Comprehensive Exam Flashcards

Question

Clinical Decision Support Systems

Answer 1

- tools to supplement decision making in client care, designed to be integrated into the EHR - prompts, alarms, reminders, or order sets that help enhance patient care and catch mistakes, identifies patients at risk for certain diseases - DO NOT DICTATE PATIENT CARE, JUST ENHANCE IT - use UNIFORM LANGUAGE-standardized language across all disciplines: - JCO has a do not use list - NANDA (for nursing diagnoses) - SNOMED CT: combines nursing terminology with the standardized language of the EHR -these support systems help close the gap b/w research and incorporating knowledge into practice

Answer 2

- with EHR, computers should be available to nurse in all settings - research is easier! Through uniform language, the ability to query client records, and internet literature searches

Answer 3

- be as accurate and timely as possible - device integration is important, but use nursing judgement and critical thinking... never allow technology to take over your knowledge. TREAT THE PATIENT, NOT THE MONITOR!!! - Outcome tracking: identifies faulty processes and assists in modifications that will improve client outcomes - Utilization review: designed to eliminate inappropriate or unnecessary medical care... we don't want to over treat patients ($$$)

Answer 4

- presents info about healthcare facility's key performance indicators - displays info in an easy-to-read format including charts and graphs - some info displayed in real time-EHR's can track data and trends

Answer 5

- Referred to as an intervention or testing that takes place with a portable or handheld device - allows bedside data entry and on-the-spot info about clients - EX: using an accucheck to get blood sugar from a finger stick; vitals machine - Remember: computer will never be able to replace face-to-face communication with anybody. Especially with a patient!!!

Answer 6

- effective nursing actions that form helping relationships based on technical knowledge, expertise, ethical principles, and clinical reasoning - academic integrity - classroom/clinical behavior

Answer 7

- undertaking and presenting work honestly without: - cheating/plagiarism/falsifying academic records/misrepresenting facts - attempt to or committing any act designed to give an unfair academic advantage

Answer 8

- arrive on time and in appropriate attire - demonstrate safe and ethical behavior - interact with others in a professional manner

Answer 9

undermine an individuals credibility, negatively affect group morale, and may affect client outcome - Include: confidentiality breach, substance abuse, discrimination, excessive absenteeism/tardiness - abuse of power, sexual harassment, intimidation

Answer 10

attempts to use authority against another individual to one's own advantage

Answer 11

verbal, emotional, or physical conduct of sexual nature that is

Answer 12

bullying, threatening, or forcing someone who is physically or emotionally weaker to do something in order to avoid retribution

Answer 13

- current, strong evidence - client perspective - clinical expertise

Answer 14

- develop a question: Background question and foreground - retrieve evidence - apply evidence - evaluate evidence

Answer 15

- background question: knowledge based, general question that seeks info - foreground: practice based, narrows facts and info about clinical issue

Answer 16

literature review, source evaluation, can use databases

Answer 17

- integrate and change practice for impact on client outcome - if change is beneficial, fully integrate into standards of care - expand EBP by sharing with colleagues

Answer 18

- validity: did it measure what it was supposed to? - reliability: was there a consistent response? - rate strength of evidence: identify the best choice - Gold standard: large randomized controlled studies - Lowest level: opinions of reviewers

Answer 19

assess, diagnose, plan, implement, evaluate

Answer 20

establishing a database about the client in order to manage needs -collecting data, organizing data, and validating/analyzing data

Answer 21

Providing the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable -describe a continuum of health: derivations from health, presence of risk factors, areas of enhanced personal growth - Components of nursing diagnosis: - diagnostic label: "what is the focus/subject of the problem?" - etiology: "where did it come from? what is it related to?" - defining characteristics: "what does it look like?"-- s/s

Answer 22

referring to client's assessment data and diagnoses for direction in formulating client goals, which become basis for nursing intervention. Nurse encourages client to participate actively in planning

Answer 23

Goals should be: -client centered (not about nurse activities -single in number for each nursing diagnosis -Specific and concise single action -Measurable/quantifiable -Attainable/realistic for an individual client -Relevant to individual -Timely (SMART)

Answer 24

Identify best priority interventions, implement those interventions - independent interventions - dependent interventions - collaborative interventions

Answer 25

activities that nurses are licensed to do within their scope of practice, unique to nursing

Answer 26

employed by the nurse under a physician's orders, under supervision and includes collaboration

Answer 27

reflect overlapping responsibilities and cooperative relationships among healthcare professionals

Answer 28

Planned, ongoing, purposeful activity that utilizes client and other healthcare professionals to determine the client's progress toward achievement of goals/outcomes and effectiveness of the nursing plan of care - collect all data-> nurse and client will determine together whether goals were met, partially met, or not met at all - at this point the nurse and client will decide whether to continuing, modifying, or terminate the nursing plan of care - reassess and record new data as needed- new data may indicate new diagnosis, goals, and interventions

Answer 29

Is normal and expected of nurses in order to overcome obstacles and maintain flow of care for clients - utilize nursing process (ADPIE), utilize trial and error, learn and adapt - always make sure to prioritize the patients in order. ABCs ALWAYS come before anything else - changes in the client's condition, deterioration of status, or the complexities of a client's condition can impact the urgency of care interventions and the order in which they need to be completed - using the 4 levels of urgency factor to set priorities for care and identify what interventions ned to be done and in what order they should be accomplished

Answer 30

ABC's ALWAYS come before anything else - Airway-> a patent airway so oxygen will have a pathway into the lungs for gas exchange and carbon dioxide can be expelled from the body - Breathing-> an effective breathing pattern and respiratory effort to take in enough oxygen to meet cellular demands for oxygen throughout the body - Circulation-> an effective circulatory system to deliver oxygen throughout the body and allow carbon dioxide removal through the pulmonary circulation network

Answer 31

Nonacute level - nonthreatening to life - delay in doing interventions - does not negatively impact client outcomes Acute level - low potential to become life threatening - necessary interventions are scheduled, expected, and typical Critical level - potential to become life threatening - quick recognition and rapid response needed to stop threat from becoming life-threatening Imminent level - life threatening - interventions are needed immediately, now, STAT!!! - know which tasks can be delegated and delegate them!!! - manage your time wisely

Answer 32

identification of the components of a multi-team system that must work together effectively to ensure patient safety

Answer 33

Structured process by which information is clearly and accurately exchanged among team members - SBAR - Call-out - Check-back - Handoff - "I PASS THE BATON"

Answer 34

A technique for communicating critical information that requires immediate attention and action concerning a patient's condition - Situation: what is going on with the patient? - Background: what is the clinical background or context? - Assessment: what do I think the problem is? - Recommendation and Request: what should be done to correct it?

Answer 35

Strategy to communicate important or critical information - informs all team members simultaneously during emergent situations - helps team members anticipate next steps - important to direct responsibility to a specific individual responsible for carrying out the task

Answer 36

using closed-loop communication to ensure that information conveyed by the sender is understood by the receiver as intended- double checking

Answer 37

the transfer of information (along with authority and responsibility) during transitions in care across the continuum. It includes an opportunity to ask questions, clarify, and confirm (Ex. shift changes and patient transfers)

Answer 38

Strategy designed to enhance information exchange - Introduction: introduce yourself and your role/job (include patient) - PASS - Patient: name, identifiers, age, sex, location - Assessment: present chief complaint, vital signs, symptoms, and diagnoses - Situation: current status/circumstances, including code status, level of (un)certainty, recent changes, and response to treatment - Safety concerns: critical lab values/reports, socioeconomic factors, allergies, and alerts (falls, isolation, etc.) - BATON - Background: comorbidities, previous episodes, current medications, and family history - Actions: explain what actions were taken or are required. Provide rationale. - Timing: level or urgency and explicit timing and prioritization of actions - Ownership: identify who is responsible (person/team), including patient/family members - Next: what will happen next? anticipated changes? what is the plan? are there contingency plans?

Answer 39

ability to maximize the activities of team members by ensuring that team actions are understood, changes in information are shared, and team members have the necessary resources

Answer 40

brief: short session prior to start to share the plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, anticipate outcomes and likely contingencies

Answer 41

huddle: Ad hoc meeting to re-establish situational awareness, reinforce plans already in place, and assess the need to adjust the plan

Answer 42

debrief: informal information exchange session designed to improve team performance and effectiveness through lessons learned and reinforcement of positive behaviors

Answer 43

process of actively scanning and assessing situational elements to gain information or understanding, or to maintain awareness to support team functioning

Answer 44

the state of "knowing what's going on around you" -a shared mental model results from each team member maintaining situational awareness and ensures that all team members are "on the same page"

Answer 45

a harm error reduction strategy that involves monitoring actions of other team members, providing a safety net within the team, ensuring that mistakes or oversights are caught quickly and easily -"watching each other's back"

Answer 46

-each team member is responsible for assessing his or her own safety status - I=illness - M=medication - S=stress - A=alcohol and drugs - F=fatigue - E=eating and elimination

Answer 47

-ability to anticipate and support team member's needs through accurate knowledge about their responsibilities and workload

Answer 48

information provided to team members for the purpose of improving team performance. Should be timely, respectful, specific, directed toward improvement, and considerate

Answer 49

-Advocate for the patient: invoked when team members' viewpoints don't coincide with that of the decisionmaker - assert a corrective action in a firm and respectful manner: - make an opening - state a concern - state the problem (real or perceived) - offer a solution - reach agreement on next steps -Two challenge rule

Answer 50

empowers all team members to "stop the line" if they sense or discover an essential safety breach. It is your responsibility to assertively voice concern at least two times to ensure that it has been heard and the team member being challenged must acknowledge that concern has been heard

Answer 51

- I am CONCERNED! - I am UNCOMFORTABLE! - This is a SAFETY ISSUE!

Answer 52

A constructive approach for managing and resolving conflict - Describe the specific situational or behavior; provide concrete data - Express how the situation makes you feel/what your concerns are - Suggest other alternatives and seek agreement - Consequences should be stated in terms of impact on established team goals; strive for consensus

Answer 53

- empathizing - attentive listening - physical attending - using silence - reflecting - imparting information -AVOID SELF DISCLOSURE!!! client is the focus, not you

Answer 54

Active listening skill that you are taught throughout your education... being able to put yourself in someone else's situation -should not transfer your own feelings into the situation

Answer 55

Mindful listening, using all senses, MOST important technique in therapeutic communication - active process that requires energy and concentration - verbal and nonverbal

Answer 56

Manner of being present to another or being with another -face person squarely, adopt an open posture, lean towards the person, maintain good eye contact, try to be relatively relaxed

Answer 57

You don't have to respond every time -Goal is to provide a therapeutic purpose such as: encouraging client to communicate with the nurse, allowing the client time to think about what has been said or to make connections, allowing the client the necessary time to collect personal thoughts, time to consider possible alternatives

Answer 58

What takes place when the nurse repeats the client's verbal or nonverbal messages for the client's benefit

Answer 59

repeating clients statement, often overused

Answer 60

Verbalizes feelings that are implied in the client's content, respect the client's opinions, helps ID any latent or connotative meanings that can clarify or distort the content that is communicated

Answer 61

nurse is helping client by supplying additional data for consideration

Answer 62

- Nursing documentation should describe the ongoing status of the patient and reflect the full range of the nursing process, should be comprehensive and continuous - SOAP Note

Answer 63

The transfer of info (along with authority and responsibility) during transitions in care across the continuum - Can occur at change of shift, bedside, over the telephone, etc... - Standardize critical content - Hardwire within your system - Allow opportunity to ask questions - Reinforce quality and measurement - Educate and coach

Answer 64

- nursing diagnosis and problem statement are interchangeable terms - NANDA= north american nursing diagnosis association - Can have 1 part; 2 part; 3 parts - 1 part: problem (diagnostic label) only - 2 part: problem and etiology ("related to") - 3 part: ("PES") Problem; etiology; signs and symptoms (defining characteristics)

Answer 65

assessment, diagnosis, planning, implementation, evaluation

Answer 66

-for every goal, nursing interventions need to be implemented - interventions need to "match" the goal: - low oxygen saturation: elevate head of bed; deep breath and cough - pain: guided imagery; distraction; repositioning - For example: do not include using distraction for low oxygen saturation: probably would not be effective -interventions can include assessment and reassessment - there must be some ACTIVE interventions: - nurse must DO something - if no active interventions, there will be little to evaluate

Answer 67

-Deductive and inductive

Answer 68

- moves from general to specific (top down) - START with a CONCLUSION; analyze it for valid significance cues - Example (disease process to signs and symptoms) 1. patient has pneumonia 2. nurse can deduce that patient would have increased sputum, decreased appetite, productive cough, low energy, etc...

Answer 69

- moves from specific to general (bottom up) - SIGNIFICANT CUES are put together to reach a CONCLUSION - example: (signs and symptoms to disease process) 1. patient is experiencing increased sputum, decreased appetite, productive cough, low energy, etc... 2. Nurse can induce (come to the conclusion) that the patient has pneumonia

Answer 70

- do not give advice - do not minimize or discount what the client is feeling - do not change the subject or make light of what the client is talking about do not interrogate - do not debate or disagree with the client - aggressive - passive -do want to be assertive

Answer 71

- subjective data - objective data - assessment: interpretation of info this is measured or observed by use of the senses - plan of care: your plan to resolve the stated problem - interventions: specific interventions that have actually been performed - evaluation: reassessment data - revisions: any changes in plan or interventions

Answer 72

- type of handoff given to all nurses on the next shift, quick summary of client's needs and details of care to be given - follow a particular order, provide basic ID info, reason for admission or medical diagnosis, surgery date, lab tests, therapies in the last 24 hours, provide exact info, report special need for emotional support, include nurse prescribed and physician orders, summary of newly admitted clients, report on transfers, clearly state, best most important info at the end, and be concise

Comprehensive Exam Flashcards

(96 cards)