110 INTRO TO PROFESSIONALISM Flashcards
(46 cards)
HIPAA
health insurance portability and accountability act
-protects sensitive patient health info from being disclosed
OSHA
occupational safety + health administration
-helps protect the safety of workers in the workplace
Nurse Practice Act
highlights the legal responsibilities, knowledge base, and skills of the RN specific to each state
California Board of Registered Nursing
[BRN]
regulates the nurse practice act in California
what CANNOT be delegated by an RN?
TAPE
T- teaching
A- assessment
P- planning
E- evaluating
UAP/CNA
unlicensed assistant personnel
LPN/LVN
licensed practical nurse
who can delegate?
RN
LPN/LVN (in some states)
never UAP/CNA
what can be delegated to UAP/CNA
- ADL’s
- ambulate
- turning
- bath/toilet
- mouth care
- linen
- VS (stable)
- I+O (except IV)
- weight/measurement
what can be delegated to LVN/LPN
- duties depend on state/facility
- maybe delegate
- stable patients w chronic + predictable outcomes
- gather data to contribute to assessment (listen to lung/bowel/hrt sounds)
- routine procedures (obtain EKG, glucose checks, insert catheters)
- give medication (except IV)
UAP/CNA CANNOT…
delegate, provide medication, VT in unstable patients, IV
cannot take care of UNSTABLE patients
ex) post-op
LPN/LVN CANNOT…
have new admissions, fresh post ops, education, comprehensive assessment,
IV medication, interpret data, blood transfusions
SMART
specific measurable attainable relevant time-bound
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
Nursing Diagnosis are composed of…
1 problem
2 etiology
3 definiting characteristics
“Problem” in nursing diagnosis
identifies what’s the problem
ex) insufficient air supply
“Etiology” in nursing diagnosis
identifies factors maintaining the unhealthy
ex) smoking (maintains breathing problems)
“Definining Characteristics” in nursing diagnosis
subjective + objective data
ex) increase bp, incr resp rate
Discharge Planning
-Planning for discharge begins on admission when information about the patient is collected and documented
Against Medical Advice
- patient is legally free to leave
- patient is informed of risk prior to signing form, patient signature must be witnessed, release form is part of medical record
ISBARQ method of hand-off
I- introduction S- situation B - background A - assessment R -recommendation Q - Q+A
Primary Care
preventative screenings, no diagnosis yet
- directed towards promoting health + preventing the development of disease processes or injury
ex) immunization, family planning services, poison-control, accident prevention
Secondary Care
checkups; focused on screening for early detection of disease w prompt diagnosis + treatment of any found
ex) assessing kids for normal growth + development, regular medical, dental, vision examination
Tertiary Care
Tertiary care: already have a complex disease and now receiving treatments
-begins after an illness is diagnosed + treated, w goal of reducing disability + rehabilitation to a maximum level of functioning
ex) teaching patients w diabetes how to recognize + prevent complications.
using physical therapy to prevent contractures in patients w stroke or spinal cord injury.
Referring woman to support group after removal of a breast bc of cancer
