PNC - FINAL EXAM

credentialing

A general term that refers to ways in which professional competence is maintained

Civility

A guide to the proper conduct of litigation.

Moralizing

A mode of value transmission in which children are taught a complete value system by parents or an institution (e.g., church or school) that allows little opportunity for them to weigh different values.

Intentional Tort

A person committing this type of tort is considered to have knowledge of the permitted legal limits of his or her words or acts. Violating these limits is grounds for prosecution.

Reporting and population health

A standardized system to produce reports that are demanded by state, federal, and local levels.

hand-off

A term a nurse's report to another nurse or health care provider about a patient's status and progress

Incidental Disclosure of PHI

A term defined as a secondary disclosure that cannot reasonably be prevented, is limited in nature, and occurs as a byproduct of an otherwise permitted use or disclosure of PHI.

felony

A term for a (1) crime punishable by imprisonment in a state or federal penitentiary for more than 1 year; (2) crime of greater offense than a misdemeanor

shamanism

A term for a belief that illness originates in the spirit world and usually involves a loss of power; treatment consists of first, restoring the individual's power, and second, treating symptoms

collaborative pathway

A term for a case management plan that is a detailed, standardized plan of care developed for a patient population with a designated diagnosis or procedure; it includes expected outcomes, a list of interventions to be performed, and the sequence and timing of those interventions

patient record

A term for a compilation of a patient's health information that serves as the only permanent legal document that details the nurse's interactions with the patient

misdemeanor

A term for a crime of lesser offense than a felony and punishable by fines, imprisonment (usually for less than 1 year), or both

source-oriented record

A term for a documentation system in which each health care group records data on its own separate form

Focus charting

A term for a documentation system that replaces the problem list with a focus column that incorporates many aspects of a patient and patient care; the focus may be a patient strength or a problem or need; the narrative portion uses the data (D), action (A), response (R) format

graphic record

A term for a form used to record specific patient variables such as pulse, respiratory rate, blood pressure readings, body temperature, weight, fluid intake and output, bowel movements,

flow sheet

A term for a graphic record of abbreviated aspects of the patient's condition (e.g., vital signs, routine aspects of care)

subculture

A term for a group of people with different interests or goals than the primary culture

traditional Chinese medicine (TCM)

A term for a healing system that believes the interaction of people with their environment is most significant in creating health

statutory law

A term for a law enacted by a legislative body

nurse healer

A term for a nurse who facilitates another person's growth toward wholeness (body-mind-spirit) or who assists another with recovery from illness or transition to peaceful death

holistic nursing

A term for a nursing practice built on a holistic philosophy

acupuncture

A term for a procedure consisting of placing very thin, short, sterile needles at particular acupoints, believed to be centers of nerve and vascular tissue, along a meridian to either increase or decrease the flow of chi along the meridian, restoring the balance of yin and yang, and thereby contributing to healing

accreditation

A term for a process by which an educational program is evaluated and then recognized as having met certain predetermined standards of education

ISBAR communication

A term for a process for effective hand-off communication among health care professionals about a patient's condition, standing for Identity/Introduction, Situation, Background, Assessment, Recommendation, and Read back

read back

A term for a process in which a nurse or other health care provider repeats a verbal order back to a physician to ensure that it was correctly heard and interpreted

naturopathic medicine

A term for a relatively new system of medicine that is not only a system of medicine but also a way of life, with emphasis on patient responsibility, patient education, health maintenance, and disease prevention

variance report

A term for a report of any event that is not consistent with the routine operation of the health care agency that results in or has the potential to result in harm to a patient, employee, or visitor

Ayurveda

A term for a science of life that delineates the diet, medicines, and behaviors that are beneficial or harmful for life and considers that balance among people, the environment, and the larger cosmos is integral to human health

ethnicity

A term for a sense of identification that a cultural group collectively has; the sharing of common and unique cultural and social beliefs and behavior patterns, including language and dialect, religious practices, literature, folklore, music, political interests, food preferences, and employment patterns

value

A term for a set of beliefs that are meaningful in life and that influence relationships with others

culture conflict

A term for a situation that occurs when people become aware of cultural differences, feel threatened, and respond by ridiculing the beliefs and traditions of others to make themselves feel more secure about their own values

Nursing informatics

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

Minimum data set

A term for a standard established by health care institutions that specifies the information that must be collected from every patient

nursing ethics

A term for a subset of bioethics; formal study of ethical issues that arise in the practice of nursing and of the analysis used by nurses to make ethical judgments

qi gong

A term for a system of posture, exercise (both gentle and dynamic), breathing techniques, and visualization that regulates the qi

assault

A term for a threat or an attempt to make bodily contact with another person without that person's permission

incident/variance report

A term for a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in or has the potential to result in harm to a patient, employee, or visitor. These reports are used for quality improvement and should not be used for disciplinary action against staff members.

whistle-blower

A term for a warning from a present or past member of an organization to the public concerning a serious wrongdoing or danger created or masked by the organization

complementary therapies

A term for alternative treatments used with traditional medical interventions

malpractice

A term for an act of negligence as applied to a professional person such as a physician, nurse, or dentist

relaxation response

A term for an alert, hypometabolic state of decreased sympathetic nervous system arousal, which can also be viewed as the opposite of Selye's general adaptation syndrome response

therapeutic touch (TT)

A term for an alternative therapy that involves using one's hands to consciously direct an energy exchange from the practitioner to the patient to facilitate healing or pain relief

principle-based approach

A term for an approach to bioethics that offers specific action guides

battery

A term for an assault that is carried out

health information exchange (HIE)

A term for an electronic system that allows physicians, nurses, pharmacists, other health care providers, and patients to appropriately access and securely share a patient's vital medical information

defamation of character

A term for an intentional tort in which one party makes derogatory remarks about another that diminishes the other party's reputation; slander is oral; libel is written

crime

A term for an offense against people or property; the act is considered to be against the government, referred to in a lawsuit as "the people," and the accused is prosecuted by the state

sentinel event

A term for an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof

progress notes

A term for any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes

stereotyping

A term for assigning characteristics to a group of people without considering specific individuality

Beneficence

A term for being of benefit to the patient, and balancing benefits against risks and harms.

cultural competence

A term for care that is planned and implemented in a way that is sensitive to the needs of individuals, families, and groups from diverse populations within society.

integrative care

A term for care that uses some combination of allopathic and complementary/alternative modalities

Implementing

A term for carrying out the plan of care

electronic health record (EHR)

A term for computer-based records in which data can be distributed among many caregivers in a standardized format, allowing them to compare and uniformly evaluate patient progress easily.

chakra

A term for concentrated areas of energy aligned vertically in the body, which relate to each other as well as to specific areas of the body/mind/spirit

yin-yang theory

A term for energy forces in Chinese teaching that must be in balance for good health; expression of strong emotions results in disharmony and imbalance between these forces

bioethics

A term for ethics that encompass all those perspectives that seek to understand human nature and behavior, the domain of social science, and the natural world

Fidelity

A term for keeping promises

fidelity

A term for keeping promises and commitments made to others

common law

A term for law resulting from court decisions that is then followed when other cases involving similar circumstances and facts arise; common law is as binding as civil law

morals

A term for like ethics, concerned with what constitutes right action; more informal and personal than the term ethics

Evaluating

A term for measuring the extent to which the patient has achieved the outcomes specified in the plan of care; identifying factors that positively or negatively influenced outcome achievement; revising the plan of care if necessary

alternative modalities

A term for methods not included in the scope of conventional medical care

meridian

A term for part of an intricate structure of 72 energy circuits that nourish and support all cells and organs of the body, through which qi flows vertically in the body

negligence

A term for performing an act that a reasonably prudent person under similar circumstances would not do, or failing to perform an act that a reasonably prudent person under similar circumstances would do

code of ethics

A term for principles that reflect the primary goals, values, and obligations of the profession

Narrative notes:

A term for progress notes written by nurses in a source-oriented record

Autonomy/Self-Determination

A term for respecting the rights of patients or their surrogates to make health care decisions.

chiropractic medicine

A term for science that investigates the relationship between structure (the spine) and function (mainly the nervous system) of the human body to restore and preserve health

autonomy

A term for self-determination; being independent and self-governing

OASIS

A term for the Outcome and Assessment Information Set, or OASIS; a group of data elements that represent core items of a comprehensive assessment for an adult home care patient and form the basis for measuring patient outcomes for purposes of outcome-based quality improvement (OBQI)

ethical agency

A term for the ability to behave in an ethical way; to do the ethically right thing because it is the right thing to do

utilitarian

A term for the action-guiding theory of ethics that states that the rightness or wrongness of an action depends on the consequences of the action

Damages

A term for the actual harm or injury resulting to the patient.

Diagnosing

A term for the analysis of patient data to identify patient strengths and health problems that independent nursing intervention can prevent or resolve

healing touch (HT)

A term for the approach that uses a collection of energy techniques to assess and treat the human energy system, thereby affecting physical, emotional, mental, and spiritual health and healing

care-based approach

A term for the approach to bioethics that directs attention to the specific situations of individual patients viewed within the context of their life narrative

Nonmaleficence

A term for the avoidance of causing harm

ethnocentrism

A term for the belief that one's own ideas, beliefs, and practices are best, superior, or most preferred to those of others; using one's cultural norms as the standard to evaluate others' beliefs

Assessing

A term for the collection, validation, and communication of patient data

change-of-shift report

A term for the communication method used by nurses who are completing care for a patient to transmit patient information to nurses who are about to assume responsibility for continuing care; may be exchanged verbally in a meeting or audiotaped

Healthcare Quality

A term for the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge

Discharge summary

A term for the description of where the patient stands in relation to problems identified in the record at discharge; documents any special teaching or counseling the patient received, including referrals

cultural diversity

A term for the diverse groups in society, with varying racial classifications and national origins, religious affiliations, languages, physical size, gender, sexual orientation, age, disability, socioeconomic status, occupational status, and geographic location

race

A term for the division of human beings based on distinct physical characteristics

problem-oriented medical record (POMR)

A term for the documentation system organized according to the person's specific health problems; includes database, problem list, plan of care, and progress notes

PIE charting

A term for the documentation system that does not develop a separate care plan; the care plan is incorporated into the progress notes in which problems are identified by number, worked up using the problem (P)-intervention (I)-evaluation (E) format, and evaluated each shift

deontologic

A term for the ethical system in which actions are right or wrong independent of the consequences they produce

personal space

A term for the external environment surrounding a person that is regarded as being part of that person

Data

A term for the facts of the World.

Breach of Duty

A term for the failure to meet the standard of care.

personal health record (PHR)

A term for the information sheets that contain the individual's medical history, including diagnoses, symptoms, and medications

transcultural nursing

A term for the knowledge and skills to adapt nursing care to cultural similarities and differences.

liability

A term for the legal responsibility for one's acts (and failure to act); includes responsibility for financial restitution of harms resulting from negligent acts

SOAP format

A term for the method of charting narrative progress notes that organizes data according to subjective information (S), objective information (O), assessment (A), and plan (P)

Causation

A term for the most difficult element of liability to prove, shows that the failure to meet the standard of care (breach) actually caused the injury.

expert witness

A term for the nurse who explains to the judge and jury what happened based on the patient's record and who offers an opinion as to whether the nursing care met acceptable standards of practice

fact witness

A term for the nurse who has knowledge of the actual incident prompting a legal case; bases testimony on firsthand knowledge of the incident, not on assumptions

ethical distress

A term for the occurrence when the nurse knows the right thing to do but either personal or institutional factors make it difficult to follow the correct course of action

defendant

A term for the one being accused of a crime or tort

value system

A term for the organization of values ranked along a continuum of importance

dosha

A term for the patient's basic condition in Ayurvedic medicine

plaintiff

A term for the person or government bringing a lawsuit against another

homeopathy

A term for the practice of medicine based on the belief of supporting the body while the symptoms are allowed to "run their course" to stimulate and strengthen the immune system and promote healing

nonmaleficence

A term for the principle of avoiding evil

beneficence

A term for the principle of doing good

certification

A term for the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition

values clarification

A term for the process by which people come to understand their own values and value system. It is a process of discovery, allowing the person to discover through feelings and analysis of behavior what choices to make when alternatives are presented.

Consultation

A term for the process in which two or more individuals with varying degrees of experience and expertise deliberate about a problem and its solution

litigation

A term for the process of a lawsuit

cultural blindness

A term for the process of ignoring differences in people and proceeding as though the differences do not exist

referral

A term for the process of sending or guiding someone to another source for assistance

justice

A term for the process that distributes benefits, risks, and costs fairly

cultural assimilation

A term for the process that occurs when a minority group, living as part of a dominant group within a culture, loses the cultural characteristics that made it different

advocacy

A term for the protection and support of another's rights

charting by exception (CBE)

A term for the shorthand method for documenting patient data that is based on well-defined standards of practice; only exceptions to these standards are documented in narrative notes

ethical dilemma

A term for the situation that arises when attempted adherence to basic ethical principles results in two conflicting courses of action

culture

A term for the sum total of human behavior or social characteristics particular to a specific group and passed from generation to generation or from one to another within the group

ethics

A term for the system dealing with standards of character and behavior related to what is right and wrong

cultural imposition

A term for the tendency of some to impose their beliefs, practices, and values on another culture because they believe that their ideas are superior to those of another person or group

holism

A term for the theory and philosophy that focuses on connections and interactions between parts of the whole

feminist ethics

A term for the type of ethical approach that aims to critique existing patterns of oppression and domination in society, especially as these affect women and the poor

Meaningful use

A term for the use of certified electronic health record technology to achieve health and efficiency goals, with a financial incentive from Medicare and Medicaid

aromatherapy

A term for the use of essential oils of plants to treat symptoms

Documentation

A term for the written, legal record of all pertinent interventions with the patient—assessments, diagnoses, plans, interventions, and evaluations

culture shock

A term for those feelings, usually negative, a person experiences when placed in a different culture

imagery

A term for using all five senses to imagine an event or body process unfolding according to a plan

Knowledge

A term for what we know. Think of this as the map of the World we build inside our brains.

Modelikng

A term for when children learn what is of high or low value by observing parents, peers, and significant others.

fraud

A term for willful and purposeful misrepresentation that could cause, or has caused, loss or harm to people or property

tort

A term for wrong committed by a person against another person or that person's property

licensure

A term referring to being given a license to practice nursing in a state or province after successfully meeting requirements

Confer

A term referring to consult with someone to exchange ideas or to seek information, advice, or instructions

Information

A term that allows us to expand our knowledge beyond the range of our senses.

aura

A term that consists of at least seven layers of energy that surround the body and relate to the chakras

intercessory prayer

A term that involves praying for the benefit of another person to the Judeo-Christian God

Duty

A term that refers to an obligation to use due care (what a reasonably prudent nurse would do) and is defined by the standard of care appropriate for the nurse-patient relationship.

linguistic competence

A term that refers to the ability of caregivers and organizations to understand and effectively respond to the linguistic needs of patients and their families in a health care encounter.

qi

A term that represents an invisible flow of energy that circulates through plants, animals, and people, as well as the earth and sky

Justice

A term to describe giving each his or her due; acting fairly.

Responsible-Choice

A value transmission methods that encourages children to explore competing values and to weigh their consequences. Support and guidance are offered as children develop a personal value system. Reflect for a moment on values you hold and see if you can identify how you developed these values.

Rewards and Punishments

A value transmission system in which children are rewarded for demonstrating values held by parents and punished for demonstrating unacceptable values.

Order management

All prescriptions are to be written electronically to reduce medical errors due to illegible handwriting. Orders are also automatically generated.

Laissez-Faire

An approach to value transmission leave children to explore values on their own (no single set of values is presented as best for all) and to develop a personal value system. This approach often involves little or no guidance and may lead to confusion and conflict.

Electronic communication and connectivity

An interoperable system that is able to connect with multiple providers, the patient, labs, and hospitals in a secure manner.

Vata (changeable), Pitta (intense), Kapha (relaxed)

Avyavera terms

1) Discussing patient information in any public area where those who have no need to know the information can overhear 2)Leaving patient medical information in a public area 3)Leaving a computer unattended in an accessible area with medical record information unsecured 4)Failing to log off a computer terminal 5) Sharing or exposing passwords 6) Copying or providing data, either in paper or machine-readable form, for one's self, coworkers, or any other party, except as required to fulfill job responsibilities 7) Improperly accessing, reviewing, and/or releasing birth dates and addresses of friends or relatives, or requesting another person to do so 8) Improperly accessing, reviewing, and/or releasing the record of a patient out of concern or curiosity, or requesting another person to do so 9) Improperly accessing, reviewing, and/or releasing a patient record to use information in a personal relationship 10) Improperly accessing, reviewing, and/or releasing the patient record of a public personality for the intent of giving or selling information to the media 11) Improperly accessing, reviewing, and/or releasing confidential information of another member of the workforce who is also a patient 12) Improperly accessing, reviewing, and/or releasing confidential information that may bring harm to the organization or people associated with it

Describe instances of HIPPA violations

Systematic: --Each nursing activity is part of an ordered sequence of activities. Dynamic: --There is great interaction and overlapping among the five steps. Interpersonal: --The nursing process ensures that nurses are person centered rather than task centered Outcome Oriented: --The patient benefits from continuity of care, and each nurse's care moves the patient closer to outcome achievement. Universally Applicable in Nursing Situations: --When nurses have a working knowledge of the nursing process, they find that they can practice nursing with well or ill people, young or old, in any type of practice setting.

Describe the 5 Characteristics of the Nursing Process.

1. State the research problem. 2. Define the purpose of the study. 3. Review-related literature. 4. Formulate hypotheses and variables. 5. Select the research design. 6. Select the population and sample. 7. Collect the data. 8. Analyze the data. 9. Communicate findings and conclusions.

Describe the steps of the Quantitative Research Process.

The 2007 survey found that in the United States, approximately 38% of adults (about 4 in 10) and approximately 12% of children (about 1 in 9) were using some form of CAT in the 12 months before the survey. CAT use was more prevalent among women, adults aged 30 to 69, adults with higher levels of education, adults who were not poor, adults living in the West, former smokers, and adults who were hospitalized in the last year. In both the 2002 and 2007 surveys, adults younger than 65 years of age and those with private health insurance were more likely than those with public health insurance or uninsured adults to use CAT. The breakdown of CAT use by race or ethnicity among adults is as follows: American Indian/Alaska Native, 50.3%; White, 43.1%; Asian, 39.9%; African American, 25.5%; and Hispanic, 23.7%. The American Association of Retired Persons (AARP) and NCCAM partnered on a telephone survey of over 1,000 people aged 50 and older. Just over half of those surveyed reported using complementary and alternative medicine and over a third take some type of herbal product or dietary supplement. Yet only a third of all respondents and a little over half of CAM users said they have ever discussed CAM with their health care providers.

Describe the use of CAT in the USA.

Hot Dry Light

Describe yang

Cool Moist Dark

Describe yin

Allopathic medical care is particularly effective in emergency or acute situations. CAT is used increasingly more as the "answer" to the problem of chronic illness. CAT has been based on observation, experience, and traditional healing manuscripts in contrast to allopathic medicine, which has moved away from these methodologies to evidence-based practice.

Differentiate between Allopathic and CAT approaches.

Analysis and Systemic Review

EBP mandates what concerning research findings?

Compromising

For this conflict resolution technique to be effective, both parties must be willing to relinquish something of equal value. If that does not occur, either or both parties may feel that they have lost the conflict and given up more than the other group.

As two-part statements listing the patient's problem and it's etiology -OR- Three-part statements that also include the problem, it's etiology, and defining characteristics

How are most nursing diagnoses written?

As intentional or unintentional acts of wrongdoing

How may torts be broadly classified?

1. Failure to follow standards of care 2. Failure to use equipment in a responsible manner: 3. Failure to assess and monitor 4. Failure to communicate 5. Failure to document 6. Failure to act as a patient advocate or to follow the chain of command

Identify the 6 common categories of malpractice claims:

Cognitive

Identify the learning domain based on the information below: +Lecture or discussion +Panel discussion +Discovery +Audiovisual materials +Printed materials +Programmed instruction +Computer-assisted instruction programs

Affective

Identify the learning domain based on the information below: +Role modeling +Discussion +Panel discussion +Audiovisual materials +Role playing +Printed materials

Psychomotor

Identify the learning domain based on the information below: Demonstration Discovery Audiovisual materials Printed materials

Cooperating/Accommodating

In this conflict resolution approach, one party makes a conscious decision to let the other group win and frequently collects an "IOU" for use in the future. This party's original loss may result in a more positive outcome in the future.

Biologically Based Practices

Includes the use of botanicals (herbs), animal-derived extracts, vitamins, minerals, fatty acids, amino acids, proteins, prebiotics and probiotics, whole diets, and functional foods.

Energy Medicine

Involves the use of energy fields, such as magnetic fields or biofields.

Common Law

Judiciary system reconciles controversies, creates body of common law

Duty Breach of Duty Causation Damages

Liability involves four elements that must be established to prove that malpractice or negligence has occurred. Identify these elements.

Competent Practice Informed Consent or Refusal Contracts Collective Bargaining Patient Education Executing Physician Orders Careful Delegation Documentation Adequate Staffing Whistle-blowing Professional Liability Insurance Risk Management Programs ++Safety program. The aim is to provide a safe environment in which the basic safety needs of patients, employees, and visitors are met. ++Product safety program. The aim is to ensure safe and adequate equipment; this involves ongoing equipment evaluation and maintenance. ++Quality assurance program. The aim is to provide quality health care to patients; this involves ongoing evaluation of all systems used in the care of patients. Incident, Variance, or Occurrence Reports Patients' Rights Good Samaritan Laws

List Defenses to Malpractice suits.

Failure to Perceive the Patient as a Human Being Failure to Listen Nontherapeutic Comments and Questions Using Questions Requiring Only a Yes or No Answer Using Questions Containing the Words Why and How Using Questions That Probe for Information Using Leading Questions Using Comments That Give Advice Using Judgmental Comments Changing the Subject Giving False Assurance Gossip and Rumor Disruptive Interpersonal Behavior

List potential barriers to communication.

Standard 1. Assessment Standard 2. Diagnosis Standard 3. Outcomes Identification Standard 4. Planning Standard 5. Implementation Standard 5a. Coordination of Care Standard 5b. Health Teaching and Promotion Standard 5c. Consultation Standard 5d. Prescriptive Authority and Treatment Standard 6. Evaluation Standard 7. Ethics Standard 8. Education Standard 9. Evidence-Based Practice and Research Standard 10. Quality of Practice Standard 11. Communication Standard 12. Leadership Standard 13. Collaboration Standard 14. Professional Practice Evaluation Standard 15. Resource Utilization Standard 16. Environmental Health Standard 17. Collegiality

List the 17 aspects that comprise the ANA Code of Ethics and Scope of Practice Standards.

Relaxation Meditation Guided Imagery Prayer Aromatherapy

List the 5 Examples of Mind-Body Modalities

Public Health Activities -Tracking and notification of outbreaks -Infection control -Stats related to problems with drugs or equipment -Medical records crucial to crime investigation -ID victims of crime or disasters -Report cases of child abuse, neglect, domestic violence -Valid subpoena -Needed by coroners, medical examiners, funeral directors -Organ donations -Law enforcement in case of death from crime Law Enforcement and Judicial Proceedings Deceased People

List the components of and situations when breaches in health information are acceptable

Conversation Listening Silence Touch Humor

Note 5 Therapeutic techniques Used in Communication

Use of sign-in sheets The possibility of a confidential conversation being overheard Placing patient charts outside exam rooms Use of white boards X-ray light boards that can be seen by passers-by Calling out names in the waiting room Leaving appointment reminder voicemail messages

Note 6 Examples of incidental disclosures that are permitted.

Effectiveness Efficiency Equity Patient Centeredness Safety Timeliness

Note 6 properties associated with Quality

Phrase the nursing diagnosis as a patient problem or alteration in health state rather than as a patient need. Check to make sure that the patient problem precedes the etiology and that the two are linked by the phrase "related to." Defining characteristics, when included in the nursing diagnosis, should follow the etiology and be linked by the phrase "as manifested by" or "as evidenced by." Write in legally advisable terms. Use nonjudgmental language. Be sure the problem statement indicates what is unhealthy about the patient or what the patient wants to change (enhance). Avoid using defining characteristics, medical diagnoses, or something that cannot be changed in the problem statement.

Note considerations to utilize when forming nursing diagnoses.

1. The initial and ongoing nursing assessment of the patient and the patient's nursing care needs 2. The determination of the nursing diagnosis, nursing care plan, evaluation of the patient's progress in relation to the care plan, and evaluation of the nursing care delivered to the patient 3. The supervision and education of nursing personnel; patient teaching that requires an assessment of the patient and the patient's education needs 4. Any other nursing intervention that requires professional nursing knowledge, judgment, and/or skill

Note nursing care or tasks that should never be delegated except to another RN.

1.) Seeking ways to improve their health and well-being 2.) To relieve symptoms associated with chronic, even terminal, illnesses or the side effects of conventional treatments for them. 3.) Having a holistic health philosophy or a transformational experience that changes one's worldview and wanting greater control over one's own health.

Note reasons for choosing CAM methods.

Ayurveda Traditional Chinese Medicine Shamanism Homeopathy Naturopathy Chiropractic Medicine

Note six examples of Whole Medical Systems

1. Choosing 2. Prizing 3. Acting

Note the 3 Main Activities of the Valuing Process:

Descriptive Research Correlational Research Quasi-experimental Research Experimental Research

Note the 4 Types of Quantitative Research

1. Modeling 2. Moralizing 3. Laissez-Faire 4. Rewarding and Punishing 5. Responsible Choice

Note the 5 Common Modes of Value Transmission

1. Content 2. Timing 3. Format 4. Accountabilty 5. Cofidentilaity

Note the 5 Elements of Documentation:

1. Assault and Battery 2. Defamation of Character 3. Invasion of Privacy 4. False Imprisonment 5. Fraud

Note the 5 intentional tort categories.

Whole Medical Systems Mind-Body Therapies Energy Medicine Biologically Based Practices Manipulative and Body-Based Practices

Note the 5 major CAT/CAM categories.

Step 1: Ask a question about a clinical area of interest or an intervention. Step 2: Collect the most relevant and best evidence. The level for strength of evidence is numerical, with level 1 being the strongest and level 7 the lowest. Step 3: Critically appraise the evidence. Ask three questions: (1) What were the results of the study? (2) Are the results valid and reliable (3) Will the results of the study improve patient care? Step 4: Integrate the evidence with clinical expertise, patient preferences, and values in making a decision to change. Step 5: Evaluate the practice decision or change. The evaluation step is essential to determining if the change is effective for a particular patient or setting and if the expected outcomes resulted from the change.

Note the 5 steps in implementing EBP.

1. Avoiding 2. Collaborating 3. Competing 4. Compromising 5. Cooperating/Accommodating 6. Smoothing

Note the 6 Conflict Resolution Approach Strategies.

1. Health information and data 2. Result management 3. Order management 4. Decision support 5. Electronic communication and connectivity 6. Patient support 7. Administrative processes and reporting 8. Reporting and population health

Note the 8 Core functions of the EHR

1. Improve quality and convenience of patient care 2. Increase patient participation in their care 3. Improve accuracy of diagnoses and health outcomes 4. Improve care coordination 5. Increase practice efficiencies and cost savings. 6. Data can be distributed among many caregivers in a standardized format, allowing them to compare and uniformly evaluate patient progress easily. 7. Nurses from hospitals with fully implemented EHRs were significantly less likely to report unfavorable outcomes 8. Fewer nurses in the fully implemented hospitals reported frequent medication errors, poor quality of care, and poor confidence in a patient being ready for discharge. These nurses also had a 14% decrease in the odds of reporting that "things fell between the cracks" when patients were transferred between units. They were also less likely to report that patient safety is a low priority for hospital management.

Note the Benefits of EHR usage.

Actual Risk Possible Wellness Syndrome

Note the five types of nursing diagnoses.

1. Disclosure 2. Comprehension 3. Competence 4. Voluntariness

Note the four elements of Informed Consent

1. Well-defined body of specific and unique knowledge 2. Strong service orientation 3. Recognized authority by a professional group 4. Code of ethics 5. Professional organization that sets standards 6. Ongoing research 7. Autonomy and self-regulation

Note the seven characteristics that qualify an occupation as a profession.

Assess Learning Needs and Learning Readiness Diagnose the Patient's Learning Needs Develop Learning Outcomes Develop a Teaching Plan Deliver the content in an organized manner using the selected teaching strategies. Evaluate whether the learner outcomes were met

Note the steps of the teaching process

Phenomenology Grounded Theory Ethnography Historical

Note the types of Qualitative Research

Therapeutic Touch Healing Touch Sound Healing

Note three examples of Energy Medicine

Botanicals (Herbal Products) and Nutritional Supplements Nutritional Therapy

Note two aspects of Biologically Based Practices

To provide highest quality of care based on scientific evidence. To provide evidence that the services and interventions being funded or reimbursed are effective in securing valued goals.

Note two aspects of rationale concerning use of EBP.

Secondary Care

Problems that require more specialized clinical expertise, such as hospital care for a patient with a myocardial infarction or stroke is known as what kind of care?

Safety

Relates to actual or potential bodily harm.

Efficiency

Relates to maximizing the quality of a comparable unit of health care delivered or unit of health benefit achieved for a given unit of health care resources used.

Patient centeredness

Relates to meeting patients' needs and preferences and providing education and support.

Timeliness

Relates to obtaining needed care while minimizing delays.

Effectiveness

Relates to providing care processes and achieving outcomes as supported by scientific evidence.

Equity

Relates to providing health care of equal quality to those who may differ in personal characteristics other than their clinical condition or preferences for care.

Outcome Identification and Planning

Terms for the specification of (1) patient outcomes to prevent, reduce, or resolve the problems identified in the nursing diagnoses; and (2) related nursing interventions

(1) identify values (2) identify structure, process, and outcome standards and criteria (3) measure the degree of attainment of criteria and standards (4) make interpretations about strengths and weaknesses based on such measurements (5) identify possible courses of action (6) choose a course of action (7) take action.

The American Nurses Association (ANA) in 1975 developed a model quality-assurance program consisting of seven steps. Note these steps.

1. It is a succinct statement of the ethical obligations and duties of every individual who enters the nursing profession. 2. It is the profession's nonnegotiable ethical standard. 3. It is an expression of nursing's own understanding of its commitment to society.

The Code of Ethics for Nurses serves the following purposes:

1. Nurses and People 2. Nurses and Practice 3. Nurses and the Profession 4. Nurses and Co-Workers

The ICN Code of Ethics for Nurses has four principal elements that outline the standards of ethical conduct. Note these four principal elements.

Tertiary Care

The Management of rare and complex disorders such as pituitary tumors and congenital malformations is known as what kind of care?

Result management

The ability to manage all test results (from labs, radiology reports).

Patient support

The ability to provide patients with educational material as well as the ability to enter data themselves concerning home monitoring devices

Health information and data

The electronic chart must hold everything that is currently included within a paper chart. All information within the electronic chart must be information/data that would be used to make critical decisions. It should be a well designed interface to enable the provider to review the information efficiently.

Primary Care

The management of common health problems (sore throats, diabetes, arthritis, depression, or hypertension) and preventive measures (vaccinations, mammograms) that account for 80% to 90% of visits to clinicians is known as what type of care?

Nursing Informatics

The term for a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in their decision making in all roles and settings. -Function - what is the primary functionof informatics -Nursing informatics page 363

1. The state practice act must permit delegation and outline the authorized task(s) to be delegated or authorize the RN to decide delegation. 2. The person making the delegation has the appropriate qualifications 3. The person receiving the delegation must have the appropriate qualifications

There are three criteria to be considered by the RN when deciding to delegate care activities. List these criteria.

Quality by Inspection Quality as Opportunity

There are two different approaches to ensuring quality. Note these approaches.

Online Clinical Databases

These databases allow literature searches for primary sources of evidence and research.

Wellness Diagnoses

These nursing diagnoses are clinical judgments about a person, group, or community in transition from a specific level of wellness to a higher level of wellness. These diagnoses are often more applicable in nursing settings that deal primarily with healthy patients. The diagnostic statement is a one-part statement that contains the label Readiness for Enhanced, followed by the desired higher-level wellness.

Risk Nursing Diagnoses

These nursing diagnoses are clinical judgments that a person, family, or community is more vulnerable to develop the problem than others in the same or similar situation.

Possible Nursing Diagnoses

These nursing diagnoses are statements describing a suspected problem for which additional data are needed. Additional data are used to confirm or rule out the suspected problem.

Syndrome Nursing Diagnoses

These nursing diagnoses comprise a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation.

Actual Nursing Diagnoses

These nursing diagnoses represent problems that have been validated by the presence of major defining characteristics. This type of nursing diagnosis has four components: label, definition, defining characteristics, and related factor.

Institutional Review Boards (IRBs)

These overseeing bodies are required by federal law, and are purposed for the review of all studies conducted to determine the risk status of all studies and to ensure that ethical principles are followed.

Quality-Assurance Programs

These programs enable nursing to be accountable to society for the quality of nursing care. Such programs also respond to the public mandate for professional accountability. They help ensure survival of the profession, encourage nursing's fidelity to its moral and ethical responsibilities, and assist nursing to comply with other external pressures.

Guideline Database

These searchable databases of evidence-based clinical practice guidelines.

Journals

These sources may contain abstracts with expert commentaries.

Professional Organizations

These sources often offer position statements, guidelines, protocols and other documents to promote evidence-based practice.

Unintentional

These types of torts are referred to as negligence.

Naturopathy

This CAM believes that health is a dynamic state of being that provides abundant energy for people to deal with life in our complex society. Much of illness can be attributed, at least in part, to ignoring "natural laws," such as engaging in a sedentary lifestyle without adequate time for exercise; exposing oneself to environmental toxins; eating processed, overcooked foods; engaging in negativity or harboring negative thoughts; and not getting adequate rest or relaxation.

Homeopathy

This CAM believes that when symptoms are suppressed, the condition "goes deeper" into the body, making it ultimately more difficult to cure. Supporters of this point to two unconventional theories: "Like cures like": the notion that a disease can be cured by a substance that produces similar symptoms in healthy people "Law of minimum dose": the notion that the lower the dose of the medication, the greater its effectiveness. Many homeopathic remedies are so diluted that no molecules of the original substance remain.

Whole Medical System

This CAM category consists of a philosophy and theory about health and illness along with specific types of treatment. These systems have developed independently from allopathic medicine and are generally culturally based

Chiropractic Medicine

This CAM focuses on the relationship between the body's structure—mainly the spine—and its functioning. Although practitioners may use a variety of treatment approaches, they primarily perform adjustments (manipulations) to the spine or other parts of the body with the goal of correcting alignment problems, alleviating pain, improving function, and supporting the body's natural ability to heal itself.

Shamanism

This CAM has been the most widely practiced medical system on our planet. This originated with indigenous people in many geographic areas of the world, including Hawaii, Ecuador, Tibet, West Africa, Israel, Peru, Colombia, and East Asia. In this view, illness and other forms of distress are thought to originate in the spirit world. An individual possesses the ability to access the spirit world, which is done on behalf of people or the community, and return to "ordinary reality" with information on the proper treatment.

Traditional Chinese Medicine

This CAM is based on the ancient Chinese perception of humans as microcosms of the larger surrounding universe—interconnected with nature and subject to its forces. The human body is regarded as an organic entity in which the various organs, tissues, and other parts have distinct functions but are all interdependent. In this view, health and disease relate to balance of the functions.

Ayurveda

This CAM originated in the Vedic civilization of India about 4,000 years ago and is one of the world's oldest medical systems. The aim is to integrate and balance the body, mind, and spirit. This is believed to prevent illness and promote wellness.

Quality by Inspection

This Quality Assurance Program focuses on finding deficient workers and removing them. Nurses and others working in a setting using this approach may be afraid to admit a mistake or error and wrongly attempt to hide a problem. Such behavior is never acceptable and may result in serious harm to patients.

Quality as Opportunity

This Quality Assurance Program focuses on finding opportunities for improvement and fosters an environment that thrives on teamwork, with people sharing the skills and lessons they have learned.

Competing

This conflict resolution approach results in a win for one party at the expense of the other group. This win-lose confrontation can leave the loser frustrated, with a desire to get even in the future. This strategy may be utilized when one party has more knowledge regarding the situation or when resistance is appropriate because of ethical concerns or unsafe patient care practices.

Avoiding

This conflict resolution strategy includes an awareness of the conflict situation, but the parties involved decide to either ignore the conflict or avoid/postpone its resolution. The conflict has not been resolved and may resurface later in an exaggerated form.

Collaborating

This conflict resolution strategy is a joint effort to resolve the conflict with a win-win solution. All parties set aside previously determined goals, determine a priority common goal, and accept mutual responsibility for achieving this goal. This focus on problem solving is based on mutual respect, honest communication, and shared decision making.

Smoothing

This conflict resolution strategy is an effort to compliment the other party and focus on agreement rather than disagreement, thus reducing the emotion in the conflict. The original conflict is rarely resolved with this technique.

Manipulative and Body-Based Practices

This group of therapies includes therapeutic massage—an assortment of techniques that involve manipulation of soft tissues of the body through pressure and movement, as well as a variety of techniques such as Rolfing, shiatsu, Feldenkrais, Alexander, myofascial release, and others. The goal is to break up tension held in body structures, promote communication between mind-body structures, promote detoxification, and generally improve body functioning. Some of these therapies can be painful while they work to oxygenate tissues, break up lymphatic congestion, release muscle tightness, and promote circulation. These therapies require specialized preparation and are typically useful in rehabilitation or health-promotion types of settings.

Qualitative Research

This is a method of research conducted to gain insight by discovering meanings. At its core is the idea that reality is based on perceptions, which differ for each person and change over time. This research primarily analyzes words or narratives rather than numbers.

Systematic Review

This is a review of available research studies focusing on a single question. The systematic review summarizes, appraises, and synthesizes large bodies of evidence relevant to a focused research question.

Administrative processes and reporting

This is referred to as the Practice Management. The administrative process is to improve the efficiency in scheduling appointments, eliminate confusions, determine insurance eligibility, etc.

Malpractice

This is the term generally used to describe negligence by professional personnel.

Affective

This learning domain includes changes in attitudes, values, and feelings.

Psychomotor

This learning domain involves learning a physical skill involving the integration of mental and muscular activity.

Cognitive

This learning domain involves the storing and recalling of new knowledge in the brain and includes intellectual behaviors such as the acquisition of knowledge, comprehension, application, analysis, synthesis, and evaluation.

Tertiary Health Promotion and Illness Prevention

This level of health promotion and illness prevention begins after an illness is diagnosed and treated, with the goal of reducing disability and helping rehabilitate patients to a maximum level of functioning. Nursing activities at this level include teaching a patient with diabetes how to recognize and prevent complications, using physical therapy to prevent contractures in a patient who has had a stroke or spinal cord injury, and referring a woman to a support group after removal of a breast because of cancer.

Secondary Health Promotion and Illness Prevention

This level of health promotion and illness prevention focuses on screening for early detection of disease with prompt diagnosis and treatment of any found. The goals are to identify an illness, reverse or reduce its severity or provide a cure, and thereby return the person to maximum health as quickly as possible. Examples of nursing activities at this level are assessing children for normal growth and development and encouraging regular medical, dental, and vision examinations. Otheractivities include screenings (e.g., blood pressure, cholesterol, and skin cancer), recommending gynecologic examinations and mammograms for women at appropriate ages, and teaching testicular self-examination to men. Direct nursing care interventions at this level include administering medications and caring for wounds.

Quantitative Research

This research type involves the concepts of basic and applied research. Basic research, sometimes called pure or laboratory research, is designed to generate and refine theory, and the findings are often not directly useful in practice. Applied research, also called practice research, is designed to directly influence or improve clinical practice.

Primary Health Promotion and Illness Prevention

This type of health promotion and illness prevention are directed toward promoting health and preventing the development of disease processes or injury. Examples of activities at this level are immunization clinics, family planning services, providing poison-control information, and accident-prevention education. Other nursing interventions include teaching about a healthy diet, the importance of regular exercise, safety in industry and farms, using seat belts, and safer sex practices.

Historical

This type of qualitative research examines events of the past to increase understanding of the nursing profession today. Many studies focus on nursing leaders, but there is increasing interest in patterns of nursing practice.

Ethnography

This type of qualitative research is developed by the discipline of anthropology and is used to examine issues of a culture that are of interest to nursing.

Grounded Theory

This type of qualitative research is the discovery of how people describe their own reality and how their beliefs are related to their actions in a social scene. The findings are grounded in the data from subjects and are used to formulate concepts and to generate a theory of the experience, supported by examples from the data (e.g., coping with a seriously ill child).

Phenomenology

This type of qualitative research seeks to describe experiences as they are lived by the subjects being studied. Analysis of data provides information about the meaning of the experience within each person's own reality (e.g., the experience of health or of having a heart attack).

Quasi-experimental Research

This type of quantitative research is used to examine cause-and-effect relationships between selected variables. Often conducted in clinical settings to examine the effects of nursing interventions on patient outcomes.

Experimental Research

This type of quantitative research is used to examine cause-and-effect relationships between variables under highly controlled conditions. These are often conducted in a laboratory setting.

Correlational Research

This type of quantitative research is used to examine the type and degree of relationships between two or more variables. The strength of the relationship varies from a -1 (perfect negative correlation, in which one increases as the other decreases) to a+1 (perfect positive correlation, with both variables increasing or decreasing together).

Descriptive Research

This type of quantitative research is used to explore and describe events in real-life situations, describing concepts and identifying relationships between and among events. Often used to generate new knowledge about topics with little or no prior research.

Invasion of Privacy

This type of tort includes: Unnecessary exposure of patients while moving them through a corridor or while caring for them in rooms they share with others Talking with patients in rooms that are not soundproof Discussing patient information with people not entitled to the information Pressing the patient for information not necessary for care planning Interacting with the patient's family in ways not authorized by the patient Using tape recorders, dictating machines, computers, and the like without taking precautions to ensure the patient's confidentiality Preparing written or oral class assignments about patients without concealing their identity Carrying out research without taking proper precautions to ensure the anonymity of patients Punishments for anyone caught in this tort include: Fines of up to $250,000 Jail for up to 10 years. Penalties and embarrassment for your and your workplace

False Imprisonment

This type of tort involves the unjustified retention or prevention of the movement of another person without proper consent. Additionally the indiscriminate and thoughtless use of restraints on a patient can constitute this tort.

Negligence and Malpractice

This type of tort is defined as performing an act that a reasonably prudent person under similar circumstances would not do or, conversely, failing to perform an act that a reasonably prudent person under similar circumstances would do.

Fraud

This type of tort is the willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property. Misrepresentation of a product is a common fraudulent act. A person misrepresenting oneself to obtain a license to practice nursing may be prosecuted under the state's Nurse Practice Act. Also, misrepresenting the outcome of a procedure or treatment may constitute this tort.

Defamation of Character

This type of tort occurs wherein which one party makes derogatory remarks about another that diminish the other party's reputation. Slander is spoken form, while libel is the written form. This tort type is grounds for an award of civil damages. Damages are awarded to the plaintiff based on the amount of harm done to the plaintiff.

Assault and Battery

This type of tort refers to a threat or an attempt to make bodily contact with another person without that person's consent.

Mind-Body Modalities

Uses a variety of techniques designed to enhance the mind's ability to affect bodily function and symptoms.

Decision support

Warnings/reminders to enhance clinical performance. This services can aid in drug interactions/prescriptions/prevention, detection of disease outbreaks, evidence-based guidelines, etc. Overall, it will assist providers in making the best decision possible for the patient.

1. Right task 2. Right circumstances 3. Right person 4. Right direction/communication 5. Right supervision

What are the Five Rights of Delegation?

hot/cold, interior/exterior, excess/deficiency, ying/yang

What are the eight principles in TCM?

Fire Earth Metal Wood Water

What are the five elements in TCM?

Nursing informatics facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in their decision making in all roles and settings. +Increases in the accuracy and completeness of nursing documentation +Improvement in the nurse's workflow and an elimination of redundant documentation +Automation of the collection and reuse of nursing data +Facilitation of the analysis of clinical data (Joint Commission indicators, core measures, federal- or state-mandated data and facility-specific data

What are the primary functions of nursing informatics?

Cognitive Psychomotor Affective

What are the three domains of learning?

Basic research, sometimes called pure or laboratory research, is designed to generate and refine theory, and the findings are often not directly useful in practice. Applied research, also called practice research, is designed to directly influence or improve clinical practice.

What are two forms of Quantitative Research?

Situation, Background, Assessment, Recommendation

What does SBAR stand for?

1. Patient's mental status 2. Skin condition 3. Oxygenation Status/Therapy

What does the "B" in SBAR include?

Deontologic

What ethical form is described as: An action is right or wrong based on a rule, independent of its consequences.

Utilitarian.

What ethical form is described as: The rightness or wrongness of an action depends on the consequences of the action.

Give conclusions about present situations. For example, use phrases like, "it might be..." or "It's possible that it is.... If unclear, at least try to indicate what body system may be involved. If appropriate, state that it could be life-threatening

What information is associated with the "A" of ISBARR?

Admission Dx and Date Pertinent Medical Hx Synopsis of Treatment Most Recent Vitals Changes noticed from prior Assessments

What information is associated with the "B" of ISBARR?

State name, title, and unit

What information is associated with the "I" of ISBARR?

Patient Name Room Number Problem

What information is associated with the "S" of ISBARR?

Say what you think would be helpful or needs to be done Ask about any changes in orders

What information is associated with the first "R" of ISBARR?

Restate the provided orders and clarify how often vitals are desired and under what circumstances to call back

What information is associated with the second "R" of ISBARR?

PICO is a format used to ask a clinical question in developing EBP. P= Patient, population, or problem of interest I= Intervention of interest C= Comparison of interest O= Outcome of interest

What is PICO?

Before you can provide culturally competent care to patients from diverse backgrounds, become aware of the role of cultural influences in your own life. Objectively examine your own beliefs, values, practices, and family experiences. As you become more sensitive to the importance of these factors, you will also become more sensitive to cultural influences in others' lives. Identify your biases. How do they affect your feelings about others? How could they affect your nursing care of others?

What is cultural awareness and why it is important?

1. This is what I think the problem is.... 2. The problem seems to be (category) 3. I'm not what the problem is, but... 4. The patient is unstable and may get worse, we need to act

What is included in the "A" portion of the SBAR?

1. Recommendation from Physician 2. Any tests needed 3. If a change in treatment orderd, ask: +how often do you want vitals +How long do you expect this issue to last +If the patient does not improve, when should we call again

What is included in the "R" portion of the SBAR?

1. Patient Name 2. Code Status 3. Current Problem 4. Current Vitals 5. I am concerned about the....

What is included in the "S" of SBAR?

Evidence-based practice(EBP) in nursing is a problem-solving approach to making clinical decisions, using the best evidence available. EBP blends both the science and the art of nursing so that the best patient outcomes are achieved.

What is the purpose of EBP usage?

1. A desire for a higher level of wellness 2. An effective present status or function

What two cues must be present for a valid wellness diagnosis?

Quantitative and Qualitative

What two research methods are utilized in nursing?

The Standard of Care—what a reasonably prudent person would or would not have done under similar circumstances

Whether negligence has occurred depends on what?

38, 4in10, 12, 1in9 Women (30-69) Higher ed

___% of adults (__ in __) and approximately ___% of children (___ in __) were using some form of CAM. CAT more prevalent in...

Bikram

done in 105 degree studio with 26 set postures

Administrative Law

empowered by executive officer

Statutory Law

enacted by legislative body

Iyengar

focuses on proper alignment and holding poses for relatively longer time

Ashtanaga

focuses on synchronizing breath with a fast-paced series of postures

Kripaula

gentle yoga focuses on relaxation and coming into balance

Constitutions

serve as guides to legislative bodies