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Flashcards in Outline Unit 1 Deck (79):
1

initiation of independent nursing interventions without medical records

autonomy

2

reasonably independent and self-governing in decision making

reach through experience, advanced education

3

professionally and legally responsible for the type and quality of nursing care provided

accountability

4

code of ethics and legal aspects of nursing

ANA - American Nurses Association

5

NPA - Nurse Practice Act

regulates the scope of nursing practice for the state and protects public health, safety, and welfare

6

NPA differs from

state to state

7

concepts for a critical thinker

truth seeking
open-mindedness
analytic approach
systematic approach
self-confidence
inquisitiveness
maturity

8

critical thinker reflecting on your own judgments

maturity

9

being eager to acquire knowledge and learn explanations

inquisitiveness

10

trust own reasoning processes

self-confidence

11

organized and focused critical thinker

systematic approach

12

alert to potentially problematic situations

analytic approach

13

tolerant to diff views and clearly know the views of PT

Open-mindedness

14

be courageous, honest, and objective about asking questions

truth seeking

15

make more conscious effort to apply critical thinking BC initially you are more task oriented and trying to learn how to organize nursing care activities

Level 1 basic critical thinking

16

develop new thought or idea based on your experience and knowledge over time

Level 2 Complex critical thinking

17

anticipate the need to make choices without assistance from others - accept accountability for decisions you make

Level 3 commitment critical thinking

18

scientific method to critical thinking

1. identify the problem
2. collecting of data
3. forming a question or hypothesis
4. testing the questing or hypothesis
5. evaluating results of the test or study

19

drawing conclusions from related pieces of evidence and previous experience with the evidence

diagnostic reasoning and inference

20

requires careful reasoning so you choose the options for the best PT outcomes on the basis of PT condition and priority of the problem

Clinical decision making

21

components of critical thinking

1. knowledge base
2. experience
3. competence
4. attitude
5. standards

22

visual representation of PT problems and interventions that illustrates and interrelationship

concept mapping

23

reasoning process used to reflect on and analyze thoughts, actions, and knowledge

developing critical thinking skills

24

decision making

responsibility, autonomy, authority, accountability

25

duties and activities an individual is employed to perform

responsibility

26

independent decisions about PT care

autonomy

27

legitimate power to give commands and make final decisions specific to give position

authority

28

answerable for the actions

accountability

29

leadership skills for nursing students

clinical care coordination, team communication, delegation, knowledge building

30

requires knowing which skills are transferable

delegation

31

improves PT care, improves efficacy, increased productivity

delegation

32

5 rights of delegation

Task, circumstance, person, direction/communication, supervision

33

always care for PT as if they can hear everything you say; tell them what you're doing before you do it

nonverbal communication

34

nonverbal communication

1. personal appearance
2. posture & gait
3. facial expression
4. eye contact
5. gestures
6. territoriality and personal space

35

all factors that influence communication

metacommunication

36

factors influencing communication

1. psychophysiological
2. relational
3. situational
4. environmental
5. cultural

37

ability to understand and accept another persons perspective

empathy

38

attentive to what PT says verbally and nonverbally

listening

39

therapeutic communication technigues to listening

S-Sit facing PT
O- Open posture
L- Lean toward the PT
E- Eye contact
R-Relax

40

observe and comment on PT appearance, sounds, acts

sharing observations

41

helps communication without extensive questioning

sharing observations

42

time to collect thoughts

using silence

43

helps PT make decisions, less anxiety, feel safe & secure

providing info

44

validates whether the person interpreted correctly

clarifying

45

direct convo on specific topic when it becomes unclear

focusing

46

restating senders message in receivers own worlds to make sure info understand accurately

paraphrasing

47

review main ideas from discussion

summarizing

48

personal statements intentionally revealed to other person

self-disclosure

49

"sense of possibility"

instilling hope

50

standards are set by federal & state regulations, state statuses, standards of care, & accreditation agencies

documentation

51

require each PT have an assessment:

physical, psychosocial, environmental, self-care, PT edu, knowledge level, discharge planning

52

guidelines for documentation

factual, accurate, complete, organized, current

53

descriptive, objective info - what you see, hear, feel, and smell

factual - guidelines of documentation

54

precise measurements make documentation more...

accurate

55

episode oriented, info can be lost from one episode to another

paper record

56

Electronic health record

1. a digital version of PT medical records
2. integrates PT info in one record
3. improves continuity of care

57

Progress notes

narrative, SOAP, SOAPIE, PIE, focus charting

58

charting by exception

focuses on documentation deviations from norms

59

incorporate a multidisciplinary approach to care; focuses to providing quality care in a cost-effective manner

case management plan and critical pathways

60

Methods of Documentation

paper records, electronic health record, progress notes, charting by exception, case management plan and critical pathways

61

SOAP

Subjective, Objective, Assessment, Plan

62

SOAPIE

Subjective, Objective, Assessment, Plan, Intervention, Evaluation

63

guides the nurse through a complete assessment to identify relevant nursing diagnoses

Admission nursing history form

64

help team members quickly see PT trends over time and decrease time spend on writing narrative notes

flow sheets in graphic records

65

computerized systems provide certain basic information in the form of a PT care summary

Patient care summary or Kardex

66

"flip-over" file a notebook with PT info

Kardex

67

Preprinted, established guidelines used to care for PT who have similar health problems

Standardized care plans

68

begin at admission and before admission on same-day surgery

discharge summary forms

69

system determines the hour of care for nursing unit and the number of staff required to care for given group of PT

acuity records

70

purpose of records

communication, reimbursement, research, legal documentation, education, quality process and performance improvement

71

standards for PT education

1. all state NPA recognize PT edu is a professional responsibility of every nurse
2. PT edu is considered basic nursing competency
3. edu takes place, evaluate if learning occurred and document all steps of the process
4. help individuals, families, or communities achieve optimal levels of health, safety and independence

72

cognitive learning

what the PT knows and understands

73

affective learning

PT feelings, attitudes, opinions and values

74

Psychomotor learning

PT acquires skills that require the integration of knowledge and physical skills

75

Domains of learning

cognitive, affective, psychomotor

76

basic learning principles

motivation and ability to learn

77

motivation to learn

address the PT desire or willingness to learn

78

ability to learn

depends of physical and cognitive abilities, developmental level, physical wellness, thought process

79

ACCESS model

Assessment
Communication
Cultural negotiation/compromise
Establishment of respect
Sensitivity
Safety