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Clinical Concepts > Exam 1 Study Guide > Flashcards

Exam 1 Study Guide Flashcards

1
Q

Missouri Nurse Practice Act

A
  • professional nursing = any act which requires substantial specialized education, judgment and skill based on knowledge and application of principles derived from the biological, physical, social, and nursing sciences
  • teaching health care and preventing illness to patient and family
  • assessment, nursing diagnosis, nursing care, and counsel of persons who are ill, injured or experiencing alterations in normal health processes
  • administration of medications and treatments as prescribed by a person licensed by a state regulatory board
  • coordination and assistance in plan of care w/ team members
  • teaching and supervision of other persons in the performance
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1
Q

Legal definition of Nursing - Nurse Practice Act

A
  • defines nursing
  • scope of practice (what the nurse is allowed to do)
  • qualifications for licensure
  • nursing titles that are allowed to be used
  • actions that can or will happen if the nurse does not follow the nursing law
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2
Q

Which of the following is NOT someone who wants to be a registered nurse in MO?

A
  • Must have a HS diploma/GED
  • Must be a good moral character
  • Must have a BSN!!! — can have associates degree too
  • Must pass the licensing exam
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3
Q

4 factors that can influence care

A
  • person, environment, health, and nursing
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4
Q

slu conceptual framework: person

A
  • individual, family, group, community
  • family: set of relationships that client defines as family (may have legal/biological ties)
  • group: assembly of people who meet over time for a specified reason
  • community: social group which may share geographic boundaries. interact bc of common interests to meet needs in larger society
  • adaptive system
  • interacting w/ environment
  • goals: meet basic needs, maximize fxn, progress toward self-actualization
  • integrated whole w/ 4 dimensions
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5
Q

slu conceptual framework: environment

A
  • external factors (surround or interact with client)
  • influence development and behavior
  • client adapts by changing self or by changing environment
  • may include individuals, families, communities, physical surroundings, settings, milieu, social/political
    > health care system
  • 6 levels of Care in HC System
    > preventive (vaccine), pc (check up), secondary care (hospital), tertiary care (bone marrow transplant), restorative care (rehab), continuing care (hospice)
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6
Q

health

A
  • fluctuates along a continuum from high level wellness to death
  • fluctuations occur bc of change in person or external environment
  • person strives to achieve maximal physiological, psychological, sociocultural, and spiritual integrity
  • internal variables: genetic influences, health habits, age/developmental state, emotional factors, spiritual factors
  • external variables: family variables (obesity), SEF, cultural background
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7
Q

goal of nursing

A
  • assist individuals who have actual or potential health related difficulties
  • goal = to assist the person toward maximal physiological, psychological, sociocultural, and spiritual integrity
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8
Q

what is the definition of health according to the sluson conceptual framework?

A
  • dynamic state of being that fluctuated along a continuum from high level of wellness to death
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9
Q

slu conceptual framework: nursing

A
  • nursing is a science and art
  • assist clients with actual or potential health related difficulties in adaptation
  • based on professional values
  • goal of nursing – maximal integrity in adaptation
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10
Q

core concepts of nursing

A
  • communication, collaboration, curiosity, competence, care, cure
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11
Q

according to the sluson framework, what is the goal of nursing care?

A
  • promote adaptation
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12
Q

according to the sluson framework, who is the patient?

A
  • client, parents and sibilings, friends
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13
Q

according to the sluson framework, what is the role of nursing in client care?

A
  • nurse is the provider of care
  • nurse is a coordinator of care
  • nurse is an educator
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14
Q

factors that influence decision making in nursing

A
  • nature of nursing practice
  • nurse/patient relationship
  • health care system
  • legal and ethical principles
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15
Q

therapeutic relationships

A
  • professional, interpersonal alliance in which the nurse and patient join tgthr for a defined period to achieve health-related treatment goals
  • time varies (short or long)
  • requires planning
    > think through and organize ideas
    > actively listen and question
    > choose messages carefully for max impact
    > seek common ground
    >how can we get tgthr to do what is best for the patient and make quality decisions
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16
Q

goals of therapeutic relationships

A
  • supporting patients and families
  • helping patients and families learn practical strategies
  • provide emotional and informational support
  • assisting patients to cope (physical touch)
  • helping patients discover new directions
  • connecting patients with members of IP team (case manager, PT, etc)
  • empowering patients to be successful advocates for their own health
  • we do for the patient what they would do for themselves and we try to make them as independent as possible
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17
Q

what is communication?

A
  • combination of verbal and nonverbal behaviors integrated for the purpose of sharing
  • info, ideas, feelings
  • intertwined with relationships
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18
Q

verbal communication

A
  • spoken or written words
  • vocab
    > words that convey meaning
    > meaning is in the people who send and receive the message
    > meanings can vary in diff context
    > medical jargon
    > generational differences (phrases)
    > cultural/regional differences
  • what a word means = very much a product of us and what we know
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19
Q

denotative

A
  • generalized meaning assigned to a word by a group
  • largely agreed upon meaning
  • dictionary definition
  • Ex: walk = to pass on foot or as if on foot thru, along, over, or upon
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20
Q

connotative

A
  • shade or interpretation of the meaning of a word influenced by thoughts, feelings, ideas that people have a word for
  • ex: walk = physically walking a patient or walking a baseball player
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21
Q

paralanguage

A
  • verbal styles that influence communication
  • pacing: appropriate speed and pacing increases success of communication
  • intonation: tone of voice can dramatically affect meaning of message
    > convey diff emotions like anger, concern
    > lack of intonation makes written communication hard to decode
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22
Q

written communication has tone

A

where are you = chill
WHERE ARE YOU = urgent

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23
Q

how to make communication more effective?

A
  • simple, brief, direct
  • avoid phrases like, basically, literally, you know = detracts from clarity
  • messages should be relevant and imp to the situation being discussed
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24
Q

Nonverbal communication

A
  • 60-75% is done nonverbally
  • unconsciously motivated (expressions)
  • nonverbal could tell us something different than their words
  • saying they aren’t in pain when they rlly are
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25
Q

body language: eye contact

A
  • people often signal readiness to communicate thru eye contact
  • can have different meanings in different cultures
    > some might not look you in the eye bc you have such high esteem
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26
Q

what can gestures do?

A
  • indicate how the person is feeling and if they are ready to communicate
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27
Q

what can posture do?

A
  • let you know of the patient is open to communicating and how they feel
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28
Q

imp sounds for nurses to note

A
  • sighs, moans, groans, and sobs
  • these indicate how the patient is feeling
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29
Q

touch

A
  • conveys caring, empathy, support, reassurance
  • also conveys anger
  • influenced by culture so might be inappropriate to some
  • may or may not be welcomed
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30
Q

how far should nurses be from the patient?

A
  • intimate distance: 0-18in (L&D)
  • personal distance: 18-40in (standing @ bedside)
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31
Q

requires therapeutic use of self

A
  • not simply what the nurse does but who the nurse is
  • authenticity
  • self-awareness: clear understanding of your personal beliefs, values, stereotypes, and personal perspectives
  • presence: full attention of the nurse being there and being with (eye contact)
  • empathy (on another card)
  • appropriate level of involvement (on another card)
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32
Q

empathy

A
  • ability to enter into the life of another person and accurately perceive their feelings
  • communicated understanding
  • increases the feeling of being connected to another
  • is NOT sympathy
  • trying to visualize how they are feeling
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33
Q

appropriate level of involvement

A
  • degree of nurse’s attachment and active participation in patient’s care
  • fluctuates
  • maintain professional boundaries
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34
Q

social relationships

A
  • mutually beneficial
  • reciprocity
  • may fulfill mutual needs for pleasure, love, econ security
  • not the same as therapeutic relationships
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35
Q

too little involvement

A
  • limited perfunctory contacts
  • minimizing patients suffering
  • defensive or judgmental communication
  • neglecting the patient
  • showing disinterest
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36
Q

undue self-disclosure

A
  • should be limited and only used with the intention of assisting the patient in a pos way
  • telling info about myself
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37
Q

secretive behavior

A
  • should never be secretes btw patient and nurse
  • if a patient asks if you can keep a secret, you can keep it confidential as long as it is not harming them or anyone else
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38
Q

super nurse behavior

A
  • no one else can take better care of the patient than me
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39
Q

special treatment

A
  • providing care that is not given to other patients
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40
Q

sexual misconduct

A
  • engaging in conduct with a patient that is sexual or may be reasonably interpreted by the patient as sexual
  • take someone w/ you if you think the patient can interpret it as sexual
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41
Q

pre-interaction phase

A
  • looking at chart before you see the patient
  • patient does not directly participate
  • identify professional goals
    > review available data
    > talk with other care givers
    > anticipate health concerns or issues that arise
  • plan time and space for initial interaction
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42
Q

orientation phase

A
  • when nurse and patient get to know one another
  • begin to develop trust
    > give patient basic info about yourself
    > name, professional status, purpose, nature, and time available of the relationship, when will relationship end
  • clarify your role and that of patient
  • assess patient’s health status
    > close ended questions (yes or no)
    > open ended questions: elicit
  • patients thoughts and perspectives w/o influencing the direction of acceptable response
    > focused questions: more specific (can you tell me more…)
  • begin to identify patient problems and goals
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43
Q

SURETY

A
  • S: sit at an angle
  • U: uncross arms and legs
  • R: relax
  • E: eye contact
  • T: touch (or physical proximity)
  • Y: your intuition
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44
Q

working phase

A
  • nurse and patient work tgthr to solve patient problems and achieve patient goals
  • utilize therapeutic communication skills to facilitate successful interactions
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45
Q

termination phase

A
  • remind the patient that termination is near
  • evaluate goal achievement with the patient
  • transition care to other caregivers as needed
  • introduce next nurse
  • talk to the next nurse
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46
Q

therapeutic communication skills

A
  • active listening
  • empathy
  • minimal cues: brief encouraging phrases and nonverbal prompts
  • clarification: listening response - ask patient for info or for elaboration of a point (can you tell me what I just said)
  • restatement: restate parts of the message in the form of a question
  • paraphrasing: focuses on the cognitive component of the message (so you were confused abt your med schedule)
  • reflection: focuses on emotional component of the message (so you’re feeling sad. can you tell me more?)
  • summarization and validation: used to pull several ideas and feelings tgthr (so the pain meds are not working. let’s try to figure out what we can do diff)
  • providing info: can decrease anxiety or help w/ decision making
  • silence
  • touch
  • humor
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47
Q

barriers to therapeutic communication

A
  • false reassurance: 007
  • giving advice (coersive)
  • false inferences: making an unsubstantiated assumption about what a patient means w/o asking for validation
  • over generalizing (it’s gonna be fine everyone gets nervous)
  • changing subject (ignoring what’s imp to them)
  • moralizing (i think it’s great you quit smoking)
  • value judgments/personal opinion: pt shouldn’t know if you approve/disapprove their actions
  • social responses: polite superficial comments that don’t focus of what the patient is feeling or trying to see
  • asking why questions: implies criticism and makes patient feel defensive
  • being defensive/arguing
  • bringing up topics best avoided (religion, politics, etc)
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48
Q

Enhancing the therapeutic relationship

A
  • CARE
  • C: connect w/ pt
  • A: appreciate the patient’s situation and acknowledge their pov
  • R: respond to their needs
  • E: empower pts to problem solve w/ u
  • keep things confidential when appropriate
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49
Q

scope of nursing practice

A
  • promoting health and wellness
  • preventing illness
  • restoring health
    > providing direct care to ill person
    > performing diagnostic procedures
    > consulting w/ other health professionals
    > teaching about recovery activities
    > rehabilitating pts to optimal fxnal level
  • caring for the dying
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50
Q

qualifications for licensure

A
  • submit a written application on forms furnished to the applicant
  • good moral character
  • completed all education requirements
  • make statement under oath
  • Be approved by the board
  • pass an exam (NCLEX)
  • pay license fee
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51
Q

define nursing

A
  • The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health, its recovery, or a peaceful death that the client would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help the client gain
    independence as rapidly as possible.
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52
Q

ANA Council of Nursing Practice definition

A
  • Nursing incorporates the art and science of caring and focuses on the protection, promotion, and
    optimization of health and abilities; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate
    presence. Nursing is the diagnosis and treatment of human response, and advocacy in the care of
    individuals, families, groups, communities and populations in recognition of the connection of all
    humanity
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53
Q

set standards of practice use of nursing process in providing care

A
  • assessment
  • diagnosis
  • outcome identification
  • planning
  • implementation
    > coordination of care
    > health teaching and health promotion
  • evaluation
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54
Q

discipline of nursing

A
  • disciplines are ways of thinking - ways to look at the world
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55
Q

meyer’s law

A
  • nurses are not paid for what they do; they are paid for how they think
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56
Q

clinical decision making

A
  • strategies used to understand the significance of data, identify real and potential patient problems and choose the best actions to achieve desired outcomes
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57
Q

self-care deficit theory of nursing - dorothea orem’s

A

used when feeding or bathing a patient until the patient can do it on their own

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58
Q

theory of goal attainment - imogene king

A
  • nurses view a patient as a unique personal system that is constantly interacting/transacting w/ other systems
  • help patients become active participants in their care by working with them to establish goals for attaining, restoring, or maintaining health
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59
Q

adaptation model - callista roy

A
  • nurses help a patient cope w/ or adapt to changes in physiological, self-concept, role fxn, and interdependence domains
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60
Q

principles of practice and nursing - virginia henderson

A

nurses assist patients w/ 14 activities (breathing, eating, drinking, elimination, movement, positioning, sleep, rest, clothing, body temp, hygiene, safety, communication, play, work, worship, learning) until patients can meet these needs themselves or they help them have a peaceful death

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61
Q

cultural care theory - madeline leininger

A

an established nursing theory that emphasizes culture and care as essential concepts in nursing

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62
Q

which of the following is NOT a part of the physiological dimension according to the SLUSON framework?

A
  • elimination
  • sleep/rest
  • sensory/perception
  • sexuality/reproduction
  • SELF PERCEPTION AND SELF CONCEPT (psychological)
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63
Q

According to the SLUSON conceptual framework “meaning and purpose of life” is a part of which dimension?

A
  • spiritual
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64
Q

which of the following is part of the sociocultural dimension according to the SLUSON framework

A
  • cultural values, norms and customs
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65
Q

SLU conceptual framework: nursing roles

A
  • designer and provider of care
  • nurse clinician – ADN, Diploma, BSN
  • Advanced Practitioner Nurses – MSN/DNP
    >NP, Clinical Nurse Specialist, Nurse Midwife, Nurse Anesthetist
  • manager/coordinator of care -> works w/ IP team
  • member of a team
  • negotiating decision making among team is essential
  • good communication paramount
    > need to understand Med terms
  • can be patient educator, politician, consultant, counselor, researcher, client advocate
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66
Q

altruism

A

concern for welfare an well being of others

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67
Q

autonomy

A

right to self-determination

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68
Q

human dignity

A

respect for inherent worth and uniqueness of populations and individuals

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69
Q

integrity

A

acting in accordance w/ appropriate code of ethics and accepted standards of practice

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70
Q

social justice

A

working to ensure equality in treatment and access

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71
Q

callista roy’s theory of nursing states that the unique fxn of nursing is

A

helping clients adapt to internal and external demands

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72
Q

nursing practice involves all of the following except

A
  • promoting health and wellness
  • DIAGNOSING DISEASE
  • restoring health
  • caring for the dying
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73
Q

a client has terminal cancer and has been accepted into a hospice program. what level of health. care are they using at the time?

A

continuing care

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74
Q

what is caring and what are the requirements?

A
  • patient centered approach focusing on the patient’s needs
  • requirements: sincerity, listening, presence, respect, acceptance
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75
Q

caring is primary (dr. benner)

A

People, events, projects,
and things matter to people. Patients are unique with
different backgrounds of experience, values, and cultural perspectives.

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76
Q

Leininger’s transcultural caring

A

Caring is very personal, thus its expression of caring differs for each patient. Expressions, processes, and patters of caring vary among cultures.

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77
Q

watson’s transpersonal caring

A

Holistic model that
supports a nurse’s conscious intention to care and promote healing and wholeness. The nurse looks for deep sources of inner healing to protect, enhance, and preserve a person’s dignity, humanity, wholeness, and inner
harmony.

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78
Q

Swanson’s theory of caring

A

Nurturing way of relating to
an individual. 1) Knowing 2)Being with 3)Doing for
4)Enabling 5)Maintaining belief

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79
Q

knowing

A
  • striving to understand an event as it has meaning in the life of the other
  • avoiding assumptions; centering on the one cared for; assessing throughly; seeking clues o clarify the event engaging the self or both
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80
Q

being with

A
  • being emotionally present to the other
  • being there, conveying ability, sharing feelings, not burdening
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81
Q

doing for

A
  • doing for the other as one would do for self
  • comforting, anticipating, performing skillfully, protecting, preserving dignity
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82
Q

enabling

A
  • facilitating the other’s passage thru life transitions and unfamiliar events
  • informing/explaining, supporting/allowing, focusing, generating alternatives, validating/giving feedback
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83
Q

maintaining belief

A
  • sustaining faith in the other’s capacity to get through an event or transition and face a future w/ meaning
  • believing in/holding in esteem, maintaining a hope filled attitude, offering realistic optimism “going the distance”
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84
Q

providing presence

A
  • eye contact
  • body language
  • voice tone
  • listening
  • positive and encouraging attitude
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85
Q

touch

A
  • ask before you touch
  • Contact touch: skin to skin (task oriented, caring, or protective) ex: holding
    patient’s hand, giving a massage, gently positioning
  • Protective touch: protects a nurse or a patient ex: holding patient to prevent
    from falling or distancing self from patient if there’s tension
  • Therapeutic touch: holistic intentional and compassionate use of touch to help patients find inner balance
  • Use touch with discretion as touch can convey many messages
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86
Q

listening

A
  • Engaging with the patient, being present in a non-judgmental and accepting manner
  • “Taking in” what a patient says + interpreting and understanding what’s said +
    give back understanding to the patient = listening
  • Silence yourself and listen with an open mind, concentrate on what the patient is saying, fully focused, observe patients tone of voice, expressions, & body language
  • paraphrasing and reflecting: i’m hearing ____ is that correct?
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87
Q

knowing the patient

A
  • Improves patient satisfaction and patient outcomes
  • In knowing, nurses are able to identify changes out of the ordinary for the patient which can improve our quality of care
  • Patients feel valued when nurses take the time to care for them by knowing more about them (favorite drink in the morning, what time they like to bathe, how they like their water, etc)
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88
Q

spiritual care

A

A caring relationship between patient and nurse help to …
– Mobilize hope for the patient and nurse
– Find an understanding of illness, symptoms, or emotions that’s acceptable to the patient
– Assist patient in using social, emotional, or spiritual resources
– Recognize that caring relationships connect us human to human, spirit to spirit

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89
Q

relieving symptoms and suffering

A
  • Relieving symptoms is more than giving pain meds,
    repositioning a patient, cleaning a wound, or providing end of life care
  • Providing comfort, dignity, respect, peace helps to relieve symptoms
  • Conveying a quiet, caring presence, touching or listening helps you determine the meaning of your patients discomfort and care for them
90
Q

family care

A
  • Each person experiences life through relationships with others
  • Caring for an individual includes a person’s family
  • It is important to know the family as thoroughly as you know the patient
91
Q

the challenge of caring

A
  • Compassion fatigue: emotional and physical exhaustion leading to diminished ability to empathize or feel compassion for others
  • Time constraints reduce the time nurses have to spend quality time with patients
  • Institutional demands place a strain on the ability to have more time for patient care
  • Focus on being task-oriented
  • Short staffed
92
Q

what is culture?

A
  • learned beliefs, values, norms, traditions of particular group -> guides our thinking, decisions, and actions
  • constantly changing due to environmental, biological, political, and social influences
93
Q

unconscious bias

A
  • We are unaware of this type of bias, happens outside our control, influenced by personal
    background, cultural environment, and personal experiences.
  • One will typically make quick judgements & assessments of people and situations
94
Q

implicit bias

A
  • Similar to unconscious bias, however, we are aware that the bias is present
  • We are responsible for this type of bias and must recognize and acknowledge our actions as they impact our behavior, decisions, and patient-centered care
  • outside of our control
95
Q

culturally congruent/transcultural care

A
  • emphasizes care based on individuals cultural beliefs, practices, and values
96
Q

patient centered care

A
  • address your own implicit bias
  • be respectful and responsive to patient preferences, needs, and values
  • ensure patient’s values guide all clinical care decisions (ex: jehovah’s witnesses)
97
Q

cultural competence

A
  • act of being culturally sensitive and appropriate
  • being culturally competent is a process of continually striving to effectively work within the cultural context of a patient
  • goal of cultural care: utilize research to provide culturally specific care to meet the needs of each person, family, and community
98
Q

worldview

A

set of assumptions that develop during childhood
- guides how one sees, things, experiences, and interprets the world
- creates a lens thru which we view life’s experiences
- evolves over a lifetime of interacting w/ family, peers, communities, organizations, media, and institutions

99
Q

insider perspective

A
  • emic worldview
  • how do i view things
  • i don’t understand that about you
100
Q

outsider perspective

A
  • etic worldview
  • ask the significance and try to understand
101
Q

how to best care for a patient through worldview

A
  • advocate for patients based on their worldviews
  • requires ongoing assessment, flexibility, and planning in partnership w/ patient
102
Q

stereotypes-assumed belief regarding a particular group

A
  • Easy to stereotype various cultural groups after reading/hearing general info about their ethnic values, practices, and beliefs
  • Avoiding stereotypes or unwarranted generalizations about any group
  • Approach each person individually
  • Ask questions to gain understanding
103
Q

health disparities

A
  • preventative differences in the burden of disease that are closely linked with socially disadvantaged racial, ethnic, and other population groups/communities
  • example: food desert where they don’t have access to foods
104
Q

social determinants of health

A
  • conditions in which people are born, grow, live, work, and age that affect health functioning and quality of life outcomes
  • examples: age, race, ethnicity, SES, access to nutritious food, transportation resources, religion, sexual orientation, level of education, literacy level, disability, geographic location
105
Q

5 categories of social determinants of health

A
  1. Economic Stability (wealthy or poor)
  2. Education Access and Quality (may not have learned about healthy foods)
  3. Health Care Access and Quality
  4. Neighborhood and Build Environment
  5. Social Community Context
106
Q

marginalized groups

A
  • oppressed or disregarded
  • LGBTQ+, people
    of color, physically/mentally challenged, not college educated
  • Nursing intersects with a variety of people from different cultures,
    awareness of marginalization is critical
107
Q

healthcare provider accountability

A
  • Inadequate resources, poor patient-provider communication, lack of culturally competent care, inadequate access to language services that lead
    to poor patient health outcomes
  • To promote equal treatment we must
    be deliberate about addressing these
    issues
108
Q

cultural awareness

A
  • Self examination of own bias toward other cultures and in-depth exploration of one’s cultural and
    professional background. Being aware of existence of racism and other “isms” in health care delivery
  • being aware of own bias
109
Q

cultural knowledge

A

HCP seeks & obtains sound
education about culturally diverse groups focusing on health-related beliefs/cultural values, care
practices, disease incidence and prevalence

110
Q

cultural skill

A
  • Performing cultural assessment of
    patient to collect relevant cultural data about a patient’s presenting
    problem, also accurately
    conducting a culturally based physical assessment
  • figuring out what they need and how we can help
111
Q

cultural encounter

A

Encourages HCP to engage in face-to-face cultural interactions. Encounters aim to modify a HCP’s
existing belief about a cultural group; prevent possible stereotyping

112
Q

cultural desire

A

Motivation of HCP to “want to” (and not have to) engage in process of becoming culturally aware,
knowledgeable, and skillful in seeking cultural encounters

113
Q

working with interpreters

A
  • Do not use family members to interpret for you or other healthcare providers. Family can include own perceptions/opinions in
    translation and reduce accuracy of information translated.
114
Q

Cultural Desire - Learn Model

A
  • L: listen to patient’s perception of the problem
  • E: explain your perception of the problem
  • A: acknowledge both differences and similarities of the problem
  • R: recommendations must involve the patient
  • N: negotiate a treatment plan
115
Q

passive behavior

A
  • avoid conflict or sidestep issues
  • often reflect feelings of sadness, depression, anxiety, powerlessness and hopelessness
116
Q

aggressive behavior

A
  • often consist of “you” statements
  • goal of dominating while suppressing the other person’s rights
  • often involves loud tone of voice
117
Q

passive-aggressive behavior

A
  • indirect expression of hostility
  • failure to confront the issues or one’s real emotions
  • Common Behaviors
  • Asking threat-based questions
  • Making wistful statements
  • Doling out backhanded compliments
  • Ignoring or saying nothing
  • Procrastination
  • Leaving someone out
  • Sabotaging someone
  • Keeping score
118
Q

assertive behavior

A
  • setting goals, acting on those goals in a clear, consistent manner and taking responsibility for the consequences of those actions
  • uses the direct expression of feeling – “I” statements
  • steps in an assertive response
  • express empathy
  • describes your feelings or the situation
  • state expectations
  • list consequences
119
Q

look at case study

A

therapeutic context of nursing 2

120
Q

constitutional law

A
  • Derived from federal and state constitutions
  • Ex: every patient has the right to refuse treatment
121
Q

administrative or regulatory law

A
  • Clearly defines expectations of civil and criminal law.
  • EX: Nurse practice act states you have a duty to care of your patients (observe, assess, diagnose, plan, intervene, evaluate patient)
122
Q

statutory law

A
  • US congress & state legislatures make decisions
  • Civil- protects rights of individuals. Fair & equitable treatment (Americans with Disabilities Act, Nurse Practice Act)
  • Criminal-protects society & provides punishment for crimes
123
Q

when can torts/lawsuits be filed?

A

if patient or family alleges the nurse knew or should have known their behavior was less than what a
reasonably prudent nurse would do under similar circumstances

124
Q

torts

A
  • civil wrongful acts or omissions of care made against a person or property
125
Q

intentional tort

A
  • deliberate acts against a person or property
  • assault: intentional threat placing person in reasonable fear of harmful, imminent, or unwelcome contact. actual contact is not required
  • battery: intentional offensive touching w/o consent or lawful justification. harmful, causes injury or merely offensive to patient’s personal dignity
126
Q

key elements of informed consent patient will…

A
  • receive explanation of procedure or treatment
  • receive names and qualifications of people performing and assisting in the procedure
  • receive description of the serious harm, including death, that may occur as result of procedure and anticipated pain and/or discomfort
  • receive explanation of alternative therapies to the proposed procedure or treatment and the risks of doing nothing
  • know the right to refuse the procedure or treatment w/o discontinuing other supportive care
  • know the right to refuse the procedure or treatment even after the procedure has began
127
Q

false imprisonment

A
  • keeping pt who’s mentally and physically stable confined
128
Q

HIPAA health insurance portability and accountability act

A
  • provides rights to patients to consent to the use and disclosure of protected health information (PHI)
  • limits who can access patient records
  • privacy: right of patients to keep personal information from being disclosed
  • confidentiality: protects private patient info once it is disclosed in health care settings
129
Q

quasi-intentional tort

A
  • intent to harm is not there but harm occurs
  • invasion of privacy (disclosing confidential info)
  • defamation of character - false communication resulting in damage to a person’s reputation (talking negatively abt someone)
  • slander (spoken)
  • libel (written)
130
Q

unintentional tort: negligence

A
  • person is harmed and the person inflicting the harm knew, or should have known, that their actions were less than the accepted scope of standard practice
  • malpractice: negligence by a professional
131
Q

negligence

A
  • act of omission: failing to do something you were supposed to do
  • act of commission: doing something you aren’t supposed to do
132
Q

necessary elements for malpractice

A
  • nurse (defendant) had duty to patient
  • nurse failed to carry out that duty
  • patient was injured as result of breech in duty
  • damges to patient
133
Q

Necessary Elements for Malpractice: 1. Duty of Plaintiff

A
  • assessment: The RN
    collects comprehensive data
    pertinent to the patient’s
    health or the situation.
  • diagnosis: The RN
    analyzes the assessment data in determining diagnoses or issues.
  • outcome: The RN
    identifies expected
    outcomes for a plan
    individualized to the
    patient or the situation.
  • planning: The RN
    develops a plan that
    prescribes strategies
    and alternatives to attain
    expected outcomes.
  • implementation: The RN
    implements the identified plan.
  • evaluation: The RN
    evaluates progress
    toward attainment of outcomes
134
Q

necessary elements for malpractice 2. failure to carry out duty

A
  • Failure to meet standard of care (Nurse Practice Act, Joint Commission for
    Accreditation of Health Organizations (JCAHO), American Nurse Association
    (ANA)
  • Failure to assess/monitor patient
  • Failure to make appropriate nursing judgement
  • Failure to implement appropriate nursing care
  • Failure to communicate important info with HCP (healthcare professional)
  • Failure to act as patient advocate
  • Failure to use equipment in a responsible manner
  • Inappropriate delegation of nursing tasks
135
Q

necessary elements for malpractice: 3 causation

A
  • breach of duty caused injury
  • foreseeability
136
Q

necessary elements for malpractice: 4. damage

A
  • actual injury to client
  • physical, emotional, financial
137
Q

common areas for nursing malpractice

A
  • meds error
  • falls
  • inadequate assessment/judgment
  • inadequate communication
  • burns
  • mistaken identity of patient
  • incidents in or
  • pressure injuries
138
Q

minimizing legal liability

A
  • document appropriately (chart it or it didn’t happen)
  • Comply with agency policies
  • Ask for help when necessary
  • Question orders when
  • A patient questions
  • If the patient’s condition has changed
  • Recording verbal orders to avoid miscommunication
  • It is illegible, unclear or incomplete
  • Malpractice insurance
139
Q

legal responsibilities of students

A
  • responsible for their own actions
  • held to same standard of performance as RN
  • to reduce liability (be prepared and comply with agency/SON policies
  • if working as PCA perform task allowed for PCA
140
Q

common law

A
  • originates from decisions that were made in the absence of law
141
Q

case law

A
  • describes decisions made in legal cases that were resolved in courts
142
Q

health care acts and informed consent

A
  • Patient’s signed consent necessary for admission to health care agency
  • Gives permission for invasive procedures and treatments such as IV insertion, surgery, etc)
142
Q

nurse practice act

A

– State laws to protect citizens, make nurses accountable, ensure consistent care with best practices (within the scope and standards of nursing).
– The nursing commission/State board of Nursing: licenses all RN’s in the state in which they practice. Permits offering
of special skills to the public
– Provides legal guidelines for protection of the public.

143
Q

good samaritan laws

A
  • encourages health care professionals to assist in emergencies
  • limits liability and offers legal immunity if a nurse helps at the scene of an accident
  • if a patient subsequently develops complications due to your actions, you are immune from liability if you acted without gross negligence
  • protects nurses from doing what is reasonable to save a life (within nurse’s scope of practice)
144
Q

public health laws

A
  • Requirements for reporting communicable diseases, school immunizations, other conditions to promote health and reduce health risks in the community
  • CDC (Center for disease control) & OSHA (Occupational Safety and Health Administration) provide guidelines on
    national level for safe and healthy communities and work environments.
145
Q

termination of pregnancy

A
  • Roe v Wade (1973) US Supreme Court ruled for a fundamental right to privacy for a woman’s decision to terminate a pregnancy.
  • Regulations put forth regarding when an abortion can take place (which trimester can one occur)
  • Decision has been overturned and now affects nursing practice in a different capacity.
146
Q

physician assisted suicide

A

– Competent individuals with terminal disease (incurable or irreversible, that will produce death
within 6 months) can request for medication to end their life in a humane and dignified manner
– The ANA (American Nurse’s Association) believes nurse’s participation in assisted suicide violates the code of ethics for nurses.
– AACN (American association of colleges of nursing) historically has supported to ensure peaceful end of life.
– It is important to know your state’s laws and ensure
that your practice falls within the law’s requirements.

147
Q

uniform determination of death act

A

– Basic definition of the actual point a person is legally dead
– Two standards for determination of death
* Cardiopulmonary: irreversible cessation
of circulatory (heart) and respiratory (lung) functions
* Whole Brain: irreversible cessation of all functions of the entire brain

148
Q

nursing workforce guidelines

A
  • staffing and nurse to patient ratios
  • nursing assignments
  • patient abandonment (refusing to care after relationship has been established)
  • nurse delegation
  • nursing students
149
Q

ethics

A
  • study of what’s right and wrong
150
Q

morals

A

judgment about behavior based on specific beliefs

151
Q

value

A

deeply held personal belief about an idea, custom, or object

152
Q

autonomy

A
  • freedom from external control
  • respect another’s right to determine course of action
  • preeminent principle
  • informed consent
153
Q

beneficence

A
  • taking positive action to help others
  • doing or promoting good AS THE PATIENT DEFINES IT
154
Q

nonmaleficence

A

avoidance of harm or hurt

155
Q

fidelity

A

faithfulness or the agreement to keep promises

156
Q

justice

A

treating all patients equal and fair

157
Q

veracity

A

truth telling

158
Q

the ANA code of ethics

A
  • practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual
  • responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy
  • primary commitment is to the patient
  • promotes, advocates for, and strives to protect the health, safety, and rights of the patient.
  • responsible and accountable for individual nursing practice
  • nurse owes the same duties to self as to others
  • participates in establishing,
    maintaining, and improving health care
  • participates in advancement of the profession
  • collaborates w/ other health professionals and the public
159
Q

ethical dilemma

A
  • two opposing courses of action can both be justified by ethical principles
160
Q

moral distress

A
  • (instead of competing options for action) Nurse feels the need to take specific action while believing that action to be wrong
161
Q

purpose of documentation

A
  • legal accountability (must be dated, timed, legible, permanent and use acceptable terminology)
  • report client response to care
  • quality assurance
  • research
  • education
  • reimbursement

/HJDO DFFRXQWDELOLW\

162
Q

advantages of the EHR

A
  • interagency accessibility
  • cost savings
  • increases access to client info
  • efficiency an ease of use
  • enhanced quality of care and communication
  • safety
163
Q

disadvantages of the EHR

A
  • cost
  • lack of standardization (hospitals systems with different programs)
  • confidentiality issues
    > don’t share username/password, logout when finished using terminal, HIPAA compliance
164
Q

privacy rule

A
  • mandates privacy protection of a person’s identifiable health info (PHI)
  • restricts the sharing/disclosure of PHI w/o a person’s permission (authorization)
  • assures individual’s basic rights (access, amend, obtain, accounting of disclosures of PHI)
  • imposes sanctions - civil and/or criminal if Rule is not obeyed
165
Q

PHI Identifiers

A
  • name, address, social security, dates, medical record numbers, phone number, email, license plate number, full facial photographs, fax numbers, health plan numbers, account numbers, certificate/license numbers, device identifiers, web universal resource locators (URLS), internet protocol address numbers, biometric identifiers, any other unique identifying number, characteristics, or code
166
Q

PHI

A
  • info about the past, present, or future physical or mental health of a person, the provision of health care to a person and payment of care
  • includes written, electronic, or oral
167
Q

identifiability

A
  • identifiable info: PHI rule applies
  • de-identifiable info: rule doesn’t apply
168
Q

when is authorization not required

A
  • treatment (not gonna have to go in every time and be like can I read your chart), payment, operations
  • students do not need specific authorization to look at a pt chart
169
Q

authorization not required

A
  • state agencies (abuse, neglect or domestic violence reporting)
  • public health agencies w/ legal authority (covid #s)
  • legal proceedings (court order, subpoena) and law enforcement
  • health oversight agencies
  • required disclosures to FDA
  • medical examiners for purposes of identification of person or cause of death
  • cadaveric eye or tissue donation
170
Q

authorization is required

A
  • psychotherapy notes, some fund raising activities, PHI generated in the context of a research study
  • opportunity to restrict
    > patient directories, informing family members
171
Q

patient care profile

A
  • non-permanent part of patient record
  • face screen/sheet
  • includes basic pt info
172
Q

admission forms

A
  • comprehensive and give you baseline data
  • first assessment and condition they came to us in
173
Q

discharge forms

A
  • description of patients condition
  • current meds, diet, treatments
  • activity level
  • restrictions
  • referrals
  • info you need to know before they go home
174
Q

care plans

A
  • standardized plans part of EHR
  • should be individualized
175
Q

progress notes

A
  • used by all members of IP team
  • nurses notes
    write down narrative
176
Q

SOAP or SOAPIE Notes

A

subjective, objective, assessment, plan, interventions, evaluation

177
Q

narrative charting

A
  • statement nurse makes regarding particular incident that occurs w/ patient
  • may refer to: sign or symptom, nursing care measure, client behavior, medication administration, patient teaching
178
Q

charting should be what?

A
  • accurate
  • clear descriptive objective information about what the nurse observes, hears, palpates and smells
  • chart data not inferences
  • avoid seems to, appears to, looks like
179
Q

which charting examples are correct

A
  • stated, “I feel sick”
  • vomited 100 ml green-tinged fluid
  • was tearful during interview

wrong
- patient is nauseated
- disoriented
- how do u know

180
Q

which charting examples are correct

A
  • patient is extremely fearful of this surgery (wrong)
  • abdomen is distended and hard
  • stated he is confused about why he needs this medication
  • respirations are normal (what’s normal)
181
Q

which charting example is correct

A
  • ambulated to bathroom w/ no c/o dizziness
  • tolerated clear liquids well (how do you know)
  • vision is poor (did they tell u)
  • drinking adequate amounts of fluid (what’s adequate)
182
Q

what not to use on charting?

A
  • U
  • IU
  • Q.D., QD, q.d., qd, Q.O.D., QOD, q.o.d., qod
  • trailing zeros (X.0 mg)
  • lack of leading zeros (.X mg)
  • MS
183
Q

what to do when you make a mistake on charting?

A
  • strike through and sign
  • use correct spelling
  • use only approved abbreviations
184
Q

charting should be…

A
  • thorough (always include how patient was left)
  • current
  • organized (military time)
  • legally prudent (don’t throw ppl under the bus)
  • confidential
  • signed (signed entry first initial, last name, title)
185
Q

charting should be concise

A
  • assessment, intervention, evaluation
  • pertinent info only
  • not housekeeping details
  • chary is about pt so no need to restate patient or mr x
186
Q

reporting

A
  • handoff
    > info exchange at critical times such as transitions in care
    > bedside
    > transfer knowledge and info about diagnosis, response to treatment, recent changes in condition and circumstances, an the plan (including contingencies)
  • authority and responsibility transferred
187
Q

ISBAR

A
  • standardized framework to communicate about a pt’s condition
  • I: introduction – self, unit, patient, room #
  • S: situation – what is happening with the patient
  • B: background – what is the clinical background
  • A: assessment – what do i think the problem is
  • R: recommendation – what would i recommend
188
Q

read-back

A
  • closed loop communication strategy used to verify and validate info exchanged
189
Q

Which of the following orders is correctly written?

A
  • wrong: Give furosemide 10 mg PO q. d., give 10U NPH insulin every morning, give MS 10 mg PO PRN
  • correct: give furosemide 20 mg IV stat, give ibuprofen 400 mg PO at HS
190
Q

what is not appropriate documentation of data collected?

A
  • is angry and inflexible
191
Q

something that is correctly charted

A
  • crying. states she doesn’t want visitors to see her like this
192
Q

telephone orders

A

only licensed personnel can accept

193
Q

elements of professional communication: courtesy

A
  • Knock on door
  • Say hello and goodbye
  • Address pt by name
  • Introduce self to all in room
194
Q

elements of professional communication: use of names

A
  • Introduce self
  • Give status (RN, student nurse, etc)
  • Use preferred name
  • Respect, dignity
  • Start with last name, clarify
  • Avoid “honey, sweetie, etc”
  • Avoid calling pt by room #, diagnosis
195
Q

elements of professional communication: trustworthiness

A
  • Essential for the nurse/patient relationship
  • Effective communication essential for trust
  • Barriers to trust
  • Withholding important information (okay if not in our scope)
  • Lying
  • Distorting truth (unethical and illegal)
  • Gossip, talking about other pts and coworkers
196
Q

assertiveness

A
  • communicates self-assurance, respect, responsibility for own decisions
197
Q

autonomy and responsibility

A
  • self-directed, independence, advocacy
  • advocate for pt autonomy
198
Q

factors to consider when communicating

A
  • language comprehension
  • variability in word usage, dialects, literacy
  • nonverbal (personal space, eye contact, touch)
  • spiritual and religious belief differences within a culture
199
Q

communication: at risk populations

A
  • Non-English speaking
  • Hearing and/or visually impaired
  • Unable to speak clearly, nonverbal
  • Cognitive impairment
  • Unresponsive (don’t talk over them)
200
Q

communication and culture implications

A
  • Personal assessment of own cultural values and biases
  • Research and learn about different cultures
  • Identify primary language and English fluency
  • Interpreter services
  • Always speak to pt
  • Written information in preferred language and English
  • Ensure understanding through teach-back, restating, etc.
  • Incorporate into plan of care
201
Q

focus on patient safety

A
  • Safety is defined as the avoidance, prevention,
    amelioration of adverse outcomes or injuries
    stemming from the process of health care itself.
    (National Patient Safety Foundation)
  • Foundational for Quality Care
202
Q

common risks for hospitalized patients

A
  • Medication errors
  • Falls & trauma
  • Hospital acquired infections
  • Pneumonia
  • DVT
  • Complications of surgery
203
Q

interpersonal conflicts

A
  • Can impact patient safety
  • Disagreement arising from differences in attitudes, values, needs, in which the actions of one party frustrate the ability of the other to achieve their expected goals
  • Results in stress or tension
204
Q

conflict

A
  • A natural part of human relationships
  • Arises from incompatible goals or needs
  • A warning that something needs closer attention
  • Can promote growth
  • Can be detrimental
205
Q

what causes conflict

A
  • Poor communication
  • Difference in values
  • Cultural belief system
  • Personality clashes
  • Stress
206
Q

avoidance

A
  • Unassertive and uncooperative: Ignores rather than confronts conflict situation
  • Advantages:
  • May allow a cooling-off period
  • Issue may be trivial or potential damage too great
  • Disadvantages:
  • Leads to stress, bottle-up of feelings, and further
    conflict
  • Important decisions may be made by default
  • “Kick the can down the road”
  • I lose-you lose
207
Q

competition

A
  • Assertive and Uncooperative: Goal oriented
  • Resolve a struggle by controlling or persuading
    others
  • Advantages:
  • Useful when quick, decisive action is needed
  • Can challenge participants to make their best efforts
  • Disadvantages:
  • More counterproductive than productive
  • Results in winners and losers
  • Fails to recognize concerns and needs of others
  • Can escalate conflict and losers may retaliate
  • I win now but then both lose-lose the situation
208
Q

accomodation

A
  • Unassertive and cooperative
  • Attends to the needs of others /ignores own needs
  • Deals with problems by deferring to others
  • Advantages:
  • Harmony in the relationship is most important goal
  • Good will may be earned
  • Disadvantages:
  • Accommodator sacrifices values and possible higher-
    quality decision
  • Credibility and influence can be lost
  • I lose-you win
209
Q

compromise

A
  • Degree of Assertiveness and Cooperation
  • Midway between avoidance and competition
  • Partially satisfies both parties
  • Advantages:
  • Expedites the process
  • Disadvantages:
  • Neither side is completely satisfied
  • May not work if initial demands are too great
  • I lose-you lose
210
Q

collaboration

A
  • Both assertive and cooperative
  • Attend fully to other’s concerns while not sacrificing or suppressing own
  • Directly confront the issue, acknowledge feelings, use open communication
  • Advantages:
  • Both sides win
  • Solutions more cost effective in the long run
  • Disadvantages:
  • Most difficult to achieve
  • Demands energy and hard work among participants
  • I win-you win
211
Q

IP teams

A
  • Single coordinated unit of interprofessional providers
  • Team members have complementary skills
    or management responsibilities in the
    delivery of patient care.
  • Require collaboration
212
Q

Constructive Criticism

A
  • Express empathy: “I understand that things are difficult at home.”
  • Describe the behavior: “But you have been coming late to work three times this pay period.”
  • State expectations: “It is necessary for you to be on time.”
  • List consequences: “If you are late again, I will have to report you to the personnel department.”
213
Q

steps in receiving criticism

A
  • Listen and paraphrase: “You are saying that being late is not acceptable.”
  • Acknowledge you are taking suggestions seriously: “I hear what you are saying.”
  • Give your side by stating supportive facts: “My car would not start.”
  • Develop a plan for the future: “I will take my car to be repaired tomorrow.”
214
Q

CUS

A
  • Use CUS when you need it
  • I am Concerned about my patient’s condition.
  • I am Uncomfortable with my patient’s condition.
  • I believe the Safety of the patient is at risk.
215
Q

process for responding to disrespect

A
  • Address the objectionable or disrespectful behavior
    > Briefly state the behavior and its impact on you
  • Emphasize the specifics of the putdown behavior
    > Refer only to the behaviors identified
  • Prepare a few standard responses
    > “I think it was out of line for you to criticize me in front of the patient.”
  • Escalate up the chain of command
216
Q

issues in teamwork in the healthcare environment

A
  • Different expectations
    • Members of the health care team often look at situations differently
    • Communication styles may differ
  • Differences in role hierarchy
    • Differences in education & experience
    • Differences in responsibilities and rewards
  • Value conflicts
    • End of life care
    • Moral distress
  • Disruptive behavior
    • Known as incivility, lateral violence, bullying
217
Q

disruptive behavior

A
  • Situations in which lack of civility or lack of respect occurs within a professional relationship frequently and over time.
  • May include
    • Overt behavior (clear)
    • Covert behavior (subtle)
218
Q

physiological dimension

A

includes processes involved in nutrition/metabolism,
activity/exercise, elimination, sleep/rest, sensory/perception, and sexuality/reproduction.

219
Q

psychological dimension

A

relates to cognitive, emotional and developmental processes, self-perception and self-concept, coping and stress tolerance, and learning and decision-making

220
Q

spiritual dimension

A

involves values and beliefs regarding the meaning and purpose of life as well
as the individual’s relationship to a higher being.

221
Q

sociocultural dimension

A

refers to the broader community, cultural, and other groups, the family, health care and other organizations, and support systems for the person. Learned patterns of behavior, cultural values, norms, customs, roles and relationships with others, and health/illness practices are included in this dimension.

Clinical Concepts (18 decks)

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