Nurs 320 Exam 4
How should information be disposed of when no longer needed?
* Shredding printed documents or using locked receptacles designated for secure disposal
Nurse Patient Interview: Termination
* Summarize the discussion and confirm information obtained. * Allow the patient to ask any remaining questions. * Conclude the interview in a friendly manner. * Inform the patient when you will return to provide care.
Maslow's hierarchy
(level 1) Physiological Needs (level 2) Safety and Security (Level 3) Love and belongingness (level 4) Self Esteem (level 5) Self Actualization
List common record keeping forms
* Admission Nursing History Form: Guides comprehensive patient assessment during admission. * Patient Care Summary: Provides updated patient information including demographics, diagnoses, care plans, and safety measures. * Care Plans: Standardized plans facilitating consistent and evidence-based patient care, modifiable to individual needs. * Discharge Summary Forms: Document comprehensive discharge plans and instructions for safe patient transition from the healthcare facility.
Nurse Patient Interview: Working phase
* Begin with open-ended questions. Listen attentively and encourage the patient to express concerns. * Seek a comprehensive understanding of the patient's situation. * Avoid rushing the patient and ensure a complete description of symptoms. * Use verbal cues to direct the assessment appropriately. * Conduct ongoing interviews to update the patient's status and concerns.
Consulting with healthcare professionals: Identify the problem: Provide relevant information: Avoid bias and be open: Facilitate communication: Incorporate recommendations:
* Clearly define the problem area and choose the appropriate professional to resolve the issue. * Share pertinent details from the patient's medical record, conversations with other nurses, and the patient's family to give the consultant a comprehensive understanding. * Prevent biases from influencing the consultant's perspective. Provide an unbiased view of the problem without overloading them with subjective conclusions. * Ensure a private, comfortable atmosphere for the consultant and patient to discuss the situation. Be present during the consultation, and aim for minimal interruptions. * Implement the consultant's recommendations into the care plan and provide feedback on the outcomes.
How do nurses maintain privacy, confidentiality, and security?
* Compliance with regulations such as HIPAA *Auto sign-off. *A firewall: a combination of hardware and software that protects private network resources from outside hackers, network damage, and theft or misuse of information. *A password: a collection of alphanumeric characters and symbols that a user types into a computer sign-on screen before accessing a program after the entry and acceptance of an access code or username.
What are sources of diagnostic error?
* During data collection * Analysis of data clusters or patterns * Interpretation
Identify methods of documentation.
* Flow sheets for organizing patient data * Progress notes for monitoring patient progress * Narrative documentation for recording patient assessments and care in a story-like format * Charting by exception (CBE) systems for documenting normal findings and deviations
Nurse Patient Interview: Orientation and setting an agenda
* Introduction: Introduce yourself to the patient. * Confidentiality: Explain that all information will be kept confidential. * Setting an agenda: Explain the purpose of data collection and the focus on the patient's concerns, goals, and preferences.
What is the role of the State Boards of Nursing?
* It licenses all RNs in the state in which they practice. * They investigate, suspend, and/or revoke licenses if a nurse's conduct violates the state's Nurse Practice Act. * They must provide notice and follow due process before revoking for suspending a license.
Describe interpretation and validation of data.
* Validating data by comparing it with other sources for accuracy. *Data interpretation involves identifying abnormal findings, clarifying information, and identifying patient problems. * Recognizing cues and making inferences based on patterns in signs and symptoms. * Continuously probing and asking questions to ensure a thorough understanding of the patient's condition. * Using critical thinking and clinical reasoning to analyze data and identify potential problems and nursing diagnoses.
What is assault?
*Intentional threat toward another person that places the person in a reasonable fear of harmful, imminent or unwelcome contact. *No actual contact is required for assault to occur.
What are standards of care?
*Reflects the knowledge and skill ordinarily possessed and used by nurses to perform within the scope of practice. *Derived from health care laws, best practice guidelines, white papers written by professional organizations, evidence-based nursing knowledge, and citizen advocacy groups.
What are the levels of critical thinking?
-Basic: usually new nurses, task oriented, relies on experts -Complex: trusts their own decision, relies less on experts -Commitment: anticipates when to make decisions and accepts accountability for decisions/actions
Uniform Determination of Death Act
-It states that health care providers can use either cardiopulmonary or whole-brain to determine death. Two standards: 1. Cardiopulmonary: requires irreversible cessation of circulatory and respiratory functions. 2. Whole-brain: requires irreversible cessation of all functions of the entire brain, including the brainstem.
What is battery?
-Medical procedure is performed without patients consent -Intentional offensive touching without consent or lawful justification. -The contact can be harmful to the patient and cause an injury, or it merely can be offensive to the patients personal dignity.
What is the nurses role in obtaining informed consent?
-Nurses do not obtain informed consent for procedures they are not doing, they only witness these and document refusals. 1. Patient receives full explanation of procedure 2. Patient receives info and names of people that are assisting 3. Patient receives description of side affects or potential risks 4. Patient receives alternative therapies and risks if nothing is done 5. Patient knows right to refuse without discontinuing other supportive care 6. Patient knows right to refuse even after procedure has begun
What are common sources of negligence?
-Nurses that do not cary out their duty of care and cause patient harm. -Hanging the wrong IV medication -Putting warm compress of patient that causes a burn.
What are sources of data?
-Primary (patient) -Secondary
emergency medical treatment and active Labor Act
-Prohibits transfer of patients from private to public hospitals without appropriate screening and stabilization. -It is intended to prevent patient dumping. -This act ensures that patients are medically screened when they come to the emergency department or the hospital. -Staff must assess all patients the enter the hospital and cannot discharge or transfer them until their condition is stabilized.
mental health parity Act
-Provides coverage for mental health and substance use disorders.
Uniform Anatomical Gift Act
-Provides foundation for the national organ donation system. -Patient autonomy, and public trust remain the ethical principles on which organ donation occurs. -Written consent, or signature on drivers license.
health insurance portability and accountability Act
-Provides right to patients and protects employees. -Establishes patients right regarding privacy of their health care information and records -Limits who can access a patients records.
What are the steps of clinical judgement?
-Recognize cues -Analyze cues & prioritize hypotheses -Generate solutions & Take action -Evaluate outcomes
Health Information Technology Act
-Was passed with HIPAA in response to new technology and social media. -Expands the principles extended under HIPAA, especially when a security breach of PHI occurs. -Nurses must ensure that protected data are not disclosed other than as permitted by patients.
What model do nurses follow to set priorities?
1. ABC 2. Maslow's hierarchy
Identify the steps of nursing assessment
1. Collection of information from a primary source ( a patient) and secondary sources (e.g., family, caregiver, family members or friends, health professional, medical record) 2. The interpretation and validation of data to determine whether more data are needed, or the database is complete
patient protection and Affordable Care Act
1. consumer rights and protections 2. affordable health care coverage 3. increased access to care 4. quality of care that meets the needs of patients -It prohibits patients from being denied health care coverage because of pre existing issues. -Increases access to health care -Increases preventive visits without copays or deductibles (BP check, cancer screening, diabetes check.)
nursing diagnosis
A clinical judgment made by a registered nurse to describe a patient's response or vulnerability to health conditions or life events that the nurse is licensed and competent to treat.
Implementation skills: Interpersonal communication skills
Apply interpersonal communication skills by developing a trusting relationship, expressing caring, and communicating clearly with the patient and their families. Listening is particularly important.
What is reflection?
It is like an instant replay. It is not intuitive. It involves purposefully visualizing a situation and taking the time to honestly review everything you remember about it.
What is the relationship between critical thinking and nursing practice?
Critical thinking is essential at each step of the nursing process for clinical decision making. It is an expectation of professional practice that nurses update and maintain their competency and knowledge base. Maintaining competency through professional development and research reviews is facilitated by the nurse using critical-thinking skills. Decisions related to delegation, collaboration, and teamwork largely depend on the use of critical thinking standards.
Implementation skills: Cognitive skills
During implementation, you apply these skills to ensure that no nursing action is automatic but instead is thoughtful and patient centered. Carefully consider each clinical situation at hand, interpret the information you observe, decide whether more information is needed, and anticipate a patient's response so that you individualize interventions appropriately.
Americans with Disabilities Act
Civil rights statue that protects the rights of people with physical to mental disabilities. -Prohibits discrimination and ensure qual opportunities for people with disabilities in employment, state and local government services, public accommodations, commercial facilities, and transportation.
Identify the three implementation skills:
Cognitive skills:, Interpersonal communication skills, and Psychomotor skills
Three-part nursing diagnosis:
Comprises a diagnostic label, related factors, and major defining characteristics. - Example: "lack of knowledge regarding postoperative care, related to inexperience with surgery as evidenced by frequent queries about postoperative routines."
What is the purpose of an incident or occurrence report?
Confidential records that help healthcare organizations identify and address care deviations, assess risks, and implement corrective measures. They serve as essential documentation for legal purposes, detailing the incident and the response taken.
Indirect care
Interventions are treatment performed away from a patient but on behalf of the patient or group of patients
Direct care
Interventions are treatments nurse provide through interactions with patient or a group of patients.
Medication: Heparin
Heparin: blood thinner o Iv/Sub Q, injectable. o Antagonist for heparin is protamine sulfate. o Monitor patient for bleeding
Consulting with healthcare professionals: ISBAR
Identify, Situation, Background, Assessment, Recommendation
Two-part nursing diagnosis:
Includes a diagnostic label and defining characteristics. - Example: "lack of knowledge regarding postoperative care,"
What is false imprisonment?
the intentional confinement or restraint of another person's activities without justification
What are types of advance directives?
Living Wills Health care proxies or Durable Power of Attorney for Healthcare
direct care examples
Medication administration, insertion of a urinary catheter, discharge instruction or counseling during a time of grief.
What are the phases of a nurse-patient interview?
Orientation/interview, Working phase, and termination
Care Area Assessment (CAA)
Part of the Resident Assessment Instrument (RAI) used to identify potential problem areas and trigger further assessment or care planning in long-term care facilities
Example of a smart goal:
Patient will report pain level of 3 or less on the pain scale within 48 hours post-administration of pain medication
What parties are to be included in the goal setting stage?
Patient, healthcare team, family/caregiver
Types of Assessments
Patient-centered interview •Periodic assessments •Physical examination
What is a standing order?
Preprinted document containing medical orders for routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems.
Define the Good Samaritan Law
Protects individuals from liability that help victims at scene of accident.
collaborative problem
Requires both medical and nursing interventions to treat.
Implementation skills: Psychomotor
Requires the integration of cognitive and motor activities. When performing a new skill, assess your level of competency, and obtain the necessary resources to ensure that your patients receive safe treatment. (Learning through actions)
Identify the assessment form used in long term care
Resident Assessment Instrument (RAI) which includes the Minimum Data Set (MDS) and Care Area Assessment (CAA) is used for documentation and reimbursement under CMS
Indirect care examples
Safety and infection control, documentation and interprofessional collaboration
What is the purpose of the medical record?
Serves as a valuable source of data for all health care members for interprofessional communication, legal documentation, financial billing justification, and quality improvement. It also acts as a resource for education and research in the healthcare field.
Family caregivers and significant other
Serves as primary source of information for infants, children's critically ill adults and pt. with intellectual disabilities or cognitive impairments / Serves as secondary source if the pt. is alert and responsive.
Goals
Specific expected outcomes of nursing intervention as related to the established nursing diagnosis.
clinical practice guidelines
Statements that include recommendations, intended to optimize patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options
Primary source of data:
Subjective data acquired directly from patient.
What is critical thinking?
The ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process
Define evaluation
The crucial final step of the nursing process that determines whether a patient's condition or well-being improved after nursing interventions were delivered
medical diagnosis
The identification of a disease condition is based on a specific assessment of physical signs and symptoms, a patient's medical history, and the results of diagnostic tests and procedures.
Diagnostic label or diagnosis:
The name of a nursing diagnosis approved by NANDA, ICNP, or any other system used in your institution. The Nanda system offers definitions for each diagnosis to describe the characteristics of the human response identified.
What is considered essential patient information for hand-off report?
The patient's plan of care, patient progress, continuing needs during the transfer of information, the current status of treatments, and the patient's expected outcomes.
Quality Documentation:
This entails using objective language, precise measurements, and clear, logical organization. Proper use of abbreviations is crucial for preventing misinterpretation and ensuring patient safety.
What are implementation skills?
Using cognitive, interpersonal and psychomotor skills as you implement direct and indirect nursing interventions. You apply the appropriate skills to the procedure you perform.
What time frame must verbal or telephone orders be signed by the health care provider?
Usually 24 hours
Medication: Warfarin (Coumadin)
Warfarin(Coumadin) - blood thinners o Oral prevents blood clots. o Vitamin k is an antagonist. o Monitor through proton. o Patient will need blood work routinely.
What is objective data?
What you observe and can measure - vital signs
When is it appropriate to revise rather than discontinue the plan of care?
When a patient's condition, needs, or abilities change. Reassessment helps identify the need for adjustments, ensuring the plan remains relevant and effective.
Diagnostic label or diagnosis: Related factors
a patient's response to a health problem is related to a set of conditions that caused or influenced the response. Related factors are etiologies, circumstances, facts, or influences that have a relationship with the nursing diagnoses.
Secondary source of data:
data acquired from another individual (such as a family member)
What are the guidelines for quality documentation?
factual accurate appropriate use of abbreviations current organized complete
What are attitudes used in critical thinking?
o Confidence - Feels sure of abilities. o Independence - Analyzes ideas for logical reasoning. o Fairness - Is objective ad non-judgmental. o Responsibility - Adheres to standards of practice. o Risk taking - Takes calculated chances in finding better solutions to problems. o Discipline - Develop a systematic approach to thinking. o Perseverance - Continues to work on a problem until there is a solution. o Creativity - Uses imagination to find solutions to unique client problems. o Curiosity - Requires more information about client and problem. o Integrity - Practice truthfully and ethically o Humility - Acknowledges weakness.
What does REFLECT stand for?
o R - Recall the event o E - Examine your response o F - Acknowledge Feelings o L - Learn from the experience o E - Explore options o C - Create a plan of action o T - Set a time
Minimum Data Set (MDS)
standardized assessment tool used to assess the needs of nursing home residents
What are clinical practice guidelines?
statements that include recommendations, intended to optimize patient care, that are informed by a systemic review of evidence and an assessment of the benefits and harms of alternative care options. -Care bundle is a form of clinical guideline: a group of interventions related to a disease process or condition,
What is subjective data?
what the patient says - Patients' reports about how they feel
Define directives
· A document developed by patients that instructs others to do tests before, during, and after their death. · It includes a statement of a patient's wishes if a respiratory or cardiac arrest occurs and a copy of the patient's durable power of attorney for health care.
Diagnostic label or diagnosis: Defining characteristics
· Another component of a diagnosis is optional: the listing of major assessment findings. Further clarity can be added to a diagnostic statement if you list major assessment findings or defining characteristics that were used to select a diagnosis.
List the components of the nursing health history.
· Biographical information: age, gender, address, insurance information, occupation, marital status. · Chief concern or reason for seeking health care. · Patient expectations. · Present illness or health concerns. · Past health history. · Family history. · Psychosocial history · Spiritual health · Review of systems (subjective data). · Observation of patient behavior.
What are legal guidelines of documentation?
· Do not document retaliatory or critical comments about a patient or care provided by another healthcare professional. Do not enter personal opinions. · Correct all errors promptly, record all facts, the document only for yourself, and protect the security of your password for computer documentation. · Avoid using generalized, empty phrases such as "status unchanged" or "had good day". · Begin each entry with the date and time and end with a signature and credentials, do not erase or scratch out errors made while recording. · Do not leave blank spaces or lines in a nurse's progress note, record all written entries legibly using black ink, and do not use pencils, felt tip pens, or erasable ink.
Discuss the differences between independent and dependent nursing
· Independent: the interventions a nurse initiates in response to a nursing diagnosis without supervision, direction, or orders from others. · Dependent: requires an order from a health care provider.
Discuss SMART goals
· Specific: outcomes reflect a specific patient behavior or response (only one behavior). · Measurable: you must be able to measure or observe whether a change takes place in a patient's status. · Attainable: outcomes are more achievable when you mutually set them with a patient. This ensures that you and your patient agree on the direction and time limits of care. · Realistic: set expected outcomes that are realistic and relevant for patients. · Timed: set a time for each outcome to be met.
What assignment are appropriate for nurses that float from other units?
· Units that the nurse has education or experience on. · Supervisors are responsible to give staff nurses assignments that they can safely handle. · If the nurse is floated to a unit they do not feel comfortable working on for patient safety reasons, they must inform supervisor that they do not have the proper education and experience to work on that unit.
