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Test 2-Foundations in Nursing > Test 2 > Flashcards

Test 2 Flashcards

(52 cards)

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1
Q

CPOE

A

Computerized Provider Order Entry

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2
Q

POMR

A

Problem-oriented medical record

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3
Q

PIE

A

Problem, Intervention, Evaluation

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4
Q

APIE

A

Assessment, Problem, Intervention, Evaluation

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5
Q

SOAP

A

Subjective Data, Objective, data, Assessment, Plan

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6
Q

SOAPIE

A

Subjective Data, Objective, Data, Assessment plan, Invention, Evaluation, Revisions to plan

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7
Q

SOAPIER

A

Subjective data, objective data, assessment, Plan, Intervention, Evaluation, Revisions to plan

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8
Q

DAR

A

Data, Action, and Response

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9
Q

CBE

A

Charting by exception-records only abnormal or significant data.

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10
Q

EMR

A

Electronic Medical Record-one episode of care

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11
Q

EHR

A

Electronic Health Record-more than one episode of care

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12
Q

EHR documentation

A

Uses ADPIE to integrate nursing process into charging and it also allows information to be shared between medical staff

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13
Q

Flow Sheets

A

used to document routine care and observations

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14
Q

MAR

A

A list of ordered medications, along with dosages, routes, and times of administration

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15
Q

BCMA-Bar coded medication administration

A

a portable scanner scans the patient’s wrist band to get information

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16
Q

Kardex

A

Nonpermanent filing system for nursing records, orders, and patient information

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17
Q

Sentinal Event

A

A safety occurrence that affects a patient and causes death, serious permanent or temporary injury, or requires interventions to sustain life

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18
Q

SBAR

A

Situation, Background, Assessment, and Recommendations. This is a standard hand off tool.

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19
Q

EBP

A

Evidence Based Practice-1. Clinical expertise, 2. pt values and needs, 3. Delivery of cost-effective health care.

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20
Q

Basic Research

A

Research conducted to generate theories

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21
Q

Applied Research

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A

Testing theories in different situations with different populations

22
Q

Clinical Research

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A

Conducted to test theories about the effectiveness of interventions

23
Q

Quantitative Research

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A

Produces data in the field in the form of numbers

24
Q

Deductive Reasoning

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A

Formulates a specific conclusion from a large amount of data.

25
Descriptive Research
Identifies data and characteristics about the populations or phenomenon
26
Correlational Research
Used to explore a relationship between two variables
27
Experimental Research
Explores the causal relationships between variables
28
Quasi-experimental research
Examines a causal relationship between variables, vut it may not meet the strict guidelines of experimental research.
29
Qualitative Research
Based on a constructivist philosophy, which assumes that reality is composed of multiple socially constructed realities of each person or group. (data in words)
30
Inductive Reasoning
Generalizes from specific facts
31
Independent Variable
Concept or idea whose value determines the value of other (dependent) variables.
32
Dependent Variable
The outcome that is affected by manipulation of the independent variable.
33
Three A's of Health Information
1. Accurate 2. Accessible 3. Actionable
34
Nursing Informatics
A specialty area of information that addresses the use of health information systems to support nursing practices.
35
6 Rights of Patients
Right patient, right medication, right dose, right time, right route, and right documentation
36
CDSSs
Computerized Clinical Decision Support Systems
37
NMDS-Nursing Minimum Data Set
Represents the first attempt to standardize the collection of essential nursing data.
38
ICNP-International Classification of Nursing Process
A standard terminology that provides a dictionary to describe and report nursing practices in a systematic way.
39
Tactile Fremitus
Decreased or absent in patients with conditions that obstruct lung tissue, such as pneumothorax, tumors, pleural effusion, or COPD
40
Adventitious Breath Sounds
Abnormal sounds that originate in the lungs and airways.
41
S1
The sound of the mitral and tricuspid valves closing and marks the beginning of systole.
42
S2
The sound of the aortic and pulmonic valves closing and marks the end of systole and the beginning of diastole.
43
Pulse Deficit
present when the patient's radial pulse rate is slower than the apical pulse rate because of cardiac contractions that are weak or ineffective at pumping blood to the peripheral tissues and extremities
44
Cardiac Murmurs
Blowing or swishing sounds heard in systole or diastole caused by increased or abnormal blood flow through the valves of the heart
45
Phlebitis
Inflammation of a vein, typically due to irritation, often from IV solutions or infections
46
S/S's of Arterial insufficiency
5 P's; Pain, pallor, pulselessness, paresthesia (numbness or tingling), or paralysis
47
Neurogenic Bladder (bladder paralysis)
The inability of the bladder to empty (bladder is unable to fully contract because of impaired nerve innervation
48
Paralytic Ileus
paralysis due to lack of peristalsis
49
Borborygmi
Intestinal tract is overstimulated or has increased motility, hyperactive bowel sounds
50
Stenosis
Harding of the arteries, which creates a bruit or "swooshing" sound
51
Rigidity (involuntary tightening)
Caused by conditions such as peritoneal inflammation, appendicitis or acute cholecystitis
52
Ascites
An abnormal accumulation of fluid in the peritoneal cavitiy

Test 2-Foundations in Nursing (1 decks)

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