive health care

focuses on educating and equipping clients to reduce and control risk factors of disease. Examples include immunizations, stress management programs, and seat belt use

Preventive HC

focuses on educating and equipping pt to reduce and control risk factors for disease. Ex. immunization, stress management, seat belt use.

Therapeutic relationship

focuses on improving the health of the client, whether an individual or community; client gains information and knowledge and works through issues, concerns, and problems related to health status, treatments, and nursing care

avoiding liability for negligence

follow standards of care, give competent care, communicating with other health team members, developing a caring rapport with client, fully documenting assessments, interventions, and evaluations.

Medicare

for clients over age 65 and/or with permanent disabilities. premiums applied as insurance program reimburses providers based on DRGs. Premiums applied as Managed Care Organizations (MCOs) provide enrolled clients with comprehensive care overseen by a primary care provider. Is federally funded.

Medicaid

for clients with low income. is federally funded and individual states determine eligibility requirements.

fist percussion is used to assess:

for tenderness over the kidneys, liver, and gallbladder

record

formal, legal document that provides evidence of a client's care and can be written or computer bases - aka chart or client record

SOAP Documentation

format of structured notes to document patient progress

expected psychosocial development (self-concept development): young adult (20-35 yrs)

formation of healthy self-concept influenced by: -avoidance of substance abuse -late formation of a family -frequent interactions with family and friends -choosing to behave in an ethical manner

Therapy groups

formed to help individual members cope with issues, improve relationships, or address stress

qid

four times a day

Fx

fracture

nursing interventions for infection

frequently wash hands before and after care, educate pt about required and recommended immunizations and where to obtain them. target group: kids, elderly, those w/ chronic disease, those immunosuppresed and their families and kids. educate the pt and ask for a return demo of good oral hygiene. encourage the client to consume an adequate amount fluids. for immobile pt ensure that pulmonnary hygiene is done q2h or as prescribed. use of aseptic techniques and PPE in the provision of care to all pt prevent unnecessary exposure, teach and use respiratory hygiene/coughing etiquette

exogenous source

from outside the client

Resident rights

further protection of rights for residents in nursing facilities that participate in Medicare programs; govern the operation of such facilities

diagnostic procedures to identify infections

gallium scan, radioactive gallium citrate, xrays, ct scan, magnetic resonance imaging (MRI), biopsies to determine the presence of infection, abscesses, and lesions.

ethics committees

generally address unusual or complex ethical issues.

Change-of-shift reports

given to all nurses on the next shift; utilizes "handoff" communication in which information is communicated in a consistent manner including an opportunity to ask and respond to questions

Transfer report

given when a patient is transferred form unit to unit or from facility to facility

kardex

gives a quick overview of basic patient care information

Security Rule of HIPAA

governs the security of electronic PHI; ensures the privacy and confidentiality of client information stored in computers

Graphic sheet

graphic forms usually have a column of data printed on the left margin of the page, times and dates printed across the top and open block within the rest of the table to plot various changes

auscultation of the lungs (abnormal or adventitious sound): pleural friction rub

grating sound produced as the inflamed visceral and parietal pleura rub against each other during inspiration or expiration

PIE documentation model

groups information into three categories: problems, interventions, and evaluation of nursing care (ongoing client assessment flow sheet and progress notes)

Hand-off reports

happen any time one health care provider transfers care of a patient to another health care provider.

receiving a transferred client

have any specialized equip ready, if appropriate inform the client's roommate of the impending admission or transfer. inform other health care team members of the clients arrival and needs, meet with the client and family on arrival to complete the admission process and orient the client and family to the new facility or unit. assess how the client tolerates the transfer, review transfer documentation, implement appropriate nursing interventions in a timely manner.

hob or HOB

head of bed

mandatory reporting

health care providers have a legal obligation to report findings in accordance with state law in the following situations; abuse-report of any suspicion of abuse following facility policy. communicable diseases-nurse must report communicable disease diagnoses to the local or state health dept. reporting allows officials to ensure appropriate tx. monitor for common-source outbreaks, plan and evaluate control and prevention plans, identify outbreaks and epidemics, and determine public health priorities based on trends.

HMO

health maintenance organization

Work-related social support groups

help members of a profession cope with the stress associated with their work

How do home care and long-term care documentation differ from hospital-based documentation?

here are the following differences from hospital-based documentation: Home care documentation must include (a) certification of homebound status, (b) ongoing assessment of the need for skilled care, (c) use of the OASIS data set, and (d) a monthly summary describing the patient's status and ongoing needs. The patient's physician signs this form, and this is submitted for reimbursement. Long-term care documentation must include (a) a comprehensive assessment using the Minimum Data Set for Resident Assessment and Care Screening (MDS) within 4 days of admission and updates every 3 months with any significant change in client condition, (b) a report of any changes in a client's condition to the primary care provider and the client's family, and (c) a summary by an LVN/LPN or RN either weekly for clients receiving skilled services or every 2 weeks for clients receiving intermediate care services.

auscultation of the lungs (abnormal or adventitious sound): wheezes

high-pitched whistling, musical sounds heard as air passes through narrowed or obstructed airways, usually louder on expiration

BP classification is based on the

highest reading of either the SBP or DBP (even if either the SBP or DBP falls in a lower classification

h/o

history of

Settings

hospitals, homes, skilled-nursing, assisted living, and extended care facilities. community/health departments, adult day care cents, schools, hospices, providers offices, ambulatory care clinics, occupational health clinics, stand alone surgical centers, or urgent care centers.

PHI (protected health information)

identifiable health information that is transmitted or maintained in any form or medium, including verbal discussions, electronic communications with or about clients, and written communications

right task

identify what tasks are appropriate to delegate for each specific client. its repetitive, requires little supervision, and is relatively noninvasive for a certain client. delegate activities to appropriate levels of team members according to professional standards of practice, legal and facility guidelines, and available resources.

standards for discharge education

identifying safety concerns at home, reviewing signs and symptoms of potential complications and when to contact either emergency care or provider, providing the phone number of the provider, providing names and phone numbers of community resources that give care at the clients residence, step-by-step instructions for performing continuing tx such as dressing changes, dietary restrictions and guidelines including those that pertain to medication administration. amount and frequency of therapies to perform to support continued independence at home. directions on how to take medications and explanations for why adherence is important.

nursing students and liabilty

if students harm clients as a result of their direct actions or inaction. they shouldnt perform tasks for which they aren't prepared and should have supervision as they learn new procedures. them, the instructor, and the facility share liability for the wrong action or inaction.

individuals with compromised health defenses

immunocompromised, had surgery, with indwelling devices, break in the skin, with poor oxygenation, impaired circulation, have chronic or acute diseases such as diabetes mellitus, adrenal insufficiency, renal failure, hepatic failure, or chronic lung disease.

myopia

impaired far vision

presbyopia

impaired near vision or farsightedness

incident reports

important part of facilities quality improvement plan. ex. of incident are medication errors, falls, and needlesticks. nurses must document the facts without judgement or opinion, nurses must not refer to an incident report in the client's medical record, incident reports contribute to changes that help improve health care quality.

A determination of death must be made:

in accordance with accordance with accepted medical standards

preauricular lymph node located

in front of ear

progress note

in the POMR is a chart entry made by all health professionals involved in a client's care; they all use the same type of sheet for notes - they are numbered to correspond to the problems on the problem list and may be lettered for the type of data - Provide info about the progress is making toward achieving desired outcomes - Include info about pt problems & nursing interventions

transmission precautions: tier two

use airborne precautions to protect against droplet infections smaller than 5 mcg (measles, varicella, pulmonary or laryngeal tuberculosis). airborne precautions require: private room, masks and respiratory protective devices for caregivers and visitors. use an N95 or high-efficiency particulate air (HEPA) respirator if pt is known or suspected to have TB. negative pressure airflow exchange in the room of at least six to 12 exchanges per hr depending on the age of the structure. if splashing or spraying is a possibility, wear full face protection.

secondary sources of data

what others tell the nurse based on what the client has told them. data nurse collects from other sources, physical therapy note in chart indicates client has decreased range of motion in left shoulder.

primary sources of data

what the client tells the nurse. data the nurse obtains through observation and examination. client grimaces when attempting to brush her hair with her left arm.

w/c

wheelchair

denotative/connotative meaning

when communicating, participants must share meanings

Late entries

when you forget to chart something and you document at a later time

handoff communication

which is defined as a process in which info about pt is communicated in a consistent manner including an opportunity to ask and respond to questions

Responsibility

willingness to respect obligations and follow through on promises

responsibility

willingness to respect obligations and follow through on promises.

steregnosis

with eyes closed, client can identify a familiar object that is place in his hand

graphesthesia

with eyes closed, client can identify a number drawn on his palm with the blunt end of a pencil

Health record

with the emphasis now on health promotion, new reference for medical chart Health record contains: care, in chronological order, provided by all healthcare providers; the patient's responses to interventions and treatments; important facts about a client's health history, including past and present illnesses, examinations, tests, treatments, and outcomes Research shows that nurses spend 15 to 25% of the work day documenting the care they give, sometimes more

WNL

within normal limits

s

without

nursing role in informed consent

witnessing the client's signature on the informed consent form and to ensure that the provider obtained informed consent appropriately.

vocabulary

words used to communicate either a spoken or written message

social worker

works with clients and families by coordinating inpatient and community resources to meet psychosocial and environmental needs that are necessary for recovery and discharge. Ex. of when to refer: a pt who has terminal Ca wishes to go home but is no longer able to perform many ADL. The spouse needs medical equip. in home to care for the pt.

For an invasive procedure or surgery, the client is required to provide ____ consent.

written

exophthalmos

bulging eyes

Nontherapeutic Communication - Giving personal opinions:

Can be interpreted as professional advice; Legal implications

Audio-recorded report

Can be time consuming, can't ask nurse questions, and cause issues if report is hard to hear.

Source- Oriented system advantages

Can easily find the care provided by each discipline

Joint Commission mandates that healthcare not use the following abbreviations. What is on "do not use" list?

"U" or "u" for units. "IU" FOR international unit. Q.D., QD, q.d., qd (daily) Q.O.D., QOD, q.o.d., qod (every other day) Trailing zeros and lack of leading zeros MS, MSO4, AND MgSO4- could mean morphine sulfate or magnesium sulfate.

Nontherapeutic Communication - Asking for explanations:

"Why" questions can be seen as accusations

Therapeutic Communication - Sharing Observations:

"You look like you're in pain"

Provider's orders

"do not resuscitate" (DNR) or "allow natural death" (AND) are orders written by a provider and must be placed in the client's medical record; the provider consults the client and family prior to administering a DNR or AND

intrapersonal communication

"self-talk"

Health Care Financing Administration of the U.S. Department of Health and Human Services requires:

(a) a home health certification and plan of treatment form and (b) a medical update and client information form which both must be signed by the home care nurse and attending primary care provider

pulse strength (amplitude) should be graded on a scale of

*0 to 4* 0 = absent, unable to palpate 1+ = diminished, weaker than expected 2+ = brisk, expected 3+ = increased 4+ = full volume, bounding

Purposes of Client Records

*Communication:* record serves as the vehicle by which different health professionals who interact w/a client communicate w/each other. This prevents fragmentation, repetition, and delays in pt. care. *Planning client care:* Health care professionals use data from the pt's records to plan care for the pt. Nurses use baseline and ongoing data to evaluate the effectiveness of the nursing care plan. *Auditing health agencies:* An audit is a review of pt records for quality assurance purposes *Research:* Info in records that have treatment plans can help treat other clients *Education:* Pt records can provide a comprehensive view of the pt, the illness, effective treatment strategies, and factors that affect the outcome of the illness. *Reimbursement:* Documentation helps a facility from the federal government; pt's clinical record must contain the correct DRG codes & appropriate care *Legal documentation:* Pt's record is a legal document and is usually admissible in court as evidence *Health care analysis:* Info from records may assist health care planners to identify agency needs, such as underutilized and underutilized hospital services.

D.A.R. pg. 257

*D*ata - "assessment phase" consists of observation of pt status & behaviors, including data from flow sheets (e.g., vital signs, pupil re-activity) *A*ction - "planning and implementing phase" immediate & future nursing actions *R*esponse - "reflects the evaluation phase"

Nursing Care Plans

*Joint Commission requires clinical record to include:* - Evidence of client assessment - Nursing diagnosis - Nursing interventions - Client outcomes - Current nursing care plans *Traditional care plans* - Written for each client *Standardized care plans* - Based on institutions standards of practice

SBAR

*S* = Situation - State your name, unit, and pt name - Briefly state the problem *B* = Background - State pt admin diagnosis & date of admin - State pertinent medical history - Provide brief summary of treatment to date - Code status (if appropriate) *A* = Assessment - Vital signs - Pain scale 0 Is there a change from prior assessments? *R* = Recommendation - State what you would like to see done or specify that the care provider needs to come and assess the pt - Ask if health care provider wants to order any tests or meds. - Ask, if no improvement, when you should call again

HCAHPS

*What is it???* - *H*ospital - *C*onsumer - *A*ssessment of - *H*ealthcare - *P*roviders & - *S*ystems

health promotion (immunizations): school-age (6-12 yrs)

--if not given between 4-5, then by 6 years: DTaP, IPV, MMR, varicella -yearly seasonal TIV or LAIV (nasal spray) -11-12 years: Tdap, meningococcal vaccine (MCV4), HPV2 in 3 doses for females and HPV4 may be given to males

Health care regulatory agencies include:

-US Dept of Health and Human Srvcs -US FDA -State and local public health agencies -State licensing boards (to ensure providers & agencies comply with state regulations) -the Joint Commission/JCAHO (set quality standards for accreditation of health care facilities) -Professional Standards Review Organizations (PSROs) -Utilization review committees (monitor for appropriate diagnosis and treatment of hospitalized clients)

LOC: alert

-client is responsive and able to fully respond by opening eyes and attending to a normal tone of voice and speech -answers questions spontaneously

General Guidelines for Recording

- *Date and Time* - *Timing* (documentation should be done as soon as possible after an assessment or intervention) - *Legibility* - *Permanence* (dark ink) - *Accepted Terminology* - *Correct Spelling* - *Signature* - *Accuracy* (when a recording mistake is made, draw a line through it and your initials) - *Sequence* (Ex: assessments, nursing interventions, then client's response) - *Appropriateness* - *Completeness* (record all assessments, dependent and independent nursing interventions, pt problems, pt comments & communication w/other members of the health team. Care that is omitted bc of the pt's condition or refusal of treatment must also be recorded. Document what was omitted, why it was omitted, & who was notified. - *Conciseness* (Recordings need to be brief as well as complete to save time in communication. The pt's name and the word client are omitted. For example, write "Perspiring profusely. Respiration's shallow, 28/min." End each thought or sentence w/a period. - *Legal Prudence* (Accurate, complete documentation should give legal protection to the nurse, the pt's other caregivers, the health care facility, and the pt.

Care Plan Conference

- A meeting of a group of nurses to discuss possible solutions to certain problems of a client - Allows each nurse the opportunity to offer an opinion about possible solutions - Other health care providers are invited to offer their expertise - Need to use terms client can understand

Nursing Discharge/Referral Summaries

- Completed when pt discharged (Written in terms that can be readily understood) - Completed when pt transferred to another institution *Discharge & Referral Summaries* - Restrictions that relate to activity, diet, and bathing - Functional/ self-care abilities - Comfort level - Support networks - Pt education - Discharge destination - Referral services - All must include - Description of client's physical, mental, & emotional status - Resolved health problems - Treatments that need to be continues - Current meds

Guidelines for Receiving a Telephone Report

- Document date and time - Record the name of person giving the information - Record the subject of the information received - Sign the notation - Repeat information to ensure accuracy - Be concise and accurate - SBAR often used (Situation, Background, Assessment, Recommendation) - State name and relationship to client

Long-Term Care Documentation

- Facilities usually provide two types of care: skilled or intermediate - The OBRA law requires that (a) comprehensive assessment be performed within 4 days of a pt's admin to a long-term care facility (b) formulated plan of care must be completed within 7 days of admin (c) assessment & care screening process must be reviewed every 3 months - Nurse usually completes a nursing care summary at least once a week for clients requiring skilled care and every 2 weeks for those requiring intermediate care *Summaries should address the following* - specific problems noted in the care plan - mental status - ADL's - Hydration and nutrition status - Safety measures needed - Meds - Treatments - Preventive measures - Behavioral mod assessments, if pertinent

Telephone Orders

- Know the state nursing board's position on who can give and accept - Know the agency policy - Write the order down on physician's order forms - Read the order back to the primary care provider - Question the primary care provider about any order that is ambiguous - Have the primary care provider verbally acknowledge the read-back order - Must be countersigned by the primary care provider within a time described by agency policy (usually 24 hrs)

Case Management Model

- Quality, cost-effective care delivered within an established length of stay - Uses a multidisciplinary approach - Use of critical pathways - Use of CBE - Documentation of variance include: - Actions taken to correct the situation - Justify the actions taken - Promotes collaboration and teamwork among caregivers, helps to decrease length of stay, and makes efficient use of time

Documenting the Nursing Process

- Record should describe the client's ongoing status - Reflect the full range of the nursing process

Guidelines for Reporting Client Data

- Should be concise, including pertinent info but no extraneous detail *Types of reporting* - Change-of-shift report - Telephone reports - Care plan conference - Nursing rounds

Guideline for Giving a Telephone Report

- State the client's name, medical diagnosis, changes in nursing assessment, vital signs related to baseline, significant laboratory data, related nursing interventions - Have chart ready to give any further information needed - Document the date, time, and content of the call

Nursing Rounds

- Two or more nurses visit selected clients at bedside - Nurses obtain information that will help plan nursing care - Provides clients opportunity to discuss their care - Evaluate the nursing care the client has received

discharge planning

- an interdisciplinary process started by nurse at time of admission -conducted with both client and client's family for optimal results

Guidelines for Change-of-Shift Report

- is given to all nurses on the next shift - Its purposes are to provide continuity of care for clients by providing critical info and to promote client safety and best practice - may be written or given orally (face-to-face or by audiotape) - Follow a particular order - Provide basic identifying info - For new pt's provide the reason for admin or medical diagnosis/ es, surgery, diagnostic tests and therapies in the past 24 hrs - Significant changes in pt's condition - Provide exact info - Report pt's need for emotional support - Include current nurse-prescribed and primary care & provider-prescribed orders - Clearly state priorities of care and care due after the shift begins - Be concise - Incorporate a verification process - SBAR format (Situation, Background, Assessment, Recommendation

a disaster is a ___ ___ or ___-___ event that overwhelms or interrupts, at least temporarily, the normal flow of services of a hospital and include ___ & ___ emergencies

- mass casualty -intra-facility -internal -external

heart sounds: S2

-"dub" -caused when closure of the aortic and pulmonary valves signals the beginning of ventricular diastole (relaxation) and produces the sound -best heard with the diaphragm of the steth at the aortic area

heart sounds: S1

-"lub" -caused when the closure of the mitral and tricuspid valves signals the beginning of the ventricular systole (contraction) and produces the sound -best heard with the diaphragm of the steth at the apex

expected physical development (fine and gross motor development): infant (birth-1 yr)

-1 month: (g) demonstrates head lag; (f) has a present grasp reflex -2 month: (g) lifts head off mattress; (f) holds hands in an open position -3 month: (g) raises head and shoulders off mattress: (f) no longer has grasp reflex, keeps hands loosely open -4 month: (g) rolls from back to side; (f) places objects in mouth -5 month: (g) rolls from front to back; (f) uses palmer grasp dominantly -6 month: (g) rolls from back to front; (f) holds bottle -7 month: (g) bears full weight on feet; (f) moves objects from hand to hand -8 month: (g) sits unsupported; (f) begins using pincer grasp -9 month: (g) pulls to standing position; (f) has crude pincer grasp -10 month: (g) changes from prone to sitting position; (f) grasps rattle by its handle -11 month: (g) walks while holding on to something; (f) can place objects into container -12 month: (g) sits down from standing position w/o assistance; (f) tries to build two-block tower w/o success

health promotion (immunizations): toddler (1-3 yrs)

-12-15 month: IPV (6-18 month), Hib, PCV, MMR, varicella -12-23 month: Hep A (given in 2 doses at lease 6 months apart) -15-18 month: DTaP -12-36 month: yearly seasonal TIV; at age 2, toddlers can receive the live, attenuated influenza vaccine (LAIV) by nasal spray

expected physical development (fine and gross motor skills): toddler (1-3 yrs)

-15 month: (g) walks w/o help, creeps up stairs; (f) uses cup well, builds two-block tower -18 month: (g) assumes standing position, jumps in place with both feet; (f) manages spoon without rotation, turns pages in book 2-3 at a time -2 year: (g) walks up and down stairs; (f) builds 6-7 block tower -2.5 year: (g) jumps with both feet, stands on 1 foot momentarily; (f) draws circles, has good hand-finger coordination

health promotion (immunizations): preschooler (3-6 yrs)

-4-6 years: DTaP, MMR, varicella, IPV -yearly: TIV or LAIV (nasally)

expected physical development (dentition): infant (birth-1 yr)

-6 to 8 teeth erupt in the infant's mouth by end of 1st yr -teething pain can be eased using cold teething rings, OTC teething gels, acetaminophen and/or ibuprofen; ibuprofen given only to children over 6 months -clean teeth using cool, wet washcloth -bottles should not be given when they are falling asleep; prolonged exposure to milk/juice can cause dental caries

Examples of tasks that can be delegated to AP

-ADLS -bathing, grooming, dressing, toileting -ambulating -feeding (w/o swallowing precautions) -positioning -bedmaking -specimen collection and I&Os -VS for stable clients

Information to be Documented

-Admission information -Abnormal laboratory tests, x-ray reports, vital sign changes -Treatments -Transfer and discharges -Patient activities -Patient concerns Medications (specific information needed for PRN (as needed) medications, parenteral medications, etc. -Safety precautions -Family concerns -Education

components of the General Adaptation Syndrome (GAS)

-Alarm reaction: body functions are heightened to respond to stressors -Resistance stage: body functions normalize while responding to the stressor; the body attempts to cope with the stressor -Exhaustion stage: body functions are no longer able to maintain a response to the stressor

What is Confidential?

-All information about patients written on paper, spoken aloud, saved on computer -Reason the person is sick -Treatment the patient receives -Information about past health conditions -HIPAA

Types of intentional torts

-Assault -Battery -False imprisonment

Right circumstance

-Assess the health status and complexity of care required by the client -match complexity of care demands to skill level if team member -consider the workload of the team member

What to Chart

-Assessment at the start of the shift -Changes in mental, psychological, physiological conditions -Reactions to procedures or medications -Teaching -Document what was taught and the client's response. Do not forget about discharge teaching -Physician visits -Time client left and returned to unit including transportation and destination -Medications: dosage, route, site, pain relieved, or side effects -Treatments -Late Entry-put current time then late entry -Chart according to your 5 senses. Include terms like: I palpated a pea sized lump I observed a yellow tint to the skin Crackles were heard upon auscultation in the left lower lung field Skin was cold and clammy to touch The patient states, "I've been having sharp chest pain for 3 days".

Change of Shift/Hand-off Reports

-Basic identifying information about each patient: name, room number, bed designation, diagnosis, and attending and consulting physicians -Current appraisal of each patient's health status -Current orders (especially any newly changed orders) -Abnormal occurrences during your shift -Any unfilled orders that need to be continued onto the next shift -Patient/family questions, concerns, needs -Reports on transfers/discharges -Focus on safety: Review CODE status, allergies, and risk for falls -Avoid gossiping or socialization during change of shirt report - focus of patient care. -Be prepared

Types of quasi-intentional torts

-Breach of confidentiality -Defamation of character

health promotion (health risks): older adult (65+ yrs)

-CV diseases include: CAD, HTN, stroke -factors affecting mobility include: arthritis, osteoporosis, falls -mental health disorders include: depression, dementia, suicide -other disorders include: diabetes mellitus, cancers, incontinence, abuse and neglect, cataracts, alcoholism, pain

The 3 classes of fire extinguishers:

-Class A: for paper, wood, upholstery, rags, or other types of trash fires -Class B: for flammable liquids and gas fires -Class C: for electrical fires

Purposes of Patient Records

-Communication-continuity of care -Diagnostic and therapeutic- meds, tests -Care planning- baseline and ongoing -Legal-wasn't charted it wasn't done -Historical documentation -Research-EBP -Education-learn about manifestations of health problems -Credentialing-compliance with standards of care and governing the profession -Reimbursement-demonstrate the patient received quality of care -Quality improvement-measure outcome performance

Licensed Practical Nurse (LPN)

-Works under supervision of the RN -Collaborate with other team members -Possess technical knowledge and skills -Participate in the delivery of nursing care, using the nursing process as a framework

Charting Specifics

-Complete, current, and organized -Black ball point pen because it microfilms best -Errors are corrected by drawing a single line through the error. Above the error, write Mistaken entry and your initial OR the word "error" and your initials above the single lined out error. -No white-out, erasers, eradicators, covering-up materials -Notes are written on each succeeding line -Lines are not omitted -A horizontal line is drawn to "fill up" a partial line -Each entry is dated and timed -Begin with a Capital letter -End with a period -Each entry is signed with your first initial, last name and status J. Smith, KSU,SN R. Jones, RN -Script not printing is used for the signature and it should appear at the right hand margin of the narrative note.

Elements of Documentation

-Content- reflect the nursing process. Avoid words such as "good" "average". Maintain professionalism and avoid subjective comments such as "child is a brat" or "patient is an angry old man" -Timing- follow agency protocol regarding frequency of documentation. Always document when there is a change in patient's status. Document ASAp after patient care to avoid batch charting. NEVER document before interventions are carried out -Format-make sure you have the right patient before charting. Use standard terminology, abbreviations and symbols. NEVER skip lines. Draw a single line through a blank space -Confidentiality-HIPPA. Actual patient names should not be used in written or oral reports---fine $250,000, jail 10 years

When documenting subjective information in a report, what information should be recorded?

-Description of episode/event in patient's words in quotation marks. -Clarify onset, location, description of condition

Potential Breaches in Patient Confidentiality

-Displaying information on a public screen-computers remember to sign off, minimize screen-50 people fired for looking in cleveland women chart -Sending confidential e-mail messages via public networks -Discarding copies of patient information in trash cans -Holding conversations that can be overheard-elevator, cafeteria, breakroom, hallways -Faxing confidential information to unauthorized persons-verify fax number and person receiving fax -Sending confidential messages overheard on pagers

If it wasn't documented, it wasn't done!

-Documentation is evidence the patient received proper care. -Do not document ahead of time -Document ASAP after care is completed to avoid errors. --AVOID batch charting- waiting until the end of your shift to document -Hand writing must be clear and easy to read

Elements of Effective Documentation

-Everything you record must be spelled correctly and be legible -Print if you must -Sentences must be complete

Disadvantages of Computer-Assisted Charting

-Expensive to purchase and update -Problems with "downtime" interfere in charting and receiving information -Increase charting time if not enough terminals -May not be user friendly. May be difficult to quickly find information needed to make care decisions

Documentation must be: F___, A___ & C___, C___ & C___, and O___.

-Factual -Accurate & Concise -Complete & Current -Organized

Basic Charting (Documentation) Information

-Follow each facilities policies regarding policies, forms and procedures relevant to nursing care documentation -When making a late entry not (addendum, or late entry with time you performed care specified) On electronic charting you can change the time -No ditto marks -Always identify third parties (Dr.'s charge nurse, if involved in communication or care)

INCIDENT REPORT

-Formal report of an unusual occurrence or accident. -An organizational report and is not part of the patient's health record. -Identify areas where staff development is needed -Maintain detailed record of incident for possible legal action -Report is filled out on occurrence of unusual event, such as falls, med errors, incorrect treatment, needle sticks, loss of patient's belongings, injury to visitor -Only the nurse who witnessed the event is to complete the IR -Describe exactly what happened -Do not document in the patient's chart that an incident report was filled out -Focus on client condition

Registered Nurse (RN)

-Functions under state nurse practice laws -Perform assessments; establish nursing diagnoses, goals, and interventions; conducts ongoing client evaluations -Participate in developing interdisciplinary plans for client care -Share best practices; continuing education

Federal laws impacting nursing practice include:

-HIPAA -ADA -the Mental Health Parity Act (MHPA) -the Patient Self-Determination Act (PSDA)

cardiac output (CO) is determined by

-HR -contractility -blood volume -venous return

Unlicensed Assistive Personnel (UAP)

-Includes CNAs, CMAs, and non-nursing personnel -Work under direct supervision of an RN or LPN -Specific tasks usually outlined in position description -Tasks may including feeding clients, preparing meals, lifting, basic care, measuring & recording vital signs, and ambulating clients

Formats for Nursing Documentation

-Initial Nursing Assessment-baseline for later comparison -Care Plan-communicate problems, goals, interventions -Patient Care Summary-overview of valuable pt data (doctor writes) -Clinical/Collaborative Pathways-abbreviated summary of key info taken from detailed care management plan—what's the physical therapist going to do -Progress Notes-info caregiver/providers of progress pt is making. Ex: narrative nursing notes, SOAP notes, focus charting -Flow Sheets and Graphic Records-quickly document aspects of pt care. Graphic record- form used to record specific variables such as vitals, weight, I & O -Medication Records-MAR must include all medications administered to the patient. It will aslo include nurse giving the drug, reason the drug was ordered and it's effectiveness -Transfer/Discharge Summary-what was done while there, how they did, what are they supposed to do when they get home -Home Health Care /Long Term Care Documentation

Types of unintentional torts

-Negligence -Malpractice (professional negligence)

Refusal of treatment

-PSDA stipulates all clients have the right to accept and refuse care and must be advised of this right upon admission -if client refuses treatment, will be asked to sign an "Against Medical Advice" form and nurse must document information was provided and provider notified -if client refuses to sign form, nurse must document -if a client decided to leave the facility w/o discharge order, nurse must notify provider and discuss risks of leaving prior to discharge

expected cognitive development: older adult (65+ yrs)

-Piaget: formal operations -many will maintain cognitive function; some decline in speed of cognitive function vs cognitive ability -many factors influence cognitive ability including: overall health, number of stressors present at a given time, client's life-long mental well-being -slowed neurotransmission, imparied vascular circulation, disease states, poor nutrition, and structural brain changes can lead to delirium, dementia, and depression -delirium: acute, temporary, and usually related to other physiologic problems; is often the first symptom of infection (UTI) in older adults -dementia: chronic, progressive, and possibly with an unknown cause (Alzheimer's disease) -depression: chronic, acute, or gradual onset (present for at least 6 weeks)

expected cognitive development: middle adult (35-65 yrs)

-Piaget: formal operations -reaction time/speed of performance slows slightly -memory is intact -crystallized intelligence remains (stored knowledge) -fluid intelligence (how one learned and process new info) declines slightly

Long-term Care Facility Resident Assessment Instrument

-Provides standardized protocols for assessment and care planning -Promotes quality improvement -Affects reimbursement

Policy for Receiving Verbal Orders in an Emergency

-Record the orders in patient's medical record. -Read back the order to verify accuracy. -Date and note the time orders were issued in emergency. -Record verbal order (VO) and name of the physician issuing the order, followed by nurse's name and initials.

Documentation

-Recording the patient's status and care written or electronically or a combination of both -The process of recording vital information that is communicated to others. -Facts and figures that are specific, clear and precise -All pertinent care and interaction with the patient -Contains correct language, medical terms and abbreviations

Patient-Centered Care

-Respects patient's values/beliefs -Includes awareness of culture, ethnicity, age, spiritual beliefs, spoken and written language, and patient literacy -Identifies/addresses patient mobility, precautions, and safety risks -Encourages active patient participation

botulism

-S/S: difficulty swallowing, progressive weakness, nausea, vomiting, abdominal cramps, difficulty breathing -treatment/prevention: airway management, antitoxin, elimination of toxin

smallpox

-S/S: high fever, fatigue, severe headache, rash (starts centrally and spreads outward) that turns to pus-filled lesions, vomiting, delirium, excessive bleeding -treatment: no cure -supportive care: hydration, pain medication, antipyretics -prevention: vaccine

inhalational anthrax

-S/S: sore throat, fever, muscle aches, severe dyspnea, meningitis, shock -treatment/prevention: IV ciprofloxacin

Ebola

-S/S: sore throat, headache, high temprature, nausea, vomiting, diarrhea, internal and external bleeding, shock -treatment: no cure -supportive care: minimize invasive procedures -prevention: vaccine

-systolic murmurs are heard just after ___ -diastolic murmurs are heard just after ___

-S1 -S2

Basic Charting (Documentation) Information

-Should have correct patient name, date, time -Use only approved abbreviations -Be legible -Be timely, specific, and complete -Follow rules of grammar, spelling -Documented after care performed -Be objective, use patient subjective descriptions or quotations and nonjudgemental

Basic Charting (Documentation) Information

-Signed (full legal name and title) V Christensen RN -Include patient education -If a mistake is made a notation of (mistaken entry, spelling) should be made. If narrative (hand-written a single line through the mistake) Never obscure -Never leave blank lines on progress notes, e.g. between notations

REPORTING: MD NOTIFICATION

-Significant changes in physical assessment, abnormal laboratory findings, test results -Identify self to MD by name, status, unit and client's name -State exact reason why you are calling -Current vital signs, laboratory results, medications etc. should be available -Telephone Communication: recorded as (TO) -Within 24 hours dr has to sign order -Insulin 2 nurses must be told by doc on phone

Methods of Documentation

-Source-oriented records -Problem-oriented medical records (SOAP) -PIE charting (problem, intervention, evaluation) -Focus charting (DAR) -Charting by exception (CBE) -Computerized documentation/Electronic health records (EHRs)

health promotion (immunizations): young adult (20-35 yrs)

-Td booster: ever 10 yr; for adults who did not receive 1 dose of Tdap previously, sub 1 Td booster dose with Tdap -MMR: 1 dose 1 dose at 19-49 with 2nd dose 4 wks later if adult is a postsecondary student, healthcare worker, or plans to travel abroad -Varicella vaccine: 2 doses to adults who do not have evidence of previous infection; 2nd dose should be given 4-8 weeks after 1st to adults who had only 1 previous dose -MCV: students entering college and living in dorm if not previously vaccinated -HPV2 or HPV4: 3 doses, recommended for females up to age 26 who were not vaccinated as a child; HPV4 may be given to males up to 26 -seasonal flu vaccine: 1 yearly

health promotion (immunizations): middle adult (35-65 yrs)

-Td booster: ever 10 yr; for adults who did not receive 1 dose of Tdap previously, sub 1 Td booster dose with Tdap -MMR: 1 dose 1 dose at 19-49 with 2nd dose 4 wks later if adult is a postsecondary student, healthcare worker, or plans to travel abroad -Varicella vaccine: 2 doses to adults who do not have evidence of previous infection; 2nd dose should be given 4-8 weeks after 1st to adults who had only 1 previous dose -pneumococcal polysaccharide vaccine (PPV): if not previously vaccinated, vaccinate once at 65 -seasonal flu vaccine: yearly; LAIV (nasal spray) only under 50 and not pregnant or immunocompromised -herpes zoster vaccine: 1 dose over age 60

health promotion (immunizations): older adult (65+ yrs)

-Td booster: every 10 years -varicella vaccine: 2 doses given to those w/o evidence of previous infection; 2nd dose 4-8 weeks after 1st for those who only had 1 previous dose -PPV: if not previously vaccinated, once at age 65 -seasonal flu vaccine: 1 dose annually -herpes zoster vaccine: 1 dose for all adults over 60

Charting by Exception (CBE)

-The nurse documents only deviations from pre-established norms (document only abnormal or significant findings). -Avoid lengthy, repetitive notes.

health-care associated infections (HAIs)

-an infection acquired while the client is receiving care in a health-care setting -formally called nosocomial infections -can come from exogenous source or endogenous source -most common setting for HAIs is the ICU -best way to prevent HAIs is through frequent and effective hand hygiene -most common site of HAIs is the urinary tract -most common causative agents are Escherichia coli, Staphylococcus aureus, and enterococci -an iatrogenic infection results from a diagnostic or therapeutic procedure -HAIs are not always preventable and not always iatrogenic

components of the chain of infection include:

-an infectious agent (bacteria, virus, fungi, protozoa) -a reservoir where the infectious agent grows (wound drainage, food, oxygen tubing) -an exit portal of the infectious agent (skin, resp or GI tracts) -a means of transmission (droplet, person-to-person contact, touching contaminated items) -an entry portal to a susceptible host (same as exit) -a host that must be susceptible to the infectious agent

According to the UDDA, death is determined by one of two criteria:

-an irreversible cessation of circulatory and respiratory functions -irreversible cessation of all functions of the entire brain, including the brain stem

expected physical development (size): toddler (1-3 yrs)

-anterior fontanel closes by 18 months -weight: should be 4 times birth weight at 24 months -height: grows by 7.5 cm (3 in) per year

standard precautions (tier 1)

-applies to all body fluids (excluding sweat), non-intact skin, and mucous membranes -hand hygiene recommended after all contact and alcohol-based waterless product is preferred unless hands are visibly dirty; also required after removal of gown -clean gloves are worn when touching all body fluids, non-intact skin, mucous membranes, and contaminated equipment/articles -gloves removed and hand hygiene completed between each client -masks, eye protection, and shields required when splashing or spraying of body fluid may occur -gloves worn whenever touching anything that has potential to contaminate hands of the nurse -sturdy, moisture resistant bag used for soiled items; contaminated laundry to be bagged and handled to prevent leaking; equipment for client care properly cleaned and one time use items disposed of -safety devices on all equipment/supplies enabled after use and sharps disposed of properly -private room not needed unless client is unable to maintain appropriate hygienic practices

expected psychosocial development (body-image changes): toddler (1-3 yrs)

-appreciates the usefulness of various body parts -develop gender identity by age 3

upon admission (but prior to client arrival to room) take necessary equipment into the room including:

-appropriate documentation forms -equipment to obtain vital signs -pulse oximeter -hospital attire for client

Examples of questions to use to determine complexity of care:

-are complex tasks required as part of the client's care? -is the delegatee legally able to perform the task and do they have the skills necessary?

evaluation related to client education includes:

-ask client to explain info in his own words -observe the client demonstrating the learned activity -use written tools to measure accuracy of info -request client's self-evaluation of progress -observe verbal and nonverbal communication -determine client's ability to use info over time but re-evaluate learning during follow-ups -revise care plan as needed

heel-to-toe walk

-ask client to place heel of one foot in front of toes of the other foot as he walks in a straight line -expected finding: client is able to walk in a straight line without losing balance

Romberg test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed -expected finding: client should be able to stand with minimal swaying for at least 5 seconds

home safety risks for infants and toddlers include:

-aspiration -suffocation -poisoning -falls -motor vehicle/injury -burns

Right person

-assess and verify the competency of the team member -continually review the performance of the team member & determine competency of care -assess team member performance based on standards & remediate if needed

transfers and use of assistive devices

-assess client's ability to help with transfers (balance, muscle strength, endurance) -determine need for additional help or assistive devices (transfer belt, hydraulic lift, sliding board) -assist and monitor the client's proper use of mobility aids (canes, walkers, crutches) -include assistance or mobility aids needed for safe transfers and ambulation in the care plan

assessment/data collection related to client education includes:

-assess/monitor the client's learning needs -assess the learning environment -assess/monitor the client's learning style (auditory, visual, kinesthetic) -identify areas of concern -assess/monitor available resources (financial, social, community) -identify the client's developmental stage -determine the client's physical and cognitive ability -identify special needs (visual impairment, decreased manual dexterity) -determine the client's motivation and readiness to learn

time requirements for handwashing

-at least 15 seconds to remove transient flora from the hands -up to 2 minutes when hands are more soiled

health promotion (injury prevention): middle adult (35-65 yrs)

-avoid drugs, inc alcohol, that can lead to substance abuse -avoid taking drugs and drinking alcohol while driving -wear a seat belt while operating vehicle -wear helmet while riding bike, skiing, or snowboarding -installing smoke and carbon monoxide detectors in the home -securing firearms in a safe location

health promotion (injury prevention): young adult (20-35 yrs)

-avoid drugs, inc alcohol, that can lead to substance abuse -avoid taking drugs and drinking alcohol while driving -wear a seat belt while operating vehicle -wear helmet while riding bike, skiing, or snowboarding -installing smoke and carbon monoxide detectors in the home -securing firearms in a safe location

health promotion (injury prevention-poisoning): infant (birth-1 yr)

-avoid exposing to lead paint -keep toxins/plants out f -use safety locks on cabinets (esp containing cleaners/chemicals) -keep poison control number near phone -keep meds in childproof containers and out of reach -have working carbon monoxide detectors in the home

general measures to prevent falls includes:

-be sure client knows how to use call light, it is within reach, and encourage its use -respond to call lights in a timely manner -orient client to setting and assistive devices -place clients at risk for falls near nursing station -ensure bedside table and frequently used items are within client's reach -maintain bed in low position -for clients who are sedated, unconscious, or otherwise compromised, bed rails are kept up and bed kept in low position -avoid use of full side bedrails for clients who get out of bed or attempt to get out of bed without assistance -provide nonskid footwear -keep floor free of clutter with a clear path to the bathroom -keep assistive devices nearby after validation of safe use by client and family -educate client and family/caregivers on identified risks and plan of care -lock wheels on beds, wheelchairs, and carts -use chair or bed sensors for clients at risk for getting up unattended

Legal guidelines of documentation

-begin each entry with date & time -legible and in black, non-erasable ink -no white out or blackened out errors -info inadvertently omitted may be added as a "late entry" -signed with signature of person making entry and dated -should reflect assessments, interventions, and evaluations

expected cognitive development (time): preschooler (3-6 years)

-begins to understand the concepts of past, present, and future -by end of preschool years, child may comprehend days of the week

health promotion (immunizations): infant (birth-1 yr)

-birth: Hep B -2 month: DTaP, rotavirus vaccine (RV), inactive poliovirus (IPV), Haemophilus influenzae type B (Hib), pneumococcal vaccine (PCV), and Hep B -4 month: DTaP, RV, IPV, Hib, PVC -6 month: DTaP, IPV (6-18 months), PVC, Hep B (6-12 months), RotaTeq (alt to RV which required 3 doses completed by 32 weeks) -6-12 month: seasonal flu yearly, trivalent inactivated influenza vaccine (TIV) is available as IM injection

a murmur sounds like a

-blowing or swishing sound -best heard with bell of steth

spider vein

-bluish -spider-shaped or may be linear -up to several inches in size

cyanosis

-bluish: best noted in nail beds, lips, mouth, skin -indication of hypoxia or impaired venous return

health promotion (nutrition-feeding alternatives): infant (birth-1 yr)

-breastfeeding provides complete diet during 1st 6 months and is recommended -iron-fortified formula is an acceptable alternative; cow's milk is not recommended

expected psychosocial development (self-concept development): infant (birth-1 yr)

-by end of 1st year will be able to distinguish themselves as being separate from their parents

health promotion (nutrition): school-age (6-12 yrs)

-by end of school-age years is eating adult proportion of food and needs quality nutritious snacks advised parents to: not use food as reward; emphasize physical activity; ensure balanced diet according to USDA recommendations; teach children to make healthy food selections for meals/snacks; avoid frequent meals at fast food; avoid skipping meals -dental health should be encouraged, including: brushing and flossing daily; having regular check-ups and fluoride treatments

Upon admission, orient client and family to room/facility including:

-call light -bed operation -telephone/tv -overhead lighting -smoking policy -restroom locations -waiting areas -meal times -usual times for physician visits -dining/vending services -visiting policies

health promotion (nutrition-weaning): infant (birth-1 yr)

-can be accomplished when infant is able to drink from a cup (sometime after 6 months) -replace 1 feeding with breast milk/formula in a cup -bedtime feeding is last to be replaced

health promotion (nutrition-solids): infant (birth-1 yr)

-can be introduced between 4-6 months -indicators for readiness include voluntary control of head and trunk, hunger less than 4 hrs after vigorous nursing or intake of 8 oz of formula, interest of the infant -iron-fortified rice offered 1st -new foods introduced 1 at a time over a 5-7 day period to assess for allergies or intolerance; veggies or fruits introduced between 6-8 months and after both have been introduced, then meats -milk, eggs, wheat, citrus fruits, peanuts, peanut butter, and honey delayed till after 1st year -chopped, cooked, and unseasoned table foods by 9 months -appropriate finger foods include: ripe bananas, toast strips, graham crackers, cheese cubes, noodles, peeled chunks of apples/pears/peaches -breast milk/formula decreased as solid food intake increases -parents encouraged to use iron-enriched foods after 6 months of age

expected cognitive development (Piaget: formal operations): adolescent (12-20 yrs)

-capable of thinking at an adult level -able to think abstractly and can deal with principles -able to evaluate the quality of own thinking -has longer attention span -highly imaginative and idealistic -makes decisions through logical operations -is future-oriented -capable of deductive reasoning -understands how the actions of an individual influences others

carbon monoxide poisoning

-carbon monoxide binds with hemoglobin and reduces oxygen supply to tissues -cannot be seen. smelled, or tasted -s/s include: nausea, vomiting, headache, weakness, and unconsciousness -death may occur with prolonged exposure -prevention by ensuring proper ventilation when using fuel-burning devices -gas-burning devices should be inspected annually -flues and chimneys should be unobstructed -carbon monoxide detectors should be installed and inspected regularly

locations to assess bruits include:

-carotid arteries: over carotid pulses -abdominal aorta: just below xiphoid process -renal arteries: MCL above umbilicus on the abdomen -iliac arteries: MCL below the umbilicus on abdomen -femoral arteries: over femoral pulses

health promotion (injury prevention-burns): infant (birth-1 yr)

-check temp of bath water -turn down thermostat on hot water heater -have working smoke detectors in the home -turn handles of pots/pans to back of stove -apply sunscreen when outdoors during daylight hours -cover electrical outlets

health promotion (injury prevention-burns): toddler (1-3 yrs)

-check temp of bath water -turn thermostat down on water heater -have working smoke detectors in the home -turn pot handles to back of stove -cover electrical outlets -use sunscreen when outside

LOC: lethargy

-client is able to open eyes and respond, but is drowsy and falls asleep readily

expected physical development: older adult (65+ yrs)

-decrease in skin turgor and subcutaneous fat, which leads to wrinkles and dry skin -loss of subcutaneous fat makes it more difficult to adjust to cold temps -thinning and graying of the hair, as well as more sparse distribution -thickening of finger and toe nails -decrease in chest wall movement, vital capacity, and cilia, which increases risk for respiratory infection -slower reaction time -decrease in touch, smell, and taste sensation -decrease in production of saliva -decline in visual acuity -decreased ability for eyes to adjust from dark to light, leading to night blindness -inability to hear high pitched sounds (presbycusis) -decrease in height due to intervertebral disk changes -decrease in muscle strength and tone -decrease in digestive enzymes -decrease in intestinal motility, which can lead to increased risk of constipation -increase in dental problems -decalcification of bones -degeneration of joints -decrease in bladder capacity -prostate hypertrophy in men -decline in estrogen/testosterone production -decline in tri-iodothyronine T3 production, yet overall function remains effective -decreased sensitivity of tissue cells to insulin -atrophy of breast tissue in women

petechia/purpura

-deep reddish/purple -flat -petechiae = 1 to 3 mm -purpura > 3 mm

expected cognitive development (language): school-age (6-12 yrs)

-defines many words and understands rules of grammar -understands that a word can have multiple meanings

coping

-describes how an individual deals with problems and issues -influencing factors include: number, duration, and intensity of stressors; individual past experiences; current support system; available resources (financial)

Objective data should be documented:

-descriptive and should include what the nurse sees, hears, feels, and smells -w/o derogatory words, judgments, or opinions -accurately

expected psychosocial development (Erikson: identity vs role confusion): adolescent (12-20 yrs)

-develops a sense of personal identity influenced by expectations of the family -group identity: may become part of a peer group that greatly influences behavior

expected cognitive development (language): adolescent (12-20 yrs)

-develops jargon within the peer group -able to communicate one way with peer group and another way with parents/teachers -development of communication skills is essential

the second number of the recorded visual acuity is the ___ at which a ___-___ ___ can read the line

-distance -normal-sighted person

expected psychosocial development (social development): preschooler (3-6 years)

-do not generally exhibit stranger anxiety and have less separation anxiety; however, prolonged separation (hospitalization) can provoke anxiety but favorite toys and play can help ease fears -pretend play is healthy and allows children to determine the difference between reality and fantasy -sleep disturbances occur frequently and problems range from difficulty going to bed and night terrors -with sleep disturbances, advise parents to: assess if bedtime is too early/late or naps needed (needs about 12 hrs of sleep per day); keep consistent bedtime routine; use a night light; reassure child that is frightened, but avoid having child sleep with them

health promotion (injury prevention-drowning): infant (birth-1 yr)

-do not leave infant unattended in bath tub

health promotion (drowning): preschooler (3-6 yrs)

-do not leave unattended in bathtub -closely supervise while in pool/other body of water -teach how to swim

health promotion (injury prevention-drowning): toddler (1-3 yrs)

-do not leave unattended in bathtub -keep toilet lids closed -closely supervise at pool/other body of water -teach how to swim

microbes can move by gravity from a nonsterile item to a sterile item:

-do not reach across or above a sterile field -do not turn your back on a sterile field -hold items to be added to a sterile field at a min of 6 inches above the field

during a severe thunderstorm or tornado

-draw shades and close drapes to protect against shattering glass -lower beds to lowest position and move away from windows -place blankets over clients confined to bed -close all doors -move as many ambulatory clients as possible into the hallways (away from windows) -do not use elevators -monitor for severe weather warnings using tv, radio, or internet

crust

-dried blood, serum, or pus -example: scab

home safety risks for preschoolers and school-age children include:

-drowning -motor vehicle/injury -burns -poison

expected psychosocial development (moral development): school-age (6-12 yrs)

-early on, may not understand the reasoning behind many rules and try to find a way around them -instrumental exchange is in place ("I'll help you if you help me.") -child wants to make the best deal, and does not really consider elements of loyalty, gratitude, or justice when making decisions -in latter parts of school years, the child moves into a law-and-order orientation with more emphasis placed on justice being administered

Factors to consider when selecting a delegated

-education, training, and experience -knowledge and skill required to perform the task -level of critical thinking required to complete the task -ability to communicate with others as it pertains to the task -demonstrated competence -agency policies and procedures -licensing legislation (state nurse practice acts)

home fire safety plan should include:

-emergency numbers near the phone -ensure number and placement of fire extinguishers and smoke alarms are adequate and that they are operable -set specific time to check batteries in alarms and operation of extinguishers -have family plan for evacuation and practice regularly -review "stop, drop, and roll" to extinguish fire of clothing or skin -review oxygen safety measures

all health care staff should:

-follow facility protocols for isolation and protection -wash hair frequently and keep it short or pulled back to prevent contamination of care area or client -not wear artificial nails while providing care and keep natural nails short and clean -remove jewelry from hands and wrists to facilitate hand disinfection

Nurses can avoid being liable for negligence by:

-following standards of care -giving competent care -communicating with other health team members -developing a caring rapport with clients -fully documenting assessments, interventions, and evaluations

categories of triage during mass casualty events

-emergent category (class I): highest priority given to clients who have life-threatening injuries but also have a high possibility of survival once they are stabilized -urgent category (class II): 2nd highest priority is given to clients who have major injuries that are not yet life threatening and can usually wait 45-60 mins for treatment -nonurgent category (class III): the next highest priority is given to clients who have minor injuries that are not life threatening and do not need immediate attention -expectant category (class IV): the lowest priority is given to clients who are not expected to live and will be allowed to die naturally; comfort measures may be provided, but restorative care will not

health promotion (injury prevention-MVA): adolescent (12-20 yrs)

-encourage attendance in driver's ed -emphasize need for adherence to seat belt use -discourage use of cell phones while driving -teach dangers of combining substance abuse with driving

prevention education for risk of drowning in preschoolers and school-age children:

-ensure child knows how to swim and knows rules of water safety -locked fences around home and neighborhood pools

seizure precautions include:

-ensure rescue equipment is at bedside -inspect client's environment for items that may cause injury in event of seizure -assist client at risk for seizure with ambulation and transferring -advise all caregivers and family not to put anything in client's mouth in event of seizure (with exception of status epilepticus) -advise caregivers and family not to restrain in event of seizure but to lower to bed/floor, protect head, move nearby furniture, provide privacy, put on side with head flexed slightly forward, and loosen clothing to prevent injury -in event of seizure, stay with client and call for help -admin meds as ordered -note duration of seizure and sequence and type of movement -after seizure, explain what happened to client and provide comfort and quiet -document the seizure along with precipitating factors along with description of event and report it to provider

trendelenburg position

-entire bed is tilted with head of bed lower than the foot of the bed -position used during postural drainage, and facilitates venous return

reverse trendelenburg

-entire bed is tilted with the foot of the bed lower than the head -position promotes gastric emptying and prevents esophageal reflux

lordosis

-exaggerated curvature of the lumbar spine -common during toddler years and pregnancy

kyphosis

-exaggerated curvature of the thoracic spine -common in older adults

factors leading to tachycardia include:

-exercise -fever -medications -changing position from lying down to sitting/standing -acute pain -hyperthyroidism -anemia/hypoxemia -stress, anxiety, fear -hypovolemia, shock, heart failure

CN VII

-facial -assess mouth for taste -assess the face for symmetrical movement

Professional negligence

-failure of person with professional training to act in a reasonable and prudent manner -issues that prompt malpractice suits include failure to: follow standards of care, use of equipment in responsible & knowledgeable manner, effectively & thoroughly communicate with the client, document care was provided

barriers to learning:

-fear, anxiety, depression -physical discomfort, pain, fatigue -environmental distractions -health and cultural beliefs -sensory and perceptual deficits -psychomotor deficits

expected psychosocial development (self-concept development): preschooler (3-6 years)

-feels good about self with regard to mastering skills, such as dressing and feeding, that allow independence -during stress, insecurity, or illness, may regress to previous immature behaviors or develop habits like nose picking, bed wetting, or thumb sucking

s/s of generalized or systemic infection

-fever -increased pulse and resp rate (in response to high fever) -malaise -anorexia, nausea, and/or vomiting -enlarged lymph nodes

expected physical development (size/growth): adolescent (12-20 yrs)

-final 20%-25% of height is achieved during puberty -acne may appear -girls may cease to grow about 2-2.5 years after onset of menarche; will grow 5-20 cm (2-8 in) and 7-25 kg (15.5-55 lbs) -in girls, sexual maturation occurs in order of: appearance of breast buds, growth of pubic hair, onset of menstruation -in males, sexual maturation occurs in order of: increased size of testes/scrotum, appearance of pubic hair, rapid growth of genitalia, growth of axillary hair, appearance of downy hair on upper lip, change in voice -changes in sleep habits

expected psychosocial development (social development): older adult (65+ yrs)

-find ways to remain socially active and to overcome loneliness -maintain sexual health

scale

-flakes of skin that exfoliate -example: dandruff or psoriasis

shape/contour of abdomen can be described as: -flat: -convex: -concave: -distended:

-flat: lies in horizontal line from the chest to the symphysis pubis -convex: rounded -concave: has sunken appearance -distended: a large protrusion of the abdomen caused by fat, fluid, or flatus that can be differentiated as follows: *fat: client has rolls of fat along sides, and the skin does not look taught *fluid: flanks also protrude, when client turns onto side, the protrusion moves to the dependent side *flatus: protrusion is mainly midline, and the flanks are unchanged *hernias: protrusions through the abdominal muscle wall are visible

secondary prevention

-focuses on early identification of individuals or communities experiencing illness, providing treatment, and conducting activities that are geared to prevent worsening health status -examples: communicable disease screening and case finding; early detection and treatment of diabetes; exercise programs for older adult clients who are frail

health promotion (health screenings): older adult (65+ yrs)

-follow age-related guidelines -DEXA screening for osteoporosis -eye exam for glaucoma every 2-3 years or annually depending on provider -mental health screening for depression

health promotion (health screenings): middle adult (35-65 yrs)

-follow age-related guidelines -dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis -eye exam for glaucoma and other disorders every 2-3 years or annually depending on provider -mental health screening for depression

risk factor assessment should assess the following:

-genetics: a predisposition to various illnesses can be attributed to heredity (heart disease, cancer) -gender: some specific diseases are more common in one gender than the other (autoimmune disorders, suicide rates) -physiologic factors: various physiologic states place a client at greater risk for health problems (BMI, pregnancy) -environmental factors: presence of toxic substances and chemicals can affect health where clients work and live; water quality, pesticide exposure, and air pollution should be commonly assessed -lifestyle-risk behaviors: stress, substance abuse, diet deficiencies, lack of exercise, and sun exposure age- early disease detection and intervention is facilitates by following screening guidelines

Change of shift report

-given at the conclusion of each shift by the nurse leaving to the nurse assuming responsibility for the client -can be given face-to-face, audiotaped, or presented during rounds -should include significant objective info, given in logical order, free of gossip and personal opinions, and relate recent changes in meds, treatments/procedures, or discharge plan

The client's responsibility for informed consent:

-giving informed consent -must give consent voluntarily (no coercion), be competent and of legal age (or authorized individual), and receive enough information to make a decision

CN IX

-glossopharyngeal -assess mouth for taste -assess mouth for movement of soft palate and the gag reflex -assess swallowing and speech

expected psychosocial development (body-image changes): young adult (20-35 yrs)

-greatly influenced by what young adults eat and how much exercise they get -pregnancy related body changes may also occur

isolation guidelines

-group of actions that include hand hygiene and use of barrier precautions, which are intended to reduce the transmission of infectious organisms -apply to everyone regardless of diagnosis, and must be implemented whenever contact with a potentially infectious material is anticipated -PPE is changed after contact with each client and between procedures with the same client if in contact with large amounts of blood and body fluids

expected physical development: young adult (20-35 yrs)

-growth has concluded around age 20 -physical senses peak -cardiac output and efficiency peak -muscles function optimally at ages 25-30 -metabolic rate decreases 2%-4% every decade after age 20 -libido higher for men -libido for women peaks during the latter part of this stage -time for childbearing is optimal -pregnancy-related changes occur

the number one measure to reduce the growth and transmission of infectious agents is:

-hand hygiene -hand hygiene refers to both handwashing with an antimicrobial or plain soap and water as well as the use of alcohol-based gels, foams, and rinses

Board of nursing

-has authority to adopt rules and regs for nursing practice in that state -has authority to both issue and revoke a nursing license -set standards for nursing programs -delineate scope of practice among RNs, LPNs, and APNs

When accepting an order from a provider over the phone or verbally, the nurse should:

-have a second RN/LPN listen to the phone order -repeat back the order given including med name, dosage, time and route -document reading back the order and presence of the second nurse on the telephone -question any order that may seem contraindicated due to a previous order or to the client's condition

responsibilities of the nurse when receiving the transferred client

-have any specialized equipment ready -inform roommate of client's arrival (if applicable) -inform other team members of arrival -meet with client and family to complete admissions/orientation process -assess how client tolerates the transfer -review transfer docs -implement appropriate nursing interventions in a timely manner

the nurse should inform the client who smokes and his/her family about:

-hazards of smoking -available resources for smoking cessation -the effect of visiting or riding in a car with a smoker can have on a non-smoker

expected psychosocial development (self-concept development): adolescent (12-20 yrs)

-healthy self-concept developed by having healthy relationships with peers, family, and teachers -identifying a skill or talent helps maintain healthy self-concept -participation in sports, hobbies, or the community can have a positive outcome

safety prevention education/modifications for older adults includes:

-home hazard evaluation conducted by nurse, physical therapist, occupational therapist if deemed necessary -remove items that could cause client to trip, such as throw rugs and loose carpets -place electrical cords against wall and behind furniture -ensure steps and sidewalks in good repair -place grab bars near toilet and in tub/shower and installing a stool riser -non-skid mat in tub or shower -place shower chair in shower -ensure lighting is adequate inside and outside home

if evacuation of a unit is necessary due to fire:

-horizontal evacuation is done 1st -lateral evacuation is done if client safety cannot be maintained

when dealing with safety, all health care workers must be aware of:

-how to assess for and recognize clients at risk for safety issues -procedural safety guidelines -protocols for responding to dangerous situations -security plans -identification and documentation of the incidents and responses per health care agency policy

external emergencies include:

-hurricanes -floods -volcano eruptions -earthquakes -pandemic flu -industrial accidents -chemical plant explosions -major transportation accidents -building collapse -terrorist acts (including biological and chemical warfare)

CN XII

-hypoglossal -assess the tongue for movement and strength

behavior-change strategies nurses can use in health promotion/disease prevention

-identify client's readiness to receive and act upon health info -identify interventions acceptable to the client -help motivate the client to change by setting realistic timelines -reinforce steps the client makes toward change -encourage the client to maintain the change

Examples of questions to use to determine level of interaction with the client:

-is there a need to provide psychosocial support or education during the performance of the task?

planning related to client education includes:

-identify mutually agreed upon client outcomes -prioritize the learning objectives with the client's needs in mind -use methods that emphasize the client's learning style -select age-appropriate teaching methods/material -provide electronic educational resources as appropriate -demonstrate use of the internet as in regard to accessing info and support services and how to recognize reliable sources -organize learning activities to move from simple to more complex tasks, and known to unknown concepts -incorporate active participation in the learning process - schedule teaching sessions to coincide with the client's daily activities

Steps in ethical decision making

-identify whether or not the issue is indeed an ethical dilemma -state the ethical dilemma including all surrounding issues and individuals involved -list and analyze all possible options for resolving the dilemma and review implications of each option -select option that is in concert with the ethical principle applicable to this situation, the decision maker's values and beliefs, and the profession's values set forth for client care; justify why chosen over other options -apply this decision to the dilemma and evaluate the outcomes

transporting client in infection control/isolation

-if movement is unavoidable, take precautions to ensure that the environment is not contaminated -for example surgical mask placed on client with airborn or droplet infection and a draining wound is well covered

health promotion (immunizations): adolescent (12-20 yrs)

-if not given during 11-12, then years 12-20: Tdap, MCV4, HPV2 series (females), HPV4 (males), yearly seasonal flu TIV or LAIV (nasal)

Incident reports (unusual occurrences)

-important part of a facility's quality improvement plan -examples of incidence include med errors, falls, and needle sticks -facts documented without judgment or opinion -should not be referred to in client's medical record

risks of infection

-inadequate hand hygiene (client and caregivers) -compromised health or defenses against infection -use of poor medical/surgical asepsis by caregivers -clients who have poor personal hygiene, poor nutrition, and those who are stressed -clients who live in a very crowded environment -older adult clients -clients who used IV drugs and share needles -clients who engage in unprotected sex -clients who have recently been exposed to poor sanitation, mosquito-born/parasitic diseases, or diseases endemic to area visited but not in client's home country

pulmonary hygiene for immobile clients

-includes turning, coughing, deep breathing, incentive spirometry -done every 2 hrs or as prescribed -decreases growth of micro-organisms and development of pneumonia by preventing stasis of pulmonary excretions, stimulating ciliary movement and clearance which expands the lungs

adult BP tends to ___ with age and older adults may have a slightly ___ SBP due to ___ elasticity of blood vessels

-increase -elevated -decreased

expected psychosocial development (Erikson: autonomy vs shame and doubt): toddler (1-3 yrs)

-independence is paramount for toddler who is attempting to do everything for himself -separation anxiety continues when parent leaves child

expected psychosocial development (body-image problems): infant (birth-1 yr)

-infant discovers mouth is a pleasure producer -hands and feet are seen as objects of play -discovers smiling causes others to react

expected age-appropriate activities: infant (birth-1 yr)

-infants have short attention spans and participate in solitary play -appropriate toys and activities: rattles, mobiles, teething toys, nesting toys, pat-a-cake, playing with balls, reading books

expected psychosocial development (Erikson: trust vs mistrust): infant (birth-1 yr)

-infants trust that their feeding, comfort, stimulation, and caring needs will be met -social development initially influenced by infant's reflexive behavior and includes attachment, separation recognition/anxiety, and stranger fear -attachment seen when infant begins to bond with parents; this development occurs w/in 1st month; process is enhanced when the infant and parents are in good health, have positive feeding experiences, and receive adequate rest -separation recognition occurs during the 1st year as learning physical boundaries from that of other people; learning how to respond to people is next phase in development; positive interactions with parents, siblings, and other caregivers help est. trust -separation anxiety develops between 4-8 months; will protest loudly when separated from parents -stranger fear becomes evident between 6-8 months when children are less likely to accept strangers

health promotion (injury prevention): older adult (65+ yrs)

-install bath rails, grab bars, and hand rails on stairways -remove throw rugs -eliminate clutter from walkways/hallways -remove extension and phone cords from walkways/hallways -instruct on proper use of ambulation-assistive devices -ensure adequate lighting -remind clients to wear eyeglasses and hearing aids -avoid drugs, including alcohol; prevent substance abuse -avoid taking drugs and/or drinking while driving -wear seat belt when operating a vehicle -wear helmet when riding bike, skiing, snowboarding -install smoke and carbon monoxide detectors in home -secure firearms in safe location

When client arrives to room the nurse should:

-intro yourself, explain your role and role of other nursing staff, provide hospital attire, position comfortably, apply ID/allergy bracelets, provide written info and info on advanced directives, document advanced directives in medical record -assess/collect: baselines, reason for seeking care, health history, family history, psychosocial history, nutrition, review of systems, spiritual info, safety assessment, discharge info -inventory personal items brought by client

affective learning

-involves feelings, beliefs, and ideals -example: a client listens to the nurse explain life changes necessary to manage diabetes and then discusses feelings regarding the diagnosis

Criminal law:

-is a subsection of public law -relates to the relationship of an individual with the government -ex: a nurse falsifies a record to cover up a serious mistake may be found guilty of breaking a criminal law

Examples of questions to use to determine potential for harm:

-is there a chance something negative may happen to the client (risk for bleeding, risk for aspiration)? -is the client unstable?

screenings and exams for clients who are asymptomatic

-routine physical: (f) every 1-3 years beginning at 20/annually beginning at 40; 9m) every 5 years starting at 20/annually beginning at 40 -dental assessment: (f&m) every 6 months -blood pressure: (f&m) starting at 20, each routing health care visit, min of every 2 yrs -BMI: (f&m) starting at 20, each routing health care visit -blood cholesterol: (f&m) starting at 20, a min of every 5 yrs -blood glucose: (f&m) starting at 45, min of every 3 yrs -colorectal screening: (f&m) fecal occult blood test annually at 50 AND flexible sigmoidoscopy every 5 yrs or colonoscopy every 10 yrs or double contrast barium enema every 5 yrs -colonoscopy: (f&m) starting at 50, every 1-10 yrs depending on test used -pap test: (f) starting at 21 (or earlier if sexually active) every 1-2 yrs; after 30 every 1-3 yrs depending on provider/test used -clinical breast exam: (f) starting at 20, every 3 yrs; at 40, annually -mammogram: (f) starting at 40, annually -clinical testicular exam: (m) starting at 20, annually -prostate-specific antigen test & digital rectal exam: (m) starting at 50, as indicated by provider

internal emergency readiness includes:

-safety and hazardous materials protocols and infection control policies and practices

health promotion (health screenings): adolescent (12-20 yrs)

-scoliosis

health promotion (health screenings): school-age (6-12 yrs)

-scoliosis: screening for lateral curve before and during growth spurts; can be at school or provider's office

expected psychosocial development development (body-image changes): adolescent (12-20 yrs)

-seem particularly concerned with body images portrayed by the media -changes during puberty result in comparisons between the child and surrounding peer group -parents also give input as to hair styles, dress, and activity -may require help if depression or eating disorders result due to poor body image

expected cognitive development (Piaget: concrete operations): school-age (6-12 yrs)

-sees weight and volume as unchanging -understands simple analogies -understands time (days/seasons) -classifies more complex information -understands various emotions people experience -becomes self-motivated -is able to solve problems

equipment and sterile fields

-select a clean area in the client's environment to set up the sterile field -check that all sterile packages are dry and have a future expiration date -make sure an appropriate waste receptacle is nearby

expected cognitive development (Piaget: sensorimotor stage from birth to 24 month): infant (birth-1 yr)

-separation: when infants learn to separate themselves from other objects in the environment -object permanence: occurs at about 9 months; the process by which an infant knows the object still exists when it is hidden from view -mental representation: recognition of symbols

the types of exudate appearing at the site of infection during the 2nd stage:

-serous (clear) -sanguineous (contains RBCs) -purulent (contains leukocytes and bacteria)

vesicle

-serous fluid-filled, <1cm -example: blister

By practicing nursing within the confines of the law, nurses are able to:

-shield oneself from liability -advocate for client's rights -provide care that is within the nurse's scope of practice -discern the responsibilities of nursing in relationship to the responsibilities of other members of the health care team -provide safe, competent care that is consistent with standards of care

discharge planning

-should begin when client is admitted (with the exception of LTC) -assess if the client will be able to return home and/or if they will need assistance at home -assess residence to see if adaptations or specific equipment will be necessary -make referral to social worker if needed -communicate client health status and needs to community service providers -if client chooses to leave before discharged, notify provider and have pt sign off

health promotion (health screenings): young adult (20-35 yrs)

-should follow age-related guideline -routine health care visits should include: height, weight, and VS; stress screenings; education related to STDs, substance abuse, and contraception; encouragement of good nutrition and regular physical activity

expected physical development (gross and fine motor skills): preschooler (3-6 yrs)

-should show great improvements in fine motor skills such as copying figures on paper and dressing themselves -3 years: (g) rides tricycle, jumps off bottom step, stands on 1 foot for a few seconds -4 years: (g) skips and hops on 1 foot, throws ball overhead -5 years: (g) jumps rope, capable of walking backward with heel to toe, moves up and down stairs easily

health promotion (injury prevention-MVA): preschooler (3-6 yrs)

-sit in approved forward-facing car seat in back set away from airbags -can usually sit in seat until 4 yo or 40 lbs -when outgrown, use booster seat in back seat -should be restrained in car seat or booster until adult belt fits correctly (laws vary from state to state)

stress may be:

-situational -developmental -caused by sociocultural -a contributor to illness vulnerability

the three essential components of hand washing include:

-soap -water -friction

expected psychosocial development (body-image changes): school-age (6-12 yrs)

-solidification of body image occurs -curiosity about sexuality should be addressed with education regarding sexual development and the reproductive process -are more modest than preschoolers and place more emphasis on privacy issues

expected age-appropriate activities: toddler (1-3 yrs)

-solitary play evolves into parallel play where toddler observes other children and then may engage in activities nearby -appropriate activities include: filling and emptying containers, playing with blocks, looking at books, toys that can be pushed and pulled, tossing a ball -temper tantrums result when frustrated with independence restrictions; providing consistent, age-appropriate expectations helps them work through frustrations -toilet training can begin when it is recognized that child has sensation of needing to urinate/defecate; parents should demonstrate patience and consistency; nighttime control may be last to develop -discipline should be consistent and with well defined boundaries established to develop appropriate social behavior

CN XI

-spinal accessory -assess the shoulders for strength

always count the apical pulse rate for

1 min

Which of the following incidents requires the nurse to complete an occurrence report? 1) Medication given 30 minutes after scheduled dose time 2) Patient's dentures lost after transfer 3) Worn electrical cord discovered on an IV infusion pump 4) Prescription without the route of administration

2) Patient's dentures lost after transfer

for an infant the expected pulse rate range is

120-160 bpm

prehypertension range

120/80 - 139/89

stage I hypertension

140/90 - 159/99

Military Time

1:00 am = 0100 2:00 am = 0200 9:00 am = 0900 1:00 pm = 1300 3:00 pm = 1500 6:00 pm = 1800 11:00 pm = 2300

the line on the Snellen chart for which ___ or ___ letters are missed is recorded as the visual acuity

2 or fewer

client must stand ___ ___ from the Snellen chart

20 feet

expected school-age respiratory rate

20-30 rpm

What is the time limit on a counter-signature by provider?

24 hours

a diagnosis of hypertension is made is made if readings are elevated on at least

3 separate occasions over several weeks

inflammatory response

3 stages. signs and symptoms during the first stage of the inflammatory response (local infection), second stage microorganisms have been killed. fluid containing dead tissue cells and WBCs accumulate and exudate appears at the site of infection. exudate leaves body by draining into the lymph system. third stage damaged tissue is replaced by scar tissue.

The client asks the nurse why an electronic health record (EHR) system is being used. Which response by the nurse indicates an understanding of the rationale for an EHR system? 1) It includes organizational reports of unusual occurrences that are not part of the client's record. 2) This type of system consists of combined documentation and daily care plans. 3) It improves interdisciplinary collaboration that improves efficiency in procedures. 4) This type of system tracks medication administration and usage over 24 hours.

3) It improves interdisciplinary collaboration that improves efficiency in procedures.

When the nurse completes the patient's admission nursing database, the patient reports that he does not have any allergies. Which acceptable medical abbreviation can the nurse use to document this finding? 1) NA 2) NDA 3) NKA 4) NPO

3) NKA

What is included in a weekly summary?

A summary of client's condition An evaluation of the client's ability to perform ADL's The client's level of consciousness and mood Hydration and nutrition status Response to medications Any treatment provided Safety measures

expected newborn respiratory rate

30-60 rpm

an older client's average body temperature is

36* C (96.8* F)

expected oral temperature ranges:

36* to 38* C (96.8* to 100.4* F) is acceptable. The average is 37* C (98.6* F)

newborns' temperature should be maintained between

36.5* and 37.5* C (97.7* and 99.5* F)

fever is not usually harmful unless it exceeds

39* C (102.2* F)

At the end of the shift, the nurse realizes that she forgot to document a dressing change that she performed for a patient. Which action should the nurse take? 1) Complete an occurrence report before leaving. 2) Do nothing; the next nurse will document it was done. 3) Write the note of the dressing change into an earlier note. 4) Make a late entry as an addition to the narrative notes.

4) Make a late entry as an addition to the narrative notes.

with menopause, intermittent body temperature may increase by up to

4* C (7.2* F)

Care Plan

A prepared outline of nursing care showing all of the patients needs and the ways of meeting them

expected range for an adult client's pulse is

60-100 bpm at rest

What is interpersonal communication?

A process in which people affect one another through the exchange of information, ideas, and feelings. An integral part of the nursing profession.

for a child age 12-14 the expected pulse rate range is

80-90 bpm

hypoxemia is an SaO2 below

90%

normal BP range

<120/80

stage II hypertension

>160/100

Preferred Provider Organizations (PPOs)

client chooses from a list of contracted providers. using non-contracted providers increases the client's out of pocket costs

Client records: education

A record can frequently provide a comprehensive view of the client, the illness, effective treatment strategies, and factors that affect the outcome of the illness.

Narrative Documentation

A charting system regarded as the traditional method for recording nursing care and activities. It uses a storylike format to document specific information about a patient's conditions and nursing care, usually presented in chronological order.

Problem-Oriented Medical Records

A charting system that emphasizes a patient's problems. Data is organized by problem or diagnosis. develops an individualized plan of care with the following 4 sections: Patient Database, Problem List, Nursing Care Plan, and Progress Notes

What is the goal of nursing documentation?

A clear, concise representation of the client's healthcare experience that is easily accessible and understood by all members of the healthcare team.

Describe the Admission Nursing History Forms

A common record keeping form that guides the admitting nurse through a complete assessment to identify relevant nursing diagnoses or problems for the patient's care plan.

Describe Acuity Records

A common record keeping form that is a method of determining the intensity of nursing care required for a group of patients

Describe Flow Sheets and Graphic Records

A common record keeping form that permits concise documentation of nursing information and patient data over time. (i.e. vital signs, medication administration

Describe Patient Care Summary or Kardex

A common record keeping form that provides concise, summarative information generated by computerized systems.

Discharge Summary forms

A common record keeping form that provides important information relating to the patient's ongoing health problems and need for health care after discharge.

Charting by exception

A documentation method by which only abnormal assessments findings or care that deviates from the standard is charted

Variance

A goal that is not met

variance

A goal that is not met - a deviation from what was planned on the critical pathway

When, where, and how is a handoff report given?

A handoff report may be given at the bedside or in a conference room using paper notes or a mobile or desktop EHR device at the end of one nurses' shift and beginning of another. They are usually given orally.

Which of the following examples illustrates the benefit of collecting data using computerized systems?

A hospital found that the highest readmission rate was seen in patients with congestive heart failure.

Care plan conference

A meeting of a group of nurses to discuss possible solutions to certain problems of a client; allows each nurse the opportunity to offer an opinion about possible solutions; other health care providers invited to offer expertise

What are some common formats for Nursing progress notes?

Can take many forms, including paper, computerized electronic documents, audio or video files, emails, faxes, scanned paper documents, electronically stored photographs, xray findings, and other images.

Therapeutic Communication - Sharing Feelings:

Can validate client's feelings; Share your feelings with your client

If chart unavailable:

Add info on first available line; Start with current date and time; Write "late entry" and reason; Document care indicating time care occurred; Sign the entry

RN delegation to AP.

ADLs, bathing, grooming, dressing, toileting, ambulating, feeding (without swallowing precautions), positioning, bed making, specimen collecting, intake and output, vital signs (for stable pts).

When are telephone orders acceptable?

Acceptable when there has been a sudden change for the worse in the patient's condition and the client's primary care provider is not in the hospital, or does not have access to placing orders electronically outside the hospital. Also acceptable in life-threatening emergency, but must apply the "read-back" safeguard.

Disadvantages to paper health records:

Access may be delayed, retrieving information may be slow, documentation is time-consuming, there is a relatively high risk for patient care error, storage of paper records is expensive, confidentiality is difficult to protect

Documentation Purposes

Accreditation Quality Assurance monitoring Peer Review Requirements for reimbursements Legal protection Research and education

Client records: auditing health agencies

Accrediting agencies such as The Joint Commission may review client records to determine if a particular health agency is meeting its stated standards.

General Guidelines for Recording (cont)

Accuracy: before making an entry, check that the chart is the correct one Sequence: document events in the order they occur Appropriateness: record only information that pertains to the client's health and care Completeness: include care that is omitted because of client's condition, refusal Conciseness: no extra details, client's name and "client" omitted Legal prudence: usually viewed by juries and attorneys in court as a legal document

How to Chart

Accurate, Concise, Complete, Specific, Timely

What is the DAR format?

Acronym for Data, Action, and Response. Data-reflects the assessment phase of nursing process. Action-reflects the planning and implementation phases Response- reflects the evaluation phase

Enhancing therapeutic communication:

Active listening, establishing trust, being assertive, restating, clarifying, and validating messages, interpreting body language and sharing observations, exploring issues, using silence summarizing the conversation

incident or occurrence

Any event that is not consistent with the routine operation of a health care unit or routine care of a patient.

Identify five components of nursing documentation that demonstrate quality care that is legally defensible.

Any five of the following components are an acceptable answer: Legibility Patient's name, information, and date are on each sheet No blank spaces between entries Accurate and objective Errors lined out and initialed No correction fluid or "inking over" the error Signature of the care provider and his title Late entries clearly noted

Documentation

Anything written or printed on which you rely as record or proof of patient actions and activities

How do nurses write problems on a client's problem list?

As a nursing diagnosis

You are a student nurse on a medical-surgical unit. You review your client's chart and notice that the physician has entered orders that do not appear to be appropriate for your client. The physician is still in the area. How would you handle this situation?

As a student nurse, you may wish to discuss the situation with your clinical instructor or the staff nurse assigned to the patient. The physician who wrote the orders must be contacted directly to question the orders. Explain your concerns objectively. If the order still stands, you may refuse to carry out the order, but you will need to go through the chain of command on the unit to do so.

What are the guidelines the nurse should follow when receiving a telephone order? (Select all that apply) A) Date & time of follow-up visit B) Clien'ts name C) Room # (if applicable) D) Insurance information E) Diagnosis F) Repeat & clarify orders with physician G) Write TO or VO to indicat taken by phone H) Date & Time order taken I) Physicians name J) Physician must sign order within timeframe required by institution (usually 24-48 hours).

B, C, E, F, G, H, I, J

SOAPIE is the SOAP meathod with what two additional steps? A) Individual care plan B) Intervention C) Expectations D) Evaluation

B, D

Problem oriented medical record (POMR) includes what information? A) Demographics B) Database C) Pain level D) Problem List E) Care Plan F) Discharge Plan G) Progress notes H) Referrals

B, D, E, G

What information is tracked on flow sheets? (Select all that apply). A) Physicians name B) Vital signs C) Lab results D) Hygiene (I/O measurements in graphs and flow charts) E) Ambulation activity F) Discharge Plan G) Restraint checks

B, D, E, G

What does Focus charting DAR include? (Select all that apply). A) Demographics B) Data C) Alertness Summary D) Action E) Referrals F) Response

B, D, F

Complete

Care given and patient response

narrative charting

is a traditional part of the source-oriented record - Ex: an agency using a charting-by-exception system may use narrative charting when describing abnormal findings

Explain the new rights for clients related to HIPPA. A) Patient right to leave healthcare facility. B) Patient education on privacy protections C) Patient's right to access their medical records. D) Provider must receive consent from patient before releasing information. E) Recourse options if privacy protections are violated.

B, C, D, E

What are the guidelines for quality documentation and reporting? (Select all that apply) A) Detailed B) Factual C) Organized D) Focused E) Accurate F) Complete G) Current H) Electronically recorded

B, C, E, F, G

Advantages of Paper Health record

Care providers comfortable with it because it is familiar. Do not require large databases and secure networks to function. No downtime for system changes, weather, etc. Relatively inexpensive to create new format and update old ones.

The use of abbreviations is a common practice in healthcare. The use of abbreviations contributes to which of the following? A. Decreased efficiency in documentation B. Increased risk for medical errors C. Uniform use in all facilities D. Ease in understanding physician orders

B. Increased risk for medical errors

clinical nurse specialist (CNS)

typically specializes in a practice setting or a clinical field.

Client records: legal documentation

client's record is a legal document and is usually admissible in court as evidence; client can sometimes object, because information the client gives the primary care provider is confidential

Public speaking

unique form of group communication; the speaker addresses a dozen to hundreds of people, with varying degrees of interaction

When reviewing your documentation of a patient, it should reflect: A. everything that could have been done during your shift. B. objective, comprehensive, accurate account of patient data, nursing care provided, and patient response. C. all the procedures, medications, and tasks that were done that day. D. a detailed narrative account of what occurred moment by moment that shift.

B. objective, comprehensive, accurate account of patient data, nursing care provided, and patient response.

Therapeutic communication

client-centered communication directed at achieving client goals; used to establish the therapeutic relationship, provide and obtain healthcare information, and express interest and concern for the client and family

What is permanently kept in Health record?

Care, in chronological order, provided by all healthcare providers. Patients responses to interventions and treatments Important facts about the client's health history, including past and present illnesses, examinations, tests, treatments, and outcomes

If an error is made while recording, the nurse should: A) Erase it or scratch it out. B) Leave a blank space in the note. C) Draw a single line through the error and initial it. D) Obtain a new nurse's note and rewrite the entries.

C.

Case Management Plan and critical Pathways

Case management programs use a multidisciplinary plan of care summarized into critical pathways. The critical pathways are multidisciplinary care plans that include key interventions and expected outcomes within an expected time frame

Cath

Catheter

When are Nursing Discharge/Referral Summaries filed?

Completed when client discharged and completed when client transferred to another institution

Name 7 purposes of documentation/records

CLEAARF Communication Legal documentation Education Assessment Auditing & Monitoring Research Financial billing

blood pressure (BP) is determined by

CO x SVR

c

Calories

CBE Advantages

CBE reduces the amount of time spent on documentation, reduces repetitive charting of routine care, provides a record that is easily read and understood, and clearly highlights any variations from the expected plan of care.

Name 4 common types of reporting by nurses

Change-of-shift Report Telephone Report Transfer Report Incident Report

Organizing the Information

Chart: admission data, advance directive, H & P, doctor's orders, progress notes, diagnostics, interdisciplinary sections; Kardex; MAR; Care plan

Vocabulary

Client must understand the words that a nurse is usingl; Use of interpreters; Medical jargon: "You're going down for a CT", "You are NPO after midnight", "Lasix 40mg po bid"; Various meanings of a word

Relationships Helping Vs Social

Client needs are met; Purpose is to enhance client growth; Interactions are goal directed and planned; Communication is therapeutic; Includes periodic evaluation of goal achievement; Has defined end; Mutual needs are met; Purpose is friendship, socialization, enjoyment or accomplishment of a task; Interactions are spontaneous; Communication may include giving advice; No or little emphasis on the evaluation of the interaction; No defined end

Purpose of Documentation

Communication re patient status and care; Legal Record of Care; Communication; Education; Legal documentation; Quality assurance -chart audits; Reimbursement; Research

How do Healthcare providers use documentation?

Communication- use health record to communicate about patients status and care. Legal record- legal evidence of care provided to patient Continuity of care- can initiate orders for other nurses to carry out. Quality Improvement- healthcare organizations perform manual chart audits of written documentation. Results are used to identify ways to improve care, decrease length of stay, control costs, etc. Reimbursement-documentation needed to be reimbursed by 3rd party payers and to determine if treatments and interventions were needed.

The computerized system should be

Complete Flexible Intuitive Compatible with existing systems

CBC

Complete blood count

Incident Reports

Completed by the staff who witnessed or found the incident; Not included in your notes; Internal record only (not discoverable)

DAR (focus charting)

D-ata A-ction R-esponse

DAR

D-data. A-action. R-response.

expected temporal temperatures are usually:

close to rectal temps, but they are nearly 0.5* C (1* F) higher than oral temps, and 1* C (2* F) higher than axillary temps

Computer Assisted Charting

Degree to which computers are used in HC setting is varied: Order entry, Medications, Reports, Charting Maintain confidentiality -do not display data where others can see it; Correct errors as per protocol; Never leave terminal unattended after you log on; Do not give your password or sign on information to anyone

Charting by exception: A. is a reliable form of documentation, minimizing errors. B. should be used only in ambulatory clinics and long-term care facilities. C. increases the risk of liability in malpractice cases because "not documented, not done." D. can be used to document care accurately on stable patients.

D. can be used to document care accurately on stable patients.

Focus Charting or DAR

DAR= data, action, response. a format of structured notes that places less importance on patient problems and focuses on patient concerns such as a sign or symptom, condition, significant event etc.

focus charting or DAR

Data Action Response

Problem Oriented Record

Database, Problem list, Plan of care, Progress notes

General Guidelines for Recording

Date and time: conventional a.m./p.m. or 24-hour Timing: no recording before providing care Legibility: must prevent interpretation errors Permanence: entries made in dark ink Accepted terminology: when in doubt, write the term out fully, may be different between agencies Correct spelling: look up in dictionary or resource book if unsure Signature: includes name and title

Medication Administration record requires:

Date of order, expiration date, name and dose, frequency and route of administration, nurse's signature

List the important factors to document when taking a physician's verbal order:

For verbal orders, the following factors are important to document: Only write the prescription if you heard it yourself; no third-party involvement is acceptable. Repeat the prescription even if you believe you understood it entirely. Spell unfamiliar names using a system like "B as in boy." Pronounce digits of numbers separately; for example, instead of "seventeen" say "one, seven." Make sure the verbal orders make sense with the patient's status. If possible, have a second nurse listen to the order to verify accuracy. Directly transcribe the prescription the possibility of error. When writing the prescription, first document the date and time. Then write the text of the prescription. Following the text of the order, document "T.O." followed by the ordering provider's name before yours. Be sure you have the phone number of the provider to allow access if future questions arise. The physician must countersign all verbal and phone orders within 24 hours.

Consultation

Form of discussion where one professional caregiver gives formal advice about the care of a patient to another caregiver

Record (chart or client record)

Formal, legal document that provides evidence of a client's care; can be written or computer based

Client records: reimbursement

From the federal government; must contain correct DRGs (diagnosis-related group) codes and reveal that the appropriate care has been given

Consider body language

Gestures that are acceptable in one culture may be taboo in another. Know what is acceptable to the client. Be aware that smiling does not universally indicate friendliness.

Giving a Hand-off Report

Goal: provides continuity of care for the patient Standardized procedure includes opportunities to ask and respond to questions

Flow Sheets

Graphic record, Intake and Output record, Medication Administration record, Skin assessment record (Braden Assessment)

HOH

Hard of hearing

Therapeutic Communication - Assertive:

Having or showing a confident and forceful personality.

HA

Headache

Legislation to protect patient privacy for health information that governs all areas of patient information and management of that information.

Health Insurance Portability and Accountability Act (HIPAA)

HIPPA

Health Insurance Privacy and Portability Act

Electronic Health Record

Health records that are recorded electronically

Therapeutic Communication - Providing Information:

Helps clients make informed decisions

What should be done if a prescription is entered electronically?

Indicate during the order entry that it was given verbally or over the telephone, the date and time the order was given, and then search for and select the prescriber's name. Click "sign" or whatever option in your EHR indicates the order is sgned and is now active.

Discussions

Informal oral communication between health care givers to identify a problem or establish strategies to resolve a problem

Discussion

Informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem

When recording a Patient teaching in a report, what criteria do I record?

Information presented, method of instruction, patient response, including questions and evidence of understanding such as return demonstration or change in behavior

the correct order for performing abdominal assessment techniques is:

Inspect, Auscultate, Percuss, Palpate

the correct order for completing a physical assessment (with exception to the abdomen):

Inspect, Palpate, Percuss, Auscultate

auscultation of the lungs (abnormal or adventitious sound): rhonchi

coarse sound heard during either inspiration or expiration resulting from fluid or mucus, may clear with coughing

Classification systems include

NANDA/NANDA-I NIC NOC

Source-Oriented Records

Narrative notes: Hand written account of the client's activities Advantages --Used with flow sheets and other systems --Chronological data quickly documented --Familiar form --Used in all types of settings --Inexpensive Disadvantages --Requires time --May be hard to read --May lack information concerning client outcomes --Quality Assurance monitoring more difficult --Relevant data found in several places

N/V/D

Nausea, vomiting, diarrhea

Confidentiality

Never leave in public areas; Never remove client information from facility; Dispose of confidential papers properly

NAS

No added salt

Can I leave blank lines in nurses' notes? Why or why not?

No because another person can add incorrect information in that space. I need to chart consecutively, line by line. If space is left, draw a line horizontally through it and sign my name at the end

Should I write retaliatory or critical comments about a patient or care by another health care professional in a report? Why or why not? If not, what should I write?

No, because the statements can be used as evidence for nonprofessional behavior or poor quality of care. I should enter only objective descriptions of the patients behavior; use quotations for patient comments.

When making an entry are phrases such as "status unchanged", or "had a good day acceptable?

No. Use complete, concise descriptions of care. Dont use documentation that is subjective and does not reflect patient assessment.

Levels of Health Care

Preventive, primary, secondary, tertiary, restorative, and continuing.

Four parts when charting in SOAP format:

Problem list Initial plan Progress notes Discharge summary

PIE documentation

Problem or nursing diagnosis for the patient Interventions or actions Evaluation of the outcomes of nursing interventions

Problem-Intervention-Evaluation: PIE

Problem: Uses data from your assessment to identify appropriate diagnosis Intervention: Document the nursing actions you take for each nursing diagnosis Evaluation: Document the patient's response to interventions and treatments

Explain use of each part of PIE

Problem: uses data to identify nursing diagnoses. Intervention: Document the nursing actions you take for each nursing diagnosis. Evaluation: Document the patients response to interventions and treatments.

Supervising

Process of directing, monitoring, and evaluating the performance of tasks by another member of the health care team

recording, charting, or documenting

Process of making an entry on a client record

Delegating

Process of transferring authority and responsibility to another member of the health care team to complete a task, while retaining accountability

Nursing documentation

Progress notes, flowsheets, education record, MAR, I/O sheets, VS graphic, computer

Access to records

Property of facility or agency; Only those with "need to know" per facility policy; Expect changes with electronic records

Consistent documentation provides

Quality control Justification for reimbursement

Critical thinking incorporates: R___, L___, and I___.

R-eflection L-anguage I-ntuition

the fire response in the health care setting always follows the ____ sequence

RACE -Rescue: protect and evacuate clients in close proximity to the fire -Alarm: report the fire by setting off the alarm -Contain: close doors and windows as well as turning off any oxygen sources; clients on life support are ventilated with bag-valve mask -Extinguish: extinguish the fire if possible using an appropriate fire extinguisher

How should you document?

Record data accurately, use neutral, nonjudgmental language, avoid vague, subjective words (ex. good, average), use only the abbreviations authorized by your organization, use correct spelling and grammar, date and time all your notes accurately, use of restraints, occurrences such as falls and medication errors, complete data about medications, unscheduled, prn, IV infusions, and STAT medications.

Computerized medical record system

Reduces errors Aids timeliness and completeness of data Assists interdisciplinary communication

Communicating

Reinforces constructive behavior; Discourages unproductive behavior; Provides recognition

What should be used for all types of oral reports?

Remember the acronym CUBAN Confidential-Uninterrupted-Brief-Accurate-Named nurse Use a standardized format (ex. PACE, SBAR)

Message:

The content of the communication; How can 2 nurses relay the same information but convey 2 different messages?

Computerized documentation

The documentation of patient information electronically

What is the focus on a Focus Chart?

The focus is often a nursing diagnosis, a client behavior, a special need, an acute change in condition, or a significant event.

Focus Charting:DAR Notes

The focus system of documentation organizes entries by data (D) actions (A) and response (R) D: BP 90/70,skin diaphoretic, pt responds to name. A: Placed Pt in Trendelenburg position, ↑ IV to 100 mL/hr per protocol Dr. Jones. R: BP ↑ 100/80 3 min post increased IV rate. M. Bacha, RN

What important factors should you document when receiving a telephone order?

The following are guidelines for telephone orders: Only write the prescription if you heard it yourself; no third-party involvement is acceptable. Repeat the prescription even if you believe you understood it entirely. Spell unfamiliar names using a system like "B as in boy." Pronounce digits of numbers separately; for example, instead of "seventeen" say "one, seven." Make sure the verbal orders make sense with the patient's status. If possible, have a second nurse listen to the prescription to verify accuracy. Directly transcribe the prescription onto the chart. Transcribing it onto a piece of paper and then copying it again introduces another chance of error. When writing the prescription, first document the date and time. Then write the text of the prescription. Following the text of the order, document "T.O." followed by the ordering provider's name before yours. Be sure you have the phone number of the provider to allow access if future questions arise. The physician must countersign all verbal and phone orders within 24 hours.

What aspects of care should be documented?

The following aspects of care should be documented: Routine care Assessment data Any significant events or changes in condition If informed consent is obtained Any occurrences Calls to the primary care provider Teaching performed Use of restraints Refusal of medicines or treatments Patient's spiritual concerns

Feedback:

The message returned by the receiver; Sender must listen effectively

What forms do nurses use to document nursing care?

Vary by purpose, institution, and unit. Regardless of system or forms used, nursing documentation reflects the nursing process.

I assess each resident in a long-term care agency receiving funding from medicare and medicaid programs using

The resident assessment instrument/minimum data set (RAI/MDS)

Environment:

The setting for communication; Consider distractions, timing & relevance

What are the key differences in the organization of source-oriented records, problem-oriented records (PORs), electronic documentation systems, and CBE systems?

The source-oriented record is organized according to discipline. Each discipline charts in its defined section of the chart. The problem-oriented record is organized around a patient problem list. All disciplines chart on shared notes that are referenced to the identified problem. The EHR can contain both source-oriented and problem-oriented records. In a CBE system only significant findings or exceptions to standards and norms of care are charted. CBE uses preprinted flow sheets to document most aspects of care, and it assumes that unless a separate entry has been made (an exception), all standards have been met, prescribed care has been done, and the patient has responded normally. Normal responses for various assessments are defined on the form.

What is under consideration for the "do not use" list:

The symbols > and < for greater and less than All abbreviations for drug names Apothecary units (use metric units instead) The symbol @ (write "at" or "each") The abbreviation "cc" (write mL and milliliters) The abbreviation "ug" (write mcg or micrograms)

Begin each entry with _________ and end with _________

The time and date; Your signature and title.

Identify at least five types of paper documentation forms.

There are many types of documentation forms. Among them are nursing admission data forms, discharge summaries, flow sheets, graphic records, checklists, intake and output records, medication administration records, Kardexes or patient care summaries, integrated plans of care (IPOCs), and occurrence reports. Occurrence forms and the Kardex® are not part of the patient record and as such are not charting forms. They are used to document unusual events (occurrence forms) or to summarize care (Kardex®).

Problem-Oriented Record Systems Advantages

There is a common problem list that includes input from all disciplines. It is easy to monitor the patients progress because each problem is readily identified in notes. Each discipline has ready access to the findings of other members in healthcare team, which can lead to greater collaboration.

What is a verbal order?

Verbal orders are spoken directions for patient care given to you in person, usually during an emergency situation. Providers should never use verbal orders as a routine method of communicating orders.

source-oriented record

Traditional client record - Narrative charting used - This type of record, info about a particular problem is distributed throughout the record. - Ex: pt had left hemiplegia *Components * *Admission (face) sheet:* legal name, birth date, age, gender, SSN, address, marital status; closest relatives or person to notify in case of emergency, allergies, name of admitting (attending) primary care provider, insurance info, any assigned diagnosis-related group (DRG) *Initial nursing assessment:* Findings from the initial nursing history and physical health assessment *Graphic record:* Body temp., pulse rate, respiratory rate, BP, daily weight, and special measurements such as fluid I&O's, and O2 *Daily care record:* Activity, diet, bathing, and elimination records *Special flow sheets:* Ex: fluid balance record, skin assessment *Medication record:* Name, dosage, route, time, date of regularly administered medications, Name or initials of person administering the meds *Nurses' notes:* Pertinent assessment of client; Specific nursing care including teaching and client's responses *Medical history and physical examination:* Past or family medical history, present medical problems, differential or current diagnoses, findings of physical examination by the primary car provider *Physician's order form:* Medical orders for meds, treatments, and so on *Physician's progress notes:* Medical observations, treatments, pt. progress, and so on *Consultation records:* Reports by medical and clinical specialists *Diagnostic reports:* Ex: lab reports, x-ray reports, CT scan reports *Consultation reports:* PT, RRT *Client discharge plan & referral summary:* Started on admin. & completed on discharge; includes nursing problems, general info., and referral data

What is a transfer report?

Transfer reports are reports given when a patient is transferred form unit to unit or facility to facility. If patient is being transported to another unit in the same facility, you will need to transport a paper chart with the patient.

Client records: research

Treatment plans for a number of clients with the same health problems can yield information helpful in treating other clients

T or F: A client's problem list is usually kept at the front of the chart and problems are listed in the order in which they are identified. All caregivers may contribute to the problem list.

True

T or F: A nurse should write complete order down and read it back to primary care provider to ensure accuracy; also, should question any order that is ambiguous, unusual, or contraindicated.

True

T or F: Health care reform has been pivotal in the process of increasing the use of the electronic health record (EHR).

True

T or F: Many agencies only allow registered nurses to take telephone orders.

True

bid

Twice a day

Nursing rounds

Two or more nurses visit selected clients at bedside; obtain information that will help plan nursing care and evaluate care given

Regulatory Agencies

U.S. Dept of Health and Human Services, U.S. Food and Drug Administration (FDA), State and local public health agencies, State licensing boards (to ensure that HC providers and agencies comply with state regulations), The Joint Commission (to set quality standards for accreditation of HC facilities), Professional Standards Review Organizations, Utilization review committees (to monitor for appropriate diagnosis and tx of hospitalized clients).

variences

Unexpected outcomes, unmet goals, and interventions not specified within the critical pathway. A varience occurs when the activities on the critical pathway are not completed as predicted or the patient does not meet the expected outcomes.

Common formats for nursing progress notes:

Use of abbreviations Narrative - tells the story of the patient's experience in a chronological formal Problem-Intervention-Evaluation (PIE) SOAP/SOAPIE/SOAPIER: subjective, objective, assessment, plan,, interventions, evaluation, revision Focus charting - uses assessment data to evaluate client care concerns, problems, or strenths FACT - flowsheets, assessment, concise and integrated progress notes and flowsheets, timely entries Electronic entry

What establishes accuracy?

Use of exact measurements.

When is Narrative charting useful?

Useful when attempting to construct a time line of events, such as a cardiac arrest or other emergency situations.

Focus charting

Uses assessment data to evaluate client care concerns, problems, or strengths. Identifies necessary revisions to the care plan as you document each entry.

Telephone order

When a health care provider gives an order over the phone to a registered nurse

An RN makes a telephone report when?

When significant events or changes in a patient's condition have occured

Background

When the benchmark is not met: - Impact in Medicare Reimbursement - Government will hold 1% of Medicare payments - This is expected to increase to 2% by 2017

When and Who

When: Document care when you perform it or shortly thereafter = timely; Never document ahead Who: Chart what you see and do; Never ask another nurse to complete your charting; Never complete anyone else's charting

Tertiary health care

involves the provision of specialized highly technical care. examples include oncology centers and burn centers

rebound tenderness (Blumberg's sign) is an indication of

irritation or inflammation somewhere in the abdominal cavity

standard precautions: tier one

applies to all body fluids except sweat, nonintact skin, and mucous membranes, implemented for all pt. hand hygiene using an alcohol-based waterless product is recommended after contact with the pt, body fluids, and contaminated equipment and articles, and after removal of gloves. alcohol-based waterless antiseptic is preferred unless the hands are visibly dirty, because alcohol-based product is more effective in removing organisms. clean gloves worn when touching all body fluids, nonintact skin, mucous membranes, and contaminated equipment and articles. remove gloves and complete and hygiene between pt. masks, eye protection, and face shields are required when care may cause splashing or spraying of body fluids, gloves are worn when toughing anything that has the potential to contaminate the hands of the nurse. hand hygiene is required after removal of gown. use a sturdy moisture resistant bag for soiled items, and tie the bag securely in a knot at the top. properly clean equipment for pt care, dispose of one-time use items according to facility policy. bag and handle contaminated laundry to prevent leaking or contamination of clothing or skin. enable safety devices on all equipment and supplies after use; dispose of all sharps in a puncture resistant container. pt doesnt need a private room unless unable to maintain appropriate hygiene practices.

Critical pathway or care maps

are multidisciplinary care plans that include pt health concerns, key interventions, & expected outcomes w/in an established time frame

Descriptive terms

are utilized to provide detailed description & clarification

Nursing informatics

area of nursing which focuses on technology in health care, promote efficiency, productivity, and effectiveness of care

shiny and translucent skin without hair on toes and foot is seen with

arterial insufficiency

ad lib

as desired, if the patient desires

prn

as needed

intentional torts

assault, battery, and false imprisonment

right person

assess and verify the competence of the team member, the task must be within the team member's scope of practice and must have the necessary competence and training. continually review the performance of the team member, and determine care competence, assess the team member's performance according to standards, and when necessary, take steps to remediate any failure to meet standards.

right circumstance

assess the health status and complexity of care the client requires, match the complexity of care demands to the skill level of the team member, consider the workload of the team member.

PT

assesses and plans for pt to increase musculoskeletal function, esp. of the lower extremities, to maintain mobility. ex. of when to refer: following hip arthroplasty, a pt requires assistance learning to ambulate and regain strength.

occupational therapist

assesses and plans for pt to regain activities of daily living skills, esp. motor skills of the upper extremities. ex. of when to refer: a pt has difficulties using an eating utensil with her dominant hand following a stroke.

provider

assesses, diagnoses, and tx disease and injury. includes medical doctors, doctors of osteopathy, advanced practice nurses, and physician assistants. state regulations vary in their requirements for supervision of APNs and PAs by a physician. ex. of when to refer: a pt has a temp of 39 degree C (102.2 degree F), is achy, shaking, and reports "feeling cold".

registered dietitian

assesses, plans for, and educates regarding nutrition needs. designs special diets, and supervises meal preparation. ex. of when to refer: a pt has a low albumin level and recently had an unexplained weight loss.

information to document

assessments, medication administration, tx and responses, client education.

noc

at night

telephone or verbal prescriptions

best to avoid these, but they are sometimes necessary during emergencies and at unusual times. have a second nurse listen to a telephone prescription, repeat it back, making sure to include the medication's name (spell if necessary), dosage, time, and route. question any prescription that may seem inappropriate for the client. make sure the provider signs the prescription in person within the time frame the facility specifies typically 24 hrs.

Nonverbal communication

body language, exchange of messages without the use of words

older children and adolescents have varying BP based on

body size (larger children have a higher BP)

inflammation

body's local response to injury or infection.

BM

bowel movement

maintaining sterile field

avoid coughing, sneezing, and talking directly over a sterile field. advise pt to avoid sudden movements, refrain from touching supplies. only sterile items may be in sterile field. outer wrappings and 1-inch edges of packages that contains sterile items arent serile. the inner surface of the sterile drape or kit is the sterile field that needs to be avoided. to position field on the table surface, grasp the border before donning sterile gloves, discard any object that comes into contact with the border. touch sterile materials only with sterile gloves, consider any object held below waist or above chest contaminated, sterile materials may touch other sterile surfaces or materials; microbes can move by gravity from a nonsterile item to a sterile item so dont reach across or above a sterile field, dont turn your back on a sterile field, hold items to add to a sterile field at a minimum of 6 inches above field. any sterile, nonwaterproof wrapper that comes into contact with moisture becomes nonsterile by wicking action, keep all surfaces dry, discard any sterile packages that are torn, punctured or wet.

nonmaleficence

avoidance of harm or injury.

Nonmaleficence

avoidance of harm or pain as much as possible when giving treatments

Passive approach

avoids conflict and allows other to take the lead

types of pathogens

bacteria, viruses, fungi, prions, and parasites

occipital lymph node located

base of skull

standardized care plans

based on nursing assessment customized for patient

assessing/ collecting data

baseline data-vitals, ht, wt, allergy status, meds. biographical info. the clients reason for seeking health care, present illness and symptoms, health hx-current illness, current meds, prior illness, chronic diseases, surgeries, previous hospitalizations, other relevant data. family hx. psychosocial assessment-alcohol, tobacco, drug, and caffeine use, hx of mental illness, hx of abuse or homelessness, home situation/significant others. nutrition-current diet, any chewing or swallowing problems, recent wt gain/loss. spiritual health/quality of life concerns-religion, advance directives, living will. review of systems, safety assessments-hx of falls, sensory deficits, use of assistive devices. discharge info-family members in the home, transportation for discharge, any relevant phone numbers, medical equipment needs at home. inventory any personal items-document leaving items at, storing, sending where, and locking up where, discourage keeping valuables at bedside. orient the client and family to the room and facility. share info, including the following-call light operation, electric bed operation, telephone services/television controls,, overhead lighting operation, smoking policy, restroom locations, waiting areas, meal times, usual time for provider's wishes, dining/vending services, visiting policies.

levels of critical thinking

basic critical thinking, complex critical thinking, and commitment.

BRP

bathrooom privileges

absence of breath sounds should:

be noted

BR

bedrest

BSC

bedside commode

prior to asepsis

before beginning task HC team must check for latex allergies.

legal guidelines

begin each entry with a date and time, record entries legibly, in nonerasble black ink, and dont leave blank spaces in the nurse's notes. dont use correction fluid, erase, scratch out, or blacken out errors in the medical records. make corrections promptly following the facility's procedure for error correction. sign all documentation as the facility requires, generally with name and title. documentation should reflect assessments, interventions, and evaluations, not personal opinions or criticism of others care.

Sender

begins the conversation to deliver a message to another person

Orientation phase

begins when you meet the client

bradycardia is

below expected range or slower than 60 bpm

quasi-intentional torts

breach of confidentiality, and defamation of character

implementation

carrying out a plan of care

CVA

cerebrovascular accident (stroke)

2 examples of hand off reports

change of shift reports and transfer reports

Handoff report

change-of-shift or handover report; alert the next caregiver about the client's status or recent changes in the client's condition and to discuss planned activities, tests, procedures, or concerns that require follow-up Methods: bedside report, face-to-face oral report, audio-recorded report Includes: SBAR, client progress made during your shift, therapies and treatments administered, teaching done, consultations done or planned with other disciplines, status of identified desired outcomes, any changes in client status, progress made on discharge planning

reporting formats

change-of-shift reports, telephone reports, telephone or verbal prescriptions, transfer reports, incident reports.

brown pigmentation of skin

changes with venous insufficiency

practices to reduce microorganisms

changing linens daily, cleaning floors, bedside stands, separating clean from contaminated materials. use masks, gloves, gowns, and protective eye wear to prevent spread and control contact of micro-organisms. dont place items on floor. cover mouth and nose when coughing, sneezing, using and disposing of facial tissue, and performing hygiene to prevent spraying and spreading droplet infections. dont shake linens, this can spread organisms through the air. keep soiled linens away from clothing. clean the least soiled areas first to prevent moving more contaminants to cleaner areas. use plastic bags for moist, soiled items. put all soiled items directly into the appropriate receptacle. place all lab specimen in biohazard containers or bags for transport or disposal. pour any liquids used for client care directly into drain and avoid splattering to prevent spreading droplets. empty body fluids at water level of toilet to prevent splashing. wash hair frequently, and keep it short or pulled back to prevent contamination of care area. keep natural nails short and clean, remove jewelry from hands and wrists.

PIE doucumentation

charting the patients progress under the headings of 1. Problem, 2. Interventions, and 3. Evaluation

ROM head: hyperextention

chin up

serous

clear

Implied consent

client adheres to instructions provided by the nurse; ex: the nurse is preparing to administer a TB test and the client holds out his arm for the nurse

risk of infections

inadequate hand washing, individuals with compromised health or defenses against infection, caregivers using medical and surgical asepsis that doesn't follow established standards, clients who have poor personal hygiene, nutrition, smoke, or consume excessive amounts of alcohol, and those experiencing stress. clients who live in a very crowded environment, older adults clients, individuals who make poor lifestyle choices that put them at risk, client who have recently been exposed to poor sanitation, mosquito-borne or parasitic diseases, diseases endemic to the area visited, but not in the client's home country.

Secondary health care

includes the diagnosis and treatment of emergency, acute illness, or injury. examples include care given in hospital settings (inpatient and EDs), diagnostic centers, or emergent care centers

Health Care Systems

incorporate interactions b/w health care providers and pts within constraints of financing mechanisms and regulatory agencies.

evolution of critical thinking

incorporates reflection, language, and intuition. evolves through three distinct levels as nurses gain knowledge and experience while maturing into a competent nursing professional.

impaired oxygen-carrying capacity of the blood that occurs with anemia or at high altitudes results in:

increases in the respiratory rate and alterations in rhythm to compensate

stages of infection

incubation, prodromal stage, illness stage, convalescence.

chain of infection

infection process: causative agent, reservoir, portal of exit, mode of transmission, portal of entry to host, susceptible host

Knowledge

information specific to nursing and acquired through: basic nursing ed; continuing ed courses; advanced degrees and certifications

___ ___ can be used to enhance access to and delivery of knowledge

information technology

knowledge

information thats specific to nursing and comes from basic nursing education, continuing education courses, and advanced degrees and certifications.

client's rights

informed consent, refusal of tx., advance directives, confidentiality, and information security. these are legal privileges or powers they possess when they receive health care services, clients using the services of a health care institution retain their rights as individuals and citizens. the American Hospital Association identifies pt rights in health care. nursing facilities that participate in medicare programs also follow "resident rights" statutes that govern their operation.

radioactive gallium citrate

injected by IV and accumulates in area of inflammation

endogenous source

inside the client when part of the client's flora has been altered.

battery

intentional and wrongful physical contact with a person that involves an injury or offensive contact. ex. a nurse restrains a client and administers an injection against her wishes.

Group communication

interaction that occurs among several people; small-group communication occurs when you engage in an exchange of ideas with two or more individuals at the same time

The electronic health record and electronic medical record are frequently used

interchangeably

Restorative HC

intermediate follow-up care for restoring health. ex. home health care, rehabilitation centers, and skilled nursing facilities.

critical thinking skills

interpretation, analysis, evaluation, inferance, and explanation used to make clinical judgements. an active, orderly, well thought-out reasoning process that guides nurses in various approaches to making a nursing judgement by applying knowledge and experience, problem-solving, logic, reasoning, and decision-making. critical thinkers prioritize, explores various courses of action, keeps ethics in mind, and determines appropriate outcomes. requires life long learning and the ability to acquire relevant experiences that can be reflected on continuously to improve nursing judgement. components: knowledge, experience, critical thinking competencies, attitudes, and intellectual and professional standards.

prodromal stage

interval b/w onset of general symptoms to more distinct symptoms. during this time pathogen is multiplying.

incubation

interval b/w the pathogen entering the body and presentation of first symptom.

convalescence

interval when acute symptoms disappear. total recovery could take days to months.

illness stage

interval when symptoms specific to the infection occur.

IVP

intravenous push (caution: do not use to mean "IV piggyback")

assessment/data collection

involves collection of info about client's present health status to identify needs and additional data to collect based on findings. nurses can collect data during initial assessments, focused assessments, or ongoing assessments. methods of data collection include observation, interview, medical hx, comprehensive or focused physical exam, diagnostic and lab reports, and collaboration. to collect data nurses must ask appropriate questions, listen carefully to responses, and have excellent head-to-toe physical assessment skills. must employ clinical judgement and critical thinking in accurately recognizing when to collect assessment data. must recognize the need to collect assessment data prior to intervention. during this the nurse validates, interprets, and cluster data. documentation of assessment data must be thorough, concise and accurate.

Restorative health care

involves intermediate follow-up care for restoring health. examples include home health care, rehab centers, and skilled nursing facilities

Patient-centered Care

involves nurses individualizing their care to patients and being responsive to meeting each patients needs

Verbal order

involves the health care provider giving orders to a nurse while they are standing near each other

client record

is a formal, legal document that provides evidence of a pt's care and can be written or computer based

SOAP, SOAPIE, SOAPIER

is an acronym for *S*ubjective data -consist of info obtained from what the client says; it is only included when it is important & relevant to the problem) *O*bjective data - consist of info that is measured or observed by use of the senses (e.g., vital signs, lab and x-ray results) *A*ssessment - is the interpretation or conclusions drawn about the subjective and objective data; should describe the client's condition and level of progress rather than merely restating the diagnosis or problem *P*lanning - is the plan of care designed to resolve the stated problem and is written by the person who enters the problem in records *I*interventions - refer to the specific interventions that have actually been performed by the caregiver *E*valuation - includes client responses to nursing interventions and medical treatments. This is primarily reassessment data. *R*evision - reflects care plan mods suggested by the evaluation. Changes may be made in desired outcomes, interventions, or target dates.

Nursing Minimum Date Set (NMDS)

is an effort to establish uniform definitions and categories (e.g., nursing diagnoses) for collecting, essential nursing data for inclusion in computer databases

Documentation

is anything entered into a patient's electronic medical record or written in a patient record

fairness

is objective, nonjudgemental

report

is oral, written, or computer-bases communication intended to convey information to others

Litigation

is the process of taking a case through court

Isol

isolation

equipment

items to transfer/discharge with client: personal belongings, valuables from the safe, medications, assistive devices, medical records or transfer form.

nystagmus

jerky or tremor-like eye movements

auscultatory sites for the heart: tricuspid

just left of the sternum at the fourth ICS

auscultatory sites for the heart: pulmonic

just left of the sternum at the second ICS

auscultatory sites for the heart: erb's point

just left of the sternum at the third ICS

auscultatory sites for the heart: aortic

just right of the sternum at the second ICS

antimicrobial therapy

kills or inhibits the growth of organisms (bacteria, fungi, viruses, protozoans). either kill pathogen or prevent their growth. give antihelmintics for worm infestations. there are currently no tx for prions. considerations: administer antimicrobial therapy as prescribed. monitor for med. effectiveness (reduced fever, and increase in the level of comfort, decreasing WBC count). maintain a med schedule to assure consistent therapeutic blood levels of the antibiotic.

social media precautions

know the implications of HIPAA before using social networking sites for school or work-related communication, become familiar with your facility's or schools policies or about using social networking, dont use or view social networking media in clinical setting, dont post info about your school, clinical sites, clinical experiences, clients, and other HC staff on social networking sites.

timing/relevance

knowing when to communicate allows the receiver to be more attentive to the message

components of critical thinking

knowledge, experience, competence, attitudes, and standards.

LMP

last menstrual period

___ is an intentional gain of new information and represents a change in behavior

learning

auscultatory sites for the heart: apical/mitral

left midclavicular line at the fifth ICS

The client's chart or medical record is the ____ record of care

legal

Client record is a ___________

legal document

Living will

legal document that expresses client's wishes regarding medical treatment in the event the client becomes incapacitated and is facing end-of-life issues

living will

legal document that expresses the client's wishes regarding medical tx in the event the client becomes incapacitated and is facing end-of-life issues. most states laws include provisions that protect health care providers who follow this from liability.

informed consent

legal process by which a client has given written permission for a procedure or tx. consent is informed when a provider explains and the client understands the reason they need the tx or procedure, how the tx or procedure will benefit them, the risks involved if they chose to receive the tx or procedure, and other options to tx the problem, including not txing the problem.

Informed consent

legal process by which the client has given written permission for a procedure or treatment to be performed

lab and diagnostic results indicating infection

leukocytes (WBCs) >10,000/nanoL. increases in specific types of WBC on differential (left shift=an increase in neutrophils). elevated erythocytes sedimentation rate (ESR) over 20mm/hr. an increase indicates an active inflammatory process or infection. presence of microorganisms on culture of the specific fluid/area.

nursing care for shingles

monitor pain, condition of lesions, presence of fever, neurologic complications, signs of infection. use an air mattress of bed cradle for pain prevention and control of affected areas, isolate the client until the vesicles have crusted over, maintain strict wound care precautions, avoid exposing pt to infants, pregnant who haven't had chickenpox, and pt who are immunocompromised. moisten dressings with cool tap water or 5% aluminum acetate (Burow's solution) and apply to the affected skin for 30-60 min, for to six times per day as prescribed. meds: analgesics (NSAIDs, narcotics) enhance client comfort, antiviral agents, such as acyclovir (zovirax), may shorten the clinical course.

RN delegation to LPNs

monitoring findings as input to RNs ongoing assessment, reinforcing client teaching from a standard care plan, performing a tracheostomy care, suctioning, checking nasogastric tube patency, administrating enteral feedings, inserting urinary catheters, administrating medications excluding IV meds in some states.

___ influences how much and how quickly a person learns

motivation

ROM head: flexion

movement chin to chest

abduction

movement of extremity away from midline

adduction

movement of extremity toward midline

dorsiflexion

movement toward the dorsum (or top of wrist or foot)

plantar flexion

movement toward the plantar surface (or bottom of the foot)

nursing role in clients rights

must ensure that pt understands their rights and protect their pt rights. regardless of the age, client's nursing needs, or the HC setting, the basic tenets are the same. the client has the right to understand the aspects of care to be active in the decision-making process, accept, refuse or request modification of the plan of care, receive care from competent individuals who treat the client's with respect.

planning

must establish priorities and optimal outcomes of care they can readily measure and evaluate. these direct nurses in selecting interventions. three types of planning. they develop a comprehensive plan of care for clients based on comprehensive assessments they complete. do ongoing planning throughout the provision of care. discharge planning is a process of anticipating and planning for clients needs after discharge. must begin as soon as client is admitted. throughout planning process nurses set priorities, determine client outcomes, and select specific nursing interventions. participate in priority setting when they identify a preferential order of problems. goals/outcomes must be client-centered, singular, observable, measurable, time-limited, mutually agreeable, and reasonable.

susceptible host

must have compromised defense mechanisms that leave host mores susceptible to infections.

NG

nasogastric

NGT

nasogastric tube

nonspecific innate

native immunity restricts entry or immediately responds to a foreign organisms through the activation of phagocytic cells, complement, and inflammation. this occurs with all micro-organisms, regardless of previous exposure. temp. immunity that doesn't have memory of past exposures, intact skin, mucous membranes, secretions, enzymes, phagocytic cells, and protective proteins. inflammatory response to phagocytic cells, the complement system, and interferons localize the invasion and prevent its spread.

decerebrate rigidity

neck and elbow extension, with wrists and fingers flexed

unintentional torts

negligence, and malpractice (professional negligence)

APIE, PIE

newer versions of SOAP format eliminate the subjective and objective data and start w/assessment, which combines the subjective and objective data. - The acronym then becomes AP, APIE, or APIER

A patient with bipolar disorder has been admitted for suicide prevention. He asks the nurse for a copy of his medical records, because he would like to read the therapist's notes from his last session. Should the nurse comply with this request?

no

NKA or NKDA

no known allergies or no know drug allergies

immune defense

nonspecific innate, and specific adaptive immunity.

hypotension is classified with a reading below

normal; systolic < 90 mm Hg; can be a result of fluid depletion, heart failure, or vasodilation

NPO

nothing by mouth

gallium scan

nuclear scan that uses a radioactive substance to identify hot spots of WBCs.

complex critical thinking

nurse begins to express autonomy by analyzing and examining data to determine the best alternative. results from an increase in nursing knowledge, experience, intuition and more flexible attitudes. ex. nurse realizes pt isnt ambulating as often as prescribed because of fear of missing her daughters phone call. the nurse assures the pt that the staff will listen for and answer her phone when she is out of her room.

airborne

sneezing and coughing

droplet

sneezing, coughing, and talking

SSE

soapsuds enema

auscultation of the lungs (expected sound): vesicular

soft, low-pitched, inspiration three times longer than expiration heard over most of the peripheral areas of the lungs

Mentor

someone more experienced who provides career development assistance, such as coaching, sponsoring advancement, providing challenging assignments, protecting proteges from adversity, and promoting positive visibility

Preceptor

someone with more experience who provides practical teaching and guidance for a student or new employee

Priority

something given special attention

Bedside report

sometimes known as "walking rounds", allows you to observe patient. Outgoing nurse can introduce you to client and it gives patient opportunity to participate in the report.

expected findings for the Weber test

sound is heard equally in both ears (negative Weber test)

Interprofessional Personnel (non-nursing)

spiritual support staff, registered dietitian, laboratory technician, occupational therapist, pharmacists, PT, provider, radiologic technologist, Resp. Therapist, Social Worker, Speech-Language pathologist.

Verbal order

spoken directions for patient care given to you in person, usually during an emergency

ISBAR

standard handoff communication tools such as introduction, background assessment, recommendation to facilitate transfers and discharges.

Clinical Pathway

standard multi-disciplinary plans for specific diagnosis or procedures that identify specific aspects of care tp be preformed during a designated length of stay

What does SBAR do?

standardizes patient's condition and is a communication strategy designed to improve patient safety.

ethical principles

standards of what is right or wrong with regard to important social values and norms. principles pertaining to the tx of clients include autonomy, beneficence, fidelity, justice, and nonmaleficence.

Ethical principles

standards of what is right/wrong with regard to important social values and norms

bacteria

staphylococcus aureus, escherichia coli, mycobacterium tuberculosis.

Critical pathway

state goals and important treatment intervention based on best practice and patient expectations

discharge instructions

step-by-step instructions for procedures at home, precautions to take when performing procedures or administering medications, signs and symptoms of complications to report, names and numbers of health care providers and community services to contact, plans for follow up care and therapies.

narrative documentation

story-like format, usually in chronological order; useful in emergency situations

direct percussion involves:

striking the body to elicit sounds

Progress notes come in various formats or

structured notes

ethics

study of conduct and character.

SOAP

subjective data, objective data, assessment, planning

advocacy

support of client's health, safety, and personal rights.

Advocacy

support of the cause of the client regarding health, safety, and personal rights

pulse equality: peripheral pulse impulses should be

symmetrical in quality and quantity from right side to left

Charting by exception (CBE)

system of charting in which only significant findings or exceptions to standards and norms of care are charted

pulse pressure is the difference between

systolic and diastolic pressure readings

Refusal of Treatment

the Patient Self-Determination Act (PSDA) stipulates that staff must inform clients they admit to a health care facility of their right to accept or refuse care. if client refuses a tx. they sign a document indicating he or she understands the risk involved with refusing and that they have chosen so. when clients decide to leave the facility against medical advice the nurse notifies the provider and discusses with the client the risks to expect when leaving the facility prior to discharge. nurse then ask client to sign an "Against Medical Advice" form and documents the incident.

Collegiality

the RN interacts with and contributes to the professional development of peers and colleagues

Accountability

the ability or state of being accountable; an obligation or willingness to accept responsibility or to account for ones actions

asepsis

the absence of illness producing micro-organisms

respiratory depth is

the amount of chest wall expansion that occurs with each breath; altered depths are described as deep or shallow

systemic vascular resistance (SVR) is determined by

the amount of constriction or dilation of the arteries

Medical diagnosis

the art or act of identifying a disease from its signs and symptoms

expected findings for the whisper test

the client can hear you whisper softly 30 to 60 cm away

Exclusive Provider Organizations (EPOs)

the client chooses from a list of providers within a contracted organization

assault

the conduct of one person makes another person fearful and apprehensive. ex. a nurse threatens to place an NG tube in a client who is refusing to eat.

right supervision/evaluation

the delegating nurse must do the following; provide supervision either directly or indirectly (assigning supervision to another licensed nurse), provide clear and understandable expectations of the tasks to perform (time frames, what to report), monitor performance, provide feedback, intervene if necessary (unsafe clinical practice), evaluate the client, and determine client outcome status, evaluate client care tasks, and identify needs for performance improvement activities and additional resources.

right supervision/evaluation

the delegating nurse must: -provide supervision (direct or indirect) -provide clear instructions and understandable expectations of the task(s) to be performed -monitor performance -provide feedback -intervene if necessary (unsafe clinical practice) -evaluate the client and determine if client outcomes were met -evaluate client care tasks and identify needs for performance improvement activities and/or additional resources

Secondary HC

the diagnosis and tx of acute illness and injury. ex. care in hospital settings, diagnostic centers, and emergent care centers.

Ethical theory examines:

the different principles, ideas, systems, and philosophies used to make judgments about what is right/wrong and good/bad

environment

the emotional and physical climate in which the communication takes place

diffusion is

the exchange of O2 and CO2 between the alveoli and the RBCs; measure with pulse oximetry

ventilation is

the exchange of O2 and CO2 in the lungs; measure with respiratory rate, rhythm, and depth

professional negligence

the failure of a person who has professional training to act in a reasonable and prudent manner.

bioethics

the field that addresses dilemmas that arise from advancing science and technology.

do not place items on the floor in the client's environment (even soiled laundry) because

the floor is considered "grossly" contaminated

perfusion is

the flow of blood to and from the pulmonary capillaries; measure with pulse oximetry

Evidence-based practice

the formulation of treatment decisions by using the best available research evidence and integrating this evidence with the practitioners skill and experience

Accreditation

the granting of approval to an institute of learning by an official review board after the school has met specific requirements

referent

the incentive or motivation for communication to occur between one person and another

Information technology

the management and processing of information, generally with the assistance of computers

respiratory rate is

the number of full inspirations and expirations in 1 min; expected reference range for adults in 12-20 rpm

pulse rate is

the number of times per min the pulse is felt or heard

respiratory rhythm is

the observation of breathing intervals; a regular rhythm with an occasional sigh is expected in adults

Nursing process

the organized sequence of problem-solving steps; Assessment, Diagnosis, Planning, Implementation, Evaluation (ADPIE)

Intake and output

the patients fluid intake and fluid loss over a 24- hour period of time that is usually recorded on the graphic sheet on documention

receiver

the person to whom the message is aimed at and received by

sender

the person who initiates the message

Planning

the process of prioritizing nursing diagnosis and collaborative patient problems. Identifying measurable goals or outcomes, selecting appropriate interventions and documenting a plan

Quality Assurance

the process of promoting care that reflects established agency standards

Encoding

the process of selecting the words, gestures, tone of voice, signs, and symbols used to transmit the message

Informatics

the property and structure of information or date

Tertiary HC

the provision of specialized and highly technical care. ex. intensive care, oncology centers, and burn centers.

pacing

the rate of speech can communicate a meaning to the receiver

autonomy

the right to make one's own personal decisions, even when those decisions might not be in that person's own best interest.

Etiology

the science and study of causes

clarity/bervity

the shortest, simplest communication is usually most effective

Military time/International time

the time based upon 24- hour clock

intonation

the tone of voice can communicate a variety of feelings

surgical asepsis

the use of precise practices to eliminate all micro-organisms from an object or area and prevent contamination. "sterile technique". it applies to parenteral med administration, insertion of urinary catheters, surgical procedures, sterile dressing changes, and many other common nursing procedures.

medical aspesis

the use of precise practices to reduce the number, growth, and spread of micro-organisms. applies to administering oral meds, managing NG tubes, providing personal hygiene, and performing many other common nursing tasks.

Morals are:

the values and beliefs held by people that guide their behaviors and decision making

Standards of Care

these define and direct the level of care nurses should give, they implicate nurses who dont follow these standards in malpractice lawsuits. nurses should refuse to practice beyond scope of practice or outside of their areas of competence regardless of reason such as staffing shortage, and lack of appropriate personnel.

tid

three times a day

Nurse's role in the informed consent process is:

to witness the client's signature on the informed consent form and to ensure the informed consent has been appropriately obtained

Source-Oriented Record

traditional client record where each discipline makes notations in a separate section or sections of the client's chart; narrative charting part of tradition; difficult to find chronologic information on a client's problem or progress

Narrative charting

traditional part of the source-oriented record; consists of written notes that include routine care, normal findings, and client problems

heat loss- radiation is:

transfer of heat from one object to another object without contact between them (heat loss from the body to a cold room)

heat loss- conduction is:

transfer of heat from the body directly to another surface (when the body is immersed in cold water)

eversion

turning body part away from midline

inversion

turning body part toward midline

iatrogenic infection

type of HAI resulting from a diagnostic or therapeutic procedure.

discharge documentation

type of discharge, date and time of discharge, who went with the client, and transportation, where the client went, a summary of the client's condition at discharge, a description of any unresolved difficulties and procedures for follow up, disposition of valuables, meds brought from home, and prescriptions, discharge instructions.

expected physical development: middle adult (35-65 yrs)

typically experience decreases in: -skin turgor and moisture -subcutaneous fat -melanin in hair (graying) -hair -visual acuity -auditory acuity -sense of taste -skeletal muscle mass -height -calcium/bone density -blood vessel elasticity -respiratory vital capacity -large intestine muscle tone -gastric secretions -estrogen/testosterone -glucose tolerance

hand washing

use an antimicrobial or plain soap and water, using alcohol based products such as gels, foams, and rinses; or performing a surgical scrub. components: soap, running water, friction. HC personnel must perform before and after every client contact, after removing gloves, after contact with body fluids, before eating and after using the restroom. when visibly soiled use soap and water. perform after contact with anything in client's room, contaminated objects, whether gloves were worn or not, and before putting gloves on and after removing them. sometimes between tasks on same client to prevent cross-contamination.

analysis/ data collection

use critical thinking skills to identify clients health status or problems, interprets or monitor the collected database, reach an appropriate nursing judgement about the health status and coping mechanisms, and provide direction for nursing care. requires nurses to look at the data and recognize patterns or trends, compare the data with expected standards or reference ranges, arrive at conclusions to guide nursing care. complete and accurate documentation is essential. it should focus on facts and should be highly descriptive.

Verbal communication

use of spoken and written words to send a message; influenced by factors such as education background, culture, language, age, and past experiences

delegating and supervision guidelines

use the 5 rights of delegation to decide, use professional judgement and critical thinking skills when delegating, right tasks, right circumstance, right person, right direction/communication, right supervision/evaluation, supervision.

evidence-based rationale

used for the selection and implementation of therapeutic interventions.

acuity records

used to make staffing decisions

Narrative chart entry and goal

used with written source-oriented and problem-oriented charts. Tells the story of the patient's experience in a chronological format. Goal is to track the client's changing health status and progress toward goals.

telephone reports

useful when contacting the provider or other members of the interprofessional team. important to have all the data ready prior to contacting any member of the interprofessional team, use a professional demeanor, use exact, relevant, and accurate information, document the name of person, time, content of the message, and the instructions or information received during the report.

creativity

uses imagination to find solutions to unique client problems

Flow sheet

uses specific assessment criteria in a particular format, such as human needs or functional health patterns - time parameters can vary mins. to months - access quickly *Different Flow Sheets* - *Graphic record* (body temp., pulse, respiratory rate, BP, weight, admin, post-op day. bowl movement, appetite, & activity) - *I & O record* (all routes of fluid intake and output(loss)) - *Med. Admin. record* (date of med order, expiration date, med name and dose, frequency of admin. & route, allergies & nurse's signature) - *Skin assessment record* (stage, drainage, odor, culture info, & treatment)

charting by exception

uses standardized forms that identify norms and allows selective documentation of deviations from those norms.

advanced practice nurse (APN)

usually have a minimum of a master's degree in nursing (or related field), advanced education in pharmacology and physical assessment, and certification in a specialized area of practice including the following roles: CNS, NP, CRNA, and CNM.

Feedback

validates that the receiver received the message and understood it as the sender intended

morals

values and beliefs that guide behavior and decision making.

interpersonal variables

variables that influence communication between the sender and the receiver

pronation

ventral surface is facing down

supination

ventral surface is facing up

message

verbal and/or nonverbal information that is expressed by the sender and intended for the receiver

Message

verbal and/or nonverbal information the sender communicates; conversation, a speech, a gesture, a letter

VO

verbal order

during palpation, the ulnar surface of the hand and the base of the fingers detect:

vibrations

herpes zoster (shingles)

viral infection. intially produced by chickenpox. usually preceded by a prodromal period of several days, during which pain, tingling, burning may occur along the involved dermatome. can be very painful and debilitating. risk factors: concurrent illness, stress, compromise to immune system, fatigue, poor nutritional status, assess elderly for local or systemic signs of infection. subjective data: paresthesia, pain that is unilateral and extends horizontally along a dermatome. objective data: vesicular, unilateral rash ( the rash and lesions occur on the skin area innervated by the infected nerve), rash the is erythematous, vesicular, pustular, or crushing (depending on the stage), rash the usually resolves in 14 to 21 days, low-grade fever. laboratory tests: cultures provide a definitive diagnosis. occasionally an immunofluorescence assay can be done.

Flow charts are used to record and show trends in:

vital signs, blood glucose levels, pain level, and other frequently performed assessments

Parts of verbal communication:

vocabulary, denotative (literal) and connotative (implied or emotional) meaning, pacing, intonation (tone of voice; feeling behind the words), clarity and brevity, timing and relevance, credibility (believability), humor

Self-help groups

voluntary organizations composed of individuals with a common need

hand washing procedure

wash with warm water and soap. rub hands together vigorously, rinse under running water. wash for at least 15 seconds to remove transient flora and up to 2 min when hands are visibly soiled. dry hands with a clean paper towel before turning off faucet. if sink doesnt have foot or knee pedals for turning off water, use a clean, dry paper towel to turn off faucet.

Student signatures

your signature; student nurse "SN"