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PCC Lecture > Exam 2 Modules 4-6 > Flashcards

Exam 2 Modules 4-6 Flashcards

(57 cards)

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1
Q

Layers of the CJM

A

o Layer 0: clinical decisions
o Layer 1: comprises the outcome = clinical judgement
o Layer 2: form, refine hypotheses; evaluation
o Layer 3: recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, evaluate outcomes ▪ Not linear
o Layer 4: context (individual and environmental factors)

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2
Q

Components of CJM Layer 3

A

recognize & analyze cues
prioritize hypotheses
generate solutions
take action
evaluate outcomes

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3
Q

What do you include in shift report to oncoming nurse?

A

demographics, relevant med hx, current treatments, pt’s response to interventions, pending labs, procedures, current status, plan of care, concerns

Use I-SBAR-R

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4
Q

Assertive communication

A

SBAR, open, direct, honest, and non-judgmental

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5
Q

Passive vs Aggressive communication

A

Passive- I don’t count, you do.
Aggressive- I count, you don’t.

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6
Q

What is the primary purpose of the chart?

A

Communication

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7
Q

The EMR documentation system is problem oriented.
What are the patient issues an interdisciplinary team of professionals work on called?

A

Collaborative problem

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8
Q

What is charting by exception?

A

Chart only significant findings/exceptions to norms
Reduces charting time for nurses = more time w/ the pt
Omissions are the biggest problem

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9
Q

At what points do you triple check medications?

A

When pulling meds, before leaving med room, and at bedside before pt receives meds

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10
Q

Six Rights of Medication Administration

A

Right Drug
Right Dose
Right Route
Right Time
Right Patient
Right Documentation

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11
Q

Ways to enhance therapeutic communication

A

Address the pt, listen actively, establish trust, be assertive, interpret body language, use silence when appropriate, explore issues, validate feelings, clarifying statements, sit at eye level

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12
Q

Vulnerable populations

A

Homeless, poor, sexual orientation, mentally ill, physical disabilities, young, elderly, some ethnic and racial minority groups, gender

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13
Q

Are incident reports only for patients?

A

No. Can be for employees (ex: needle stick)

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14
Q

Do you reference incident report in the pt’s chart?

A

No

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15
Q

What do you include in incident report?

A

-Only state facts
-Do not place any blame
-Does not go in pt’s chart

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16
Q

Adverse event

A

An event in which care resulted in an undesirable clinical outcome

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17
Q

Near miss event

A

Caught before hand

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18
Q

Sentinel event

A

An event that results in death, permanent harm, or severe temporary harm

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19
Q

Examples of sentinel event

A

-Pt abduction
-Pt suicide
-A foreign body, such as sponge or forceps that was left in a patient after surgery
-A hospital operates on the wrong side of the patient’s body
-Hemolytic transfusion reaction involving major blood group incompatibilities

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20
Q

Documentation guidelines

A

Be clear and concise
Use correct terminology, spelling, and grammar
Timely
Signature

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21
Q

What time should be used when documenting?

A

The time the assessment/procedure was completed

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22
Q

Stereotype vs archetype

A

Archetypes- something recurrent, based on facts; usually not negative
Ex: eye or skin color based on region or geographic data

Stereotypes- Widely held unsubstantiated beliefs that have no basis in facts; negative beliefs
Ex: “Naturally athletic” “Naturally intelligent”

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23
Q

Discrimination

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A

When a person acts on prejudice (stereotypes) and denies another person one or more of his/her fundamental rights
Ex: Not giving suspected drug user pain meds

24
Q

VORB

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A

Verbal Order Read Back

In person

25
TORB
Telephone Order Read Back
26
What is the purpose of the read back component?
Avoid medical errors and ensure order accuracy
27
Process for safe medication administration
-Know your patient history (HX, labs and assess your patient) -Follow the orders -Perform the Rights of Safe Med. Administration -Triple check the medications against the MAR before the patient takes them -Reassess your patient afterwards and document
28
Ampule is a __________ dose only. Use __________ needle when drawing up medication to avoid chards of glass.
single; filter
29
What type of needle must be used when drawing up insulin?
Insulin needle (orange) only because it is in units Must be dual verified by another RN
30
Can you give personal advice/opinion to pt's and their families?
No
31
How to enhance cultural awareness
Self assessment for bias and prejudices
32
What is needed to deliver culturally competent care?
Cultural awareness and sensitivity
33
What should you tell a trained interpreter before beginning any translations?
Advise them to translate everything that is said and leave nothing out Be sure to use interpreter when obtaining consent
34
How to complete a cultural assessment
-Open-ended questions -Allow patient time to explain -Listen with respect and remain non-judgmental Advise pt you want to provide the best care by identifying their cultural practices
35
I-SBAR-R
o Intro o Situation o Background o Assessment o Recommendation o Read back
36
Parameters for Nitroglycerin
-Check vitals before and after each dose -1 SL tab every 5 minutes for a maximum of 3 doses -Must wear gloves -Make sure pt doesn't take Cialis/Viagra or any other ED medications -Warn pt before first dose about wicked headache -Instruct pt to hold med under tongue, and not to chew- -If patient’s HR is below 60 or Systolic BP (SBP) is less than 90 hold dose and notify HCP
37
Should you give food with NSAIDs?
Yes. Upset stomach without it.
38
How to administer ear drops for adults and kids
-Use solutions at room temperature – too cold leads to dizziness -Pull pinna up and back for adults, down and back for children -Push on tragus to instill meds
39
Race is strictly related to
biology
40
Potential violations of HIPAA
 Discussing pt’s in public areas  Leaving charts out  Not logging/locking computers  Copying forms  Social media Providing shift report to oncoming RN does not violate HIPAA
41
Cardinal rule of documentation
If it was not documented, it was not done
42
How to correct an error in the chart
Strikethrough, write “mistaken entry”, date, and initial Do not use whiteout
43
Culturally competent model of care ASKED
Awareness- Take an honest look at your own biases Skills- Ability to conduct a cultural assessment with sensitivity Knowledge- Information about cultural worldviews Encounters- Takes practice to become competent Desire- Must want to be culturally competent
44
Insulin injections are
Subcutaneous (subq)
45
General rules for subq injections
-Max. injection is 1 mL -Sites include upper arm, abdomen, upper back, lower back, and top of thighs -Rotate sites -45-90 degree angle
46
How should you draw up insulin?
Inject air into each vial first and then draw up regular (clear) insulin before long acting insulin (cloudy)
47
General rules for intramuscular injections
-Z track method -Max. injection is 1 mL to 5 mL depending on site -Deltoid, Vastus Lateralis, and Ventrogluteal
48
Max. injection & landmark for Deltoid is
1 mL 2 fingerbreadths below the acromion process in the middle third of the muscle
49
Max. injection & landmark for Vastus Lateralis is
3 to 5 mL Between greater trochanter and the lateral femoral condyle - injection site is the middle third of the muscle
50
Max. injection & landmark for Ventrogluteal is
3 to 5 mL Place your palm on the greater trochanter and thumb towards the groin avoiding the anterior superior iliac spine and iliac crest inject in the muscle
51
When can PHI be released?
For payment, treatment, and normal healthcare operations
52
What should be considered when administering the Albuterol?
-Check vitals before and after administering. Medication raises HR. -Oral care -If pt is unable to use hands, use a spacer.
53
General rules for intradermal injections
-Max. injection is 0.1 mL -5-15 degree angle -Sites include forearms, upper chest, and upper back -Ex: TB skin test
54
Universals
values, beliefs, and practices that people from all cultures share
55
Specifics
values, beliefs, and practices that are special/unique to a culture
56
When do you document in the pt's chart?
At the time of admission, transfer, discharge, ongoing care per policy, change in condition, communication
57
MAR
Medication Administration Record Comprehensive list of all ordered medications for pt

PCC Lecture (3 decks)

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