Exam 1 Flashcards
Study (140 cards)
1
Q
Subjective Data
A
what the patient says
2
Q
Objective Data
A
what the nurse observes
3
Q
TCJ Model - Noticing
A
a perceptual grasp of the situation (patient says)
4
Q
TCJ Model - Interpreting
A
developing an understanding of the case (think about what patient said)
5
Q
TCJ Model - Responding
A
deciding on the appropriate action (solution)
6
Q
Nursing Process - Diagnosis
A
identify and prioritize problems; identify nursing diagnoses
7
Q
TCJ Model - Reflecting
A
attending to the patient’s responses (if it didn’t work go back)
8
Q
Nursing Process - Assessment
A
gather data from the medical record and assess the patient
9
Q
Nursing Process - Planning
A
develop SMART goals and outcomes
10
Q
Nursing Process - Intervention
A
perform nursing action
11
Q
Nursing Process - Evaluation
A
analyze results and document the patient’s response
12
Q
Clinical Judgment Measurement Model - Assessment
A
Recognize Cues
13
Q
Clinical Judgment Measurement Model - Diagnosis
A
Analyze Cues; Prioritize Hypotheses
14
Q
Clinical Judgment Measurement Model - Planning
A
Generate Solutions
15
Q
Clinical Judgment Measurement Model - Intervention
A
Take Actions
16
Q
Clinical Judgment Measurement Model - Evaluation
A
Evaluate Outcomes
17
Q
CT&NP - Novice
A
Starting out in an area of learning; Uses rules to guide performance
18
Q
CT&NP - Proficient
A
Adding to time and experience; Understands the patient situation as a whole rather than individual parts-apply long term goals
19
Q
CT&NP - Competency
A
Building on 2 to 3 years of clinical expertise; See actions in the context of patient goals or plans
20
Q
First-Level Priority
A
Emergent, life-threatening, and immediate; airway, breathing, circulation
21
Q
CT&NP - Expert
A
Attained mastery of an area of learning; PErforms clinical judgment using intuitive analysis
22
Q
Second-Level Priority
A
Next in urgency, requiring attention so as to avoid further deterioration: mental status changes, acute pain
23
Q
Third-Level Priority
A
Important to patient’s health but can be addressed after more urgent problems are addressed (ex Lack of knowledge, mobility, family coping)
24
Q
SMART Goals - S
A
Specific
25
SMART Goals - M
Measurable
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SMART Goals - A
Attainable
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SMART Goals - R
Relevant
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SMART Goals - T
Time-Bound
29
Evidence-Based Assessment
Current and best clinical practice based on research standards focused on systematic reviews on randomized clinical trials
30
Evidence-Based Practice
Integration of research evidence, clinical expertise, and patient values and preferences
31
Clinical Decision Making
The best evidence from literature review, the patient's own preference, clinician's experience/expertise, and physical exam
32
5 Steps to EBP - 1
Ask the clinical question
33
5 Steps to EBP - 2
Acquire sources of evidence
34
5 Steps to EBP - 3
Appraise and synthesize evidence
35
5 Steps to EBP - 5
Assess the outcomes
36
5 Steps to EBP - 4
Apply relevant evidence in practice
37
Complete Total Health Database
Describes current and past health state and forms a baseline to measure all future changes (outpatient that has not been seen before)
38
Follow-Up Database
Status of all identified problems should be evaluated at regular and appropriate intervals (phone call)
39
Episodic or Problem-Centered Database
Collect mini database, smaller scope, and more focused the complete database (cough/fever)
40
The interval of assessment varies with ______
illness and wellness needs
41
Emergency Database
Rapid collection of data often compiled concurrently with lifesaving measures (focused on urgent problem not history or background)
42
Routine periodic examination might include ______
the following services for preventative health care: well-child visits, annual exams, follow-up visits
43
Holistic health views _____
the mind, body, and spirit as interdependent and functioning as a whole within the environment
44
Social determinants of health are _____
factors that influence a person's health and well-being; affect a person from preconception to birth; EBP indicates that poverty has the greatest influence on health status;they include the environment, access to health care, community, education, and economic stability; SDOH Screening
45
Epigenetics is the _____
study of how environment and behaviors impact gene expression
46
61.6% of the population identified as _____
non-hispanic whites
47
Minority or emerging majority accounts for _____
38%
48
Hispanics are ______
the largest and fastest growing group
49
Blacks are ______
the second largest group
50
Asians, American Indians, Alaska Natives, Native Hawaiians, and other Pacific Islanders make up the ______
third largest part of the population
51
Health Care Disparity
a particular type of health difference that is closely linked with, social, economic, or environmental disadvantage
52
National Standard for Culturally and Linguistically Appropriate Services in Health Care
15 Standards; Provide blueprint for diverse populations to eliminate health disparities
53
Title VI Civil Rights Act 1964
Limited English Proficiency; Providing assistance with communication utilizing resources such as interpreters
54
Basic Characteristics of Culture-Related Concepts - L
Learned from birth through process of language acquisition and socialization
55
Basic Characteristics of Culture-Related Concepts - S
Shared by all members of the cultural group
56
Basic Characteristics of Culture-Related Concepts - A
Adapted to specific conditions r/t environmental and technical factors in the context of available resources
57
Ethnicity refers to ______
a social group that may possess shared traits, such as common geographic region origin, migratory status, religion, language, values, traditions or symbols, and food preferences
58
Basic Characteristics of Culture-Related Concepts - D
Dynamic interphase that is ever-changing
59
Socialization
process of being raised within a culture and acquiring characteristics of that group
60
Assimilation
process of developing a new cultural identity and becoming like members of dominant culture
61
Acculturation
process of adapting to and acquiring another culture
62
Biculturalism
dual pattern of identification and often of divided loyalty
63
Culturally Sensitive
Possessing basic knowledge of and constructive attitudes toward diverse cultural populations
64
Culturally Appropriate
Applying the underlying background knowledge necessary to provide the best possible healthcare
65
Cultural Care
Provision of health care across cultural boundaries in consideration of context
66
Culturally Competent
Understanding and attending to the total context of the patient's situation including the following: immigration status, stress and social factors, cultural similarities and differences
67
5 Steps to Cultural Competence - 2
Identify meaning of health to patient
68
5 Steps to Cultural Competence - 1
Understand one's own heritage-based values, beliefs, attitudes, and practices
69
5 Steps to Cultural Competence - 3
Understand how healthcare system works
70
5 Steps to Cultural Competence - 5
Become familiar with languages, interpretive services, and community resources available to nurses and patients
71
5 Steps to Cultural Competence - 4
Acquire knowledge about social backgrounds of patients
72
Cultural Sensibility/
the deliberate proactive behavior by healthcare providers who examine cultural situations through thoughtful reasoning, responsiveness, and discreet interactions
73
Cultural Assessment
List of Domains of Interest: Heritage, health practices and communication, family roles and social orientation, nutrition and pregnancy, birth/childrearing, spirituality/religion, death, and health providers
74
Transcultural Expression of Illness
Expectations, anifestations, and mangement of pain are all embedded in a cultural context; pain is highly personal experience; silent suffering has been identified as the most valued response to pain by healthcare professionals
75
Spirituality
broader term focuses on a connection to something larger than oneself and a belief in transcendence
76
Religion
refers to an organized system of beliefs as a shared experience that can assist in meeting one's individual spiritual needs
77
FICA Spiritual History Tool
guide for fostering open dialogue and not as a checklist of questions to ask the patient; Faith, Importance/Influence, Community, and Address/Action
78
FICA - Importance/Influence
What importance does your faith or belief have in your life? Have your beliefs influenced you in how you handle stress? Do you have specific beliefs that influence your healthcare decisions? If so, are you willing to share those with your healthcare team?
79
FICA - Faith
Do you consider yourself spiritual or religious? Do you have spiritual beliefs, values, or practices that help you cope with stress?
80
FICA - Community
Are you a part of s spiritual or religious community? If so, how does this group support you? Is there a group of people you really love or who are important to you?
81
FICA - Address/Action
How should I address these issues in your health care?
82
Brief R-Cope
examines patient's coping mechanisms
83
Interview Purpose
best chance to get an understanding of the patient's beliefs, concerns and perception of their individual health state; Allows for compilation of subjective data and awareness of objective data (physical appearance, posture, ability to carry on a conversation, and demeanor)
84
Nutritional Status
The condition of health as it relates to the intake and utilization of nutrients
85
5 Successful Interview Characteristics - G
Gather complete and accurate data about person's health state, including description and chronology of any symptoms of illness
86
5 Successful Interivew Characteristics - E
Establish rapport and trust so patient feels accepted and free to share all relevant data
87
5 Successful Interview Characteristics - T
Teach patient about health state so that they may participate in identifying problems
88
5 Successful Interview Characteristics - BR
Build raaport to continue therapeutic relationship and to facilitate future diagnoses, planning, and treatment
89
5 Successful Interview Characteristics - BT
Begin teaching for health promotion and disease prevention
90
Interview Contract Terms - Location
Time and place with follow-up for physical exam
91
Interview Contract Terms - Explanation
Introduction and delineation of role
92
Interview Contract Terms - Purpose
Mutual goal is optimal heath
93
Interview Contract Terms - Time frame
Length of time for process
94
Interview Contract Terms - Participation
Expected participation and/or presence of others
95
Interview Contract Terms - Confidentiality
Reasonable and/or limited as it applies to legal/ethical standards
96
Verbal Communication
Words you speak and tone used in conversation
97
Non-Verbal Communication
Body language helps to provide cues that may be correlated with truer feelings
98
The receiver attaches meaning determined by their _______
past experiences, culture, self-concept, and current physical and emotional state
99
Process of Communication: Internal Factors are specific to ________
you as the healthcare team member which can help you to maximize your communication skills
100
Process of Communication: Internal Factors - Ability to listen
using an active process
101
Process of Communication: Internal Factors -Liking others
using a genuine approach
102
Process of Communication: Internal Factors - Empathy
develop an understanding and sensitivity for other's feelings
103
Process of Communication: External Factors defines the ______
environment to foster communication
104
Process of Communication: Internal Factors - Self-Awareness
Be aware of implicit bias
105
Process of Communication: External Factors - Ensure privacy
aim for geographic privacy but ensure psychological privacy
106
Process of Communication: External Factors - Avoid interruptions
minimize and/or refuse
107
Process of Communication: External Factors - Dress
appearance and comfort
108
Process of Communication: External Factors - Note-taking
keep to a minimum, offer focused attention
109
Process of Communication: External Factors - Physical environment
equal status seating
110
Introducing the Interview
Keep it short and formal
111
Working Phase
Data gathering; Asking questions to patient and responding to what is said
112
Open-Ended Questions
113
Closed/Direct Questions
114
Client's Perspective - Faciliation
115
Client's Perspective -Silence
116
Client's Perspective - Reflection
117
118
Intimate Zone
0 to 1 1/2ft; Visual distortion occurs; Best for assessing breath and body odors
119
Personal Space
1 1/2 to 4 ft; Perceived as an extension of the self, similar to a bubble; voice moderate; body odors inapparent; no visual distortion; Much of physical assessment occurs at this distance
120
Social Distance
4 to 12ft; Used for impersonal business transactions; Perceptual information much less detailed; Much of interview occurs at this distance
121
Public Distance
12+ft; Interaction with others impersonal; Speaker's voice must be projected; Subtle facial expression imperceptible
122
Equal-Status Seating
Both you and client should be comfortably seated at eye level at 90 degree angle
123
Electronic health records improve _____
quality and safety but can become a barrier affecting communication
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