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NURS 115 > Outline Unit 1 > Flashcards

Outline Unit 1 Flashcards

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1
Q

initiation of independent nursing interventions without medical records

A

autonomy

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2
Q

reasonably independent and self-governing in decision making

A

reach through experience, advanced education

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3
Q

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

A

accountability

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4
Q

code of ethics and legal aspects of nursing

A

ANA - American Nurses Association

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5
Q

NPA - Nurse Practice Act

A

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

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6
Q

NPA differs from

A

state to state

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7
Q

concepts for a critical thinker

A 
truth seeking
open-mindedness
analytic approach
systematic approach
self-confidence
inquisitiveness
maturity
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8
Q

critical thinker reflecting on your own judgments

A

maturity

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9
Q

being eager to acquire knowledge and learn explanations

A

inquisitiveness

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10
Q

trust own reasoning processes

A

self-confidence

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11
Q

organized and focused critical thinker

A

systematic approach

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12
Q

alert to potentially problematic situations

A

analytic approach

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13
Q

tolerant to diff views and clearly know the views of PT

A

Open-mindedness

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14
Q

be courageous, honest, and objective about asking questions

A

truth seeking

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15
Q

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

A

Level 1 basic critical thinking

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16
Q

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

A

Level 2 Complex critical thinking

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17
Q

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

A

Level 3 commitment critical thinking

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18
Q

scientific method to critical thinking

A
  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
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19
Q

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

A

diagnostic reasoning and inference

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20
Q

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

A

Clinical decision making

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21
Q

components of critical thinking

A
  1. knowledge base
  2. experience
  3. competence
  4. attitude
  5. standards
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22
Q

visual representation of PT problems and interventions that illustrates and interrelationship

A

concept mapping

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23
Q

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

A

developing critical thinking skills

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24
Q

decision making

A

responsibility, autonomy, authority, accountability

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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 ```

NURS 115 (3 decks)

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