Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Foundations 1 > Unit 1 > Flashcards

Unit 1 Flashcards

(278 cards)

Start Studying
1
Q

first colonial hospital

A 
•1658
•New York
•untrained male nurses
•folk remedies
*more died from disease or care complications, rather than war wounds
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Florence Nightingale

A
  • educated woman (math/science)
  • sanitation, infection control, etc
  • founder of modern nursing
  • “lady with the lamp”
  • reduced mortality from 42.7 to 2.2 in 6 months
  • Nightingale training school- diploma school
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Clara Barton

A
  • started Red Cross
  • emphasis on sanitary conditions in hospital
  • recognized for primary prevention
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

1st US schools of nursing

A
  • post civil war
  • combo of classroom and clinical experience
  • based on Nightingale model
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Rockefeller Foundation

A
  • committee to study nursing education

* expanded nursing since not enough to meet all needs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

what increased demands for nurses

A
  • war

* baby-boom and post-war economy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Mobile Army Surgical Hospitals

A
  • MASH units
  • paved way for ICU development and improved ER and trauma care
  • established concept of nursing diagnosis at this time
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Linda Richards

A

•1st trained US nurse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Isabel Hampton Robb

A

•established ANA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Mary Mahoney

A

•America’s 1st professional black nurse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Lillian Wald

A
  • opened Henry Street Settlement Service in New York and established public health nursing
  • HIV place
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Margaret Sanger

A
  • 1st birth control clinic in America

* went to jail

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Lucille Petry

A

•1st woman appointed to position of Assistant Surgeon General of US Public Health Service

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Mary Breckinridge

A

•founded Frontier Nursing Service (1st organized midwifery service)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Orem

A
  • Nursing theorist
  • theory of self- you are responsible for yourself
  • patient is responsible about his or her own health care
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

contemporary developments in health care

A
  • insurance companies run medicine
  • focus on cost containment and efficiency
  • increased jobs in outpatient and home health care
  • managed health care
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

managed care organization (MCO)

A
  • provides preventive and treatment services to voluntarily enrolled people
  • insurance provider oversees care of client
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

preferred provider organiation (PPO)

A
  • type of managed care plan that limits an enrollee’s choice to a list of “preferred” hospitals, physician, and providers
  • enrollee pays more out of pocket if using provider not on list
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

medicare

A

•federally funded national health insurance program in US for people 65+

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

medicaid

A

•federally funded program that provides

  1. ) health insurance to low income
  2. ) heal assistance to low income
  3. ) supplemental care to mediare pts
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

nursing

A
  • protection, promotion, and optimization of health and abilities
  • prevention of illness and injury
  • alleviation of suffering thru dx and treatment
  • accountable discipline guided by science, theory, code of ethics, and art of care and comfort to
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Four Essential Features of Contemporary Nursing

A
  1. ) attention to full range of human, without restriction to specific problem
  2. ) integration of objective/subjective data and knowledge
  3. ) provision of a caring relationship that facilitates health and healing
  4. ) application of scientific knowledge to diagnosis/treatment
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

objective data

A
  • what you see

* includes looking at previous results in medical records

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

subjective data

A
  • what pt tells you
  • written in quotes
  • can you prove it?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
UAMS philosophy of nursing (PACE)
* Professionalism * Accountability * Communication * Excellence
26
professionalism
•behavior that upholds the status, methods, character, and standards of a given profession
27
continuing education (CEU)
•formal, organized educational programs offered by universities, hospitals, state nurses associations, etc •updates your knowledge about latest research and practice developments •teaches new skills and techniques *15/yr required in AR
28
in-service education
* programs are instruction or training provided by health care agency/institution * designed to increase knowledge and kills of nurses employed by the institution
29
standards of care
* define and direct the level of care a nurse should give * nurses should not practice beyond their legal scope * assessment * diagnosis * outcome ID * planning * implementation * evaluation
30
standards of professional performance
* quality of care * performance appraisal * education * collegiality- getting along * ethics * collaboration * research * resource use
31
professional nursing roles
* providing care and comfort to clients and performing specific nursing fxns * illness prevention * health promotion * and concern for client holistically
32
caregiver
* help pts maintain and regain health, manage disease and symptoms, and attain maximal level fxn and independence thru the healing process * help with healing process through physical and interpersonal skills
33
patient advocate
* protect pts human and legal rights * provide additional infer about treatment to help pt make decision * clarify to pt and family
34
registered nurse (RN)
* associate or baccalaureate degree * directs nursing team * ultimately responsible for the care given to clients * supervise AP and LPNs
35
LPN
* licensed practical nurse | * collaborates within the nursing process
36
AP
* assistive personell | * assigned specific task to complete
37
NA
* nutrition aid | * member of the health care team but not the nursing team
38
nurse administrator
•manages pt care and delivery of specific nursing services within a health care agency
39
nurse researcher
•investigates problems to improver nursing care and expand practice
40
advanced practice registered nurse (APRN)
* most independently functioning nurse * masters degree in nursing * certification in area of expertise * has potential for authority
41
clinical nurse specialist
•APRN who is expert clinician in specialized area of practice
42
certified registered nurse anesthetist (CRNA)
* APRN with advanced education in anesthesia | * provide surgical anesthesia under guidance/supervision of anesthesiologist
43
certified nurse midwife (CNM)
* APRN who is educated/certified in midwifery * provide independent care for women nursing normal preggo, labor, delivery * associated with a health care agency that provides medical consultation
44
National League for Nursing (NLN)
•advances excellence in nursing education to prepare nurses in changing environments
45
American Nurses Association (ANA)
•improve standards of health and availability of health care
46
International Council of Nurses (ICN)
•international version of ANA
47
statutory law
* written law with the intention to clarify * Americans with Disabilities Act * Nurse Practice Acts * abuse laws
48
Nurse Practice Acts
•defines nature and scope of the practice •defines rules and regulations •outlines relationship w/ other health care providers •establishes licensure requirements •creation of State Board of Nurses *what nurses can/cannot do
49
public law
* law governing relationship between individuals and govt. * Law applicable to an entire group of people * Ex: mandatory annual tb testing of all health care workers
50
regulatory (administrative law)
* reflects decisions made by administrative bodies, such as the State Board of Nursing * Ex: requirement to report incompetent/unethical nursing conduct
51
common law
* results form judicial decisions made in courts when individual legal cases are decided * Ex: informed consent, right to refuse treatment, malpractice
52
civil law
* protects rights of individuals within society | * provide fair treatment when wrongs occur
53
good samaritan law
•offer legal protection to people who give reasonable assistance to those who are injured, ill, in peril, or otherwise incapacitated
54
tort law
•a wrongful act that results in injury to another's person, property, reputation, etc
55
intentional tort
* assault * battery * fasle imprisonment
56
professional negligence
* failure of nurse to act with reasonable judgment, intelligence, foresight, and skill expected of them * nursing care below level of standard care
57
malpractice
* professional negligence | * nurse owed duty to patient and did not carry out duty, which caused pt injury
58
liability
•legal obligation or responsibility to provide care to a client that meets the accepted standard of care
59
potential for liability suits
* failure to monitor/assess * failure to ensure safety * medication errors * documentation errors * improper implementation of skills/procedures
60
defamation of character
•publication of false statements that result in damage to person's reputation
61
slander
* when one speaks falsely about another | * verbal defamation
62
libel
* written defamation | * Ex: false entries in medical record
63
nurse role in protecting pt rights
* informed consent * advance directives * confidentiality * information security
64
informed consent
•client has given written permission for procedure/treatment •risks, benefits, alternatives, consequences of refusal •Physician is responsible for conveying information and obtaining consent for procedures *nurses role is to witness signature and be sure provider explained everything properly
65
advance directives
* communicate a clients wishes regarding end-of-life care * living will * durable power of attorney for health care * providers orders * nurses provide information, document info, and inform healthcare providers
66
living will
•expresses client's legal wishes regarding medical treatment in the even he/she become incapacitated
67
durable power of attorney
•client designates a health care proxy (any competent adult) to make health care decisions for them if they are unable to do so
68
providers orders
* unless provers writes a DNR or AND (allow natural death) prescription, the nurse initiates CPR when necessary * provider consult client and family before getting DNR or AND
69
confidentiality
* protects private patient info once it has been disclosed in health care setting * client’s right to privacy in the health care system
70
HIPPA provides client..
•The right for sensitive health information to be kept confidential
71
uniform determination of death act
•provides right to a accurate determination of death
72
Uniform Anatomical Gift Act
•protects right to donate body organ
73
Patient Self-determination act
•The right to refuse treatment
74
credentialing
•methods by which the profession attempts to ensure and maintain practitioner competency
75
certification
•voluntary process granting recognition for meeting criteria established by a nongovernment assoc.
76
accreditation
•monitors educational program’s ability to meet predetermined standards for student outcomes
77
code of ethics
•philosophical ideals of right and wrong that define principles you will use to provide care to pts
78
ethical principles
•standards of what is right or wrong with regard to social values/norms 1. ) autonomy 2. ) beneficence 3. ) fidelity 4. ) justice 5. ) non-maleficence 6. ) confidentiality 7. ) veracity- adhering to the truth
79
autonomy
•right to make one's own personal decisions, even if not in one's best interest
80
beneficence
•positive actions to help others
81
fidelity
•agreement to keep promises
82
justice
•fairness in care and use of resources
83
maleficence
•to cause harm/injury
84
nonmaleficence
•avoiding harm/injury
85
basic principles of ethics
* advocacy * responsibility * accountability * confidentiality
86
responsibility
•willingness to respect one's professional obligations and follow thru on promises
87
Choosing not to have surgery despite significant coronary arty blockage is example of what ethical principle?
•autonomy
88
What type of care delivery is offering pain medication to a client who is postoperative prior to ambulation?
•benefice
89
what aspect of care delivery is waiting for a kidney transplant b/c everyone has to meet the same qualifications
•justice
90
what ethical principles is practiced when a nurse questions a medication that is too extreme in the light of the client's advanced age and unstable status?
•non-malefice
91
mandatory reporting
•health care providers have a legal obligation to report abuse and communicable diseases
92
If an PCT reprimands a patent for not using a urinal properly and threatens a diaper, she is committing what tort?
* assault | * threatening pt
93
What type of tort is committed when a nurse issues a sedative to a patient that says he is going to leave the hospital AMA?
•false imprisonment
94
what is a statement that indicates that a client understands his advance directives?
•I plan to write that I don't want them to keep me on a breathing machine
95
What are the appropriate actions of informed consent for a nurse providing preoperative?
•make sure surgeon has obtained client's consent •witness the client's signature *the physician explains benefits, consequences, alternatives
96
what should a nurse do if a coworker seems unable to focus and is drowsy?
•report observations to nurse manager
97
health
•integration of physical, emotional, intellectual, social, cultural and spiritual wellbeing that enables the performance deemed necessary and desirable to maintain existence in the environment
98
health beliefs
•person's ideas, conviction, and attitudes about health and illness
99
health behaviors
•actions you take regarding your health
100
positive health behaviors
* activities related to maintaining, attaining, or regaining good health and preventing illness * immunizations, sleep, exercise, stress management, nutrition
101
health models
•explain relationship between health and illness
102
continuum model
* looks at health as points on a scale | * high level of wellness on one end and low/death/illness level on other
103
health belief model
* relationship b/t beliefs and behaviors | * can help predict client behavior and how they will comply with therapeutic regiment
104
components of health belief model
* Perceived susceptibility * Perception of seriousness of the illness * Probability of taking action
105
self-efficacy
•perceived ability to carry out recommended action
106
health promotion model
* Developed by Pender * models of health protection * aim to increase client's level of well being
107
health promotion
* the advancement of health through the encouragement of activities that enhance the wellness of individuals, families, and communities * exercise, nutrition, etc
108
Maslow's Hierarchy
•needs necessary for a person's survival •basic needs must be met before higher needs *nurses use to determine client's need and prioritizing intervention
109
levels of Maslow's Hierarchy
* basic (survival) * safety (comfort) * psychological * self-actualization * peak experiences
110
holistic health model
* focuses on the whole patient, and addresses the social, emotional, and spiritual needs of a patient as well as their physical treatment * clients are an active participant in the healing process and have responsibilities
111
health perception
•knowledge and experience of one’s state of wellness and well-being
112
wellness education
* teaches people how to care for themselves in a healthy way * physical awareness * stress management * self-responsibiity
113
illness
* state in which a person's physical, emotions, intellectual, social developmental, or spiritual functions is diminished or impaired compared to previous experience * NOT a disease
114
illness behavior
* How people monitor their bodies, define and interpret symptoms, take remedial action, and engage the healthcare system * Affected by person history, social situations and norms, opportunities and constraints in community institutions * May be used as a coping mechanism
115
stages of illness behavior (5)
``` Stage 1: Symptom experience Stage 2: Assumption of sick role Stage 3: Medical care contact Stage 4: Dependent client role Stage 5: Recovery/rehabilitation/adaptation ```
116
acute illness
* sudden onset | * short duration
117
chronic illness
* lasts > 6 months * cannot be cured * fluctuate between maximal functioning and serious illness
118
remission
•when symptoms disappear or are minimal
119
exacerbation
•chronic illness when symptoms reappear or become worse
120
illness prevention
•activities that protect individuals from actual or potential illness and disease
121
primary prevention
* true prevention, aimed at health promotion * applied to healthy pts * education programs * immunizations * physical/nutritional fitness activities
122
secondary prevention
* applied to pts w/ existing conditions | * activities directed at diagnosis and prompt intervention
123
tertiary prevention
* occurs when disability is permanent/irreversible * involves minimizing effects and preventing complications- palliative care * emphasis on rehabilitation, rather than diagnosis/treatment * preventative care b/c prevents further disability or reduced fxning
124
active strategies
* motivated to adopt specific health programs | * Ex: weight loss; exercise/diet
125
passive strategies
* individuals gain from the actions of others, but don’t actively participate * Ex: Fluoridation of water, Vehicle emissions standards, Product safety guidelines; vitamin D fortified milk
126
stages of health behavior change
1. ) pre contemplation 2. ) contemplation 3. ) preparation 4. ) action 5. ) maintenance stage
127
pre-contemplation
* not intending to make changes w/in next 6 months | * often defensive
128
contemplation
* considering change w/in next 6 months | * accept defect
129
preparation
* making small changes in prep for change in next month | * planning for change
130
action
•actively engaged in strategies to change behavior
131
maintenance stage
* sustained change over time | * changes integrated into pt's lifestyle
132
preventive care
* focuses on educating and equipping patients with means to reduce risks of disease * screenings * immunizations * mental health counseling * community legislation (seat belt, helmet, etc)
133
primary care
``` *health promotion and disease control •prenatal and well-baby care •nutrition counseling •family planning •exercise classes •office; clinics visits •school nurse ```
134
secondary acute care
* diagnosis/treatment of acute illness/injury * emergency care * acute med-surg care * radiological procedures
135
tertiary care
* specialized and technical care * intensive care * sub acute care * oncology centers * burn centers
136
restorative care
* immediate follow-up care * rehabilitation * sports med * home care
137
continuing care
* addresses long-term/chronic healthcare needs * assisted living * psychiatric care * hospice * adult day care
138
respite care
* provide short term relief for people providing home care to an ill, dialed, or frail older adult * offered in home, day care setting, or health care institution
139
palliative care
•specializes in relief of pain, symptoms, and stress of serious illness •not curative treatment •care provided by hospice *continuing care
140
evidence based care
•use of current knowledge from research and other credible sources to base clinical judgment and client care
141
hospice
continuing care (palliative)
142
immunizations
preventive
143
school-based screenings
preventive
144
emergency services
secondary
145
regional cancer center
tertiary
146
home health care
restorative
147
internal variables influencing health
* developmental stage * intellectual background * perception of fining * emotional factors * spiritual factors
148
external variables influencing health
* family practices * socioeconomic factors * culture
149
risk factors
1. ) genetics 2. ) gender 3. ) physiologic 4. ) environmental 5. ) life-style risk behaviors 6. ) age
150
genomics
* study of all the genes in a person and interactions of these genes with one another and with environment * tells health care providers about potential conditions or treatment responses
151
care management
•One person coordinates care form admission through discharge and are accountable for client outcomes •Often uses a critical pathway to guide care *nurse has set of patients that is her specialty and follows that patient to make sure he/she has best outcomes
152
critical care pathway
•multidisciplinary treatment plan that sequences clinical interventions over a projected length of stay
153
discharge planning
* a centralized, coordinated, multidisciplinary process that ensures that the client has a plan for continuing care after leaving an agency * starts when the client is admitted
154
case management
•Type of care delivery that coordinates health care services to clients/families across care areas and between agencies to ensure integration of services
155
case manager
•collaborates with the physician and disciplines to ensure that diagnostic and treatment approaches are appropriate, delivered promptly, and cost-effective
156
patient focused care
* Involves bringing all care providers and services to the client instead of taking the client to the provider/services * Each unit has its own admissions dept., pharmacy, lab, and radiology areas * Ex: multiple myeloma unit
157
What is the first intervention to determine a client's need for health promotion and disease prevention?
•determine the client's risk factors
158
nutrition presentation
* primary prevention | * strategy that helps prevent illness/injury
159
critical thinking
* a reasoning process used to reflect on and analyze thoughts, actions, and knowledge * requires open mind * major part of nursing process
160
basic critical thinking
* nurse trusts experts and thinks con retell based on rules * less experienced nurses * based on set of rules/guidelines * Ex: looking for answer in textbook
161
complex critical thinking
* nurse begins to express autonomy by analyzing and examining data to determine the best alternative * practice/recognize alternatives * implementation based on objective data
162
commitment
* expert level of critical thinking knowledge * nurse expects to make choices w/o help from others and fully assumes responsibility for those choices * ability to anticipate need for future intervention
163
components of critical thinking
* knowledge * experience * competence * attitudes * standards
164
knowledge
•info that's specific to nursing and comes from education
165
experiences
•decision making ability derived from opportunities to observe, sense, and interact with clients
166
competence
•cognitive processes nurse uses to make nursing judgments | *nursing process
167
attitudes
* mindsets that affect how a nurse approaches a problem | * confidence, independence, fairness, responsibility, etc
168
standards
•model for comparing care to determine acceptability, excellence, and appropriateness
169
intellectual standards
•Clear, Precise, Specific, Accurate, Relevant, Plausible, Consistent, Logical, Deep, Broad, Complete
170
professional standards
•are judgments based on ethics, evidence based practice, and professional responsibility
171
reflective journaling
* A tool used to clarify concepts through reflection by thinking back or recalling situations * helps develop critical thinking skills
172
concept mapping
* A visual representation of patient problems and interventions that illustrates an interrelationship * helps develop critical thinking skills
173
circle of meaning
* encourages concept clarification and searching for meaning in nursing practice * series of questions to help you find meaning in clinical experience
174
critical thinking skills (6)
* interpretation- data collection * analysis * inference- look for significance * evaluation- be objective * explanation- support findings/conclusions * self-regulation- reflect on experiences
175
diagnostic reasoning
•a nurse collects patient data and analyzes them to determine the patient’s problems
176
clinical decision making
•nurse identifies a patient’s problem and selects a nursing intervention
177
nursing process
•5 step clinical decision making approach 1. ) assessment 2. ) diagnosis 3. ) planning 4. ) implementation 5. ) evaluation
178
attitudes a nurse needs
1. ) confidence- be sure 2. ) independence 3. ) fairness- listen to both sides 4. ) responsibility- ask for help 5. ) risk taking- try diff. approach 6. ) discipline- be thorough 7. ) perseverance- don't give up 8. ) curiosity- ask why? 9. ) creativeness 10. ) integrity- keep standards and truth 11. ) humility- ask questions
179
philosophy of care
* nursing staff’s values and concerns for the way they view and care for patients * supports professional nursing standards
180
magnet recognition
* practice environment that is dynamic, autonomous, collaborative, and positive for nurses * Nurses have professional autonomy over their practice and control over the practice environment
181
nursing care delivery model
* RN gives direct pt care | * provide faster diagnosis and intervention, which promotes a safer patient environment
182
team nursing
* nursing care delivery model that encourages collaboration * hierarchy of communication * team leader has high level of autonomy
183
total pt care
* care delivery model where the RN works with pt, family, and other team members * emphasizes high degree of collaboration with other health care professionals
184
primary care
* care delivery where one nurse is responsible for group of patients * communication is lateral
185
case management
* care delivery which coordinates and links health care services to patients and their families while streamlining costs and maintaining quality * APRN serves as case manager
186
decentralized management
•decision making occurs at the level of the staff
187
aspects of clinical care coordination
* clinical decisions * priority setting * organized skills * use of resources * time management * evaluation
188
priority setting
* determining which pt's needs should be addressed first * high- immediate threat to survival * intermediate- non-life threatening * low- problems may/may not be related to disease
189
organized skills
* pt care in orderly manner * use resources/time well * perform tasks correctly * evaluate success/inefficiency
190
time management
* remain goal oriented | * identify priorities
191
team communications
* share info * respect other's input * stay informed
192
communication w/ physicians
* refer by name * have pt chart for reference * don't be aggressive
193
delegation
* transferring responsibility to another staff member, while remaining responsible for outcomes * have to know what can be delegated and when
194
5 RIGHTS of delegation
•what can be delegated 1. ) right task 2. ) right circumstance 3. ) right person 4. ) right direction 5. ) right supervision
195
right task
* repetitive * require little supervision * non-invasive * minimal risks
196
right circumstance
* appropriate pt setting | * available resources
197
right person
* person delegating the right tasks must delegate to the right person for the job * assess delegatee by asking open ending ???s (how long thermometer, etc)
198
right direction
* clear description of task * objectives * limits * expectations
199
right supervision
•appropriate monitoring, evaluation, intervention, and feedback when necessary
200
effective delegations
* assess knowledge and skills of delegatee * match tasks to delegates skills * communicate clearly * provide feedback
201
documentation
* anything written or printed on which you rely as a record or proof of patient actions and activities * "care not documented is care not provided"
202
confidentiality
•nurses are ethically and legally obligated to keep pt info confidential and protected from ALL unauthorized personnel
203
records or chart
* accurate account of pt's health status * confidential, permanent legal document * any changes to status must be documented immediately
204
reports
* oral, written, or taped exchange of info * change of shift * telephone * transfer * incident
205
conference
* team members communicate in group | * Ex: discharge planning requires meeting of RN, nutritionist, social worker, physician, etc
206
consultation
* professional caregiver giving advice to another caregiver | * Ex: RN consult w/ wound care specialist
207
referral
•arrangement of services by another care provider
208
legal guidelines for recording
* correct errors promptly * state facts * chart for self only * begin w/ date/time * end w/ signature and title
209
fixing error in record
* draw single line thru error * write error above * initial and date * record note correctly
210
quality documentation
* factual * accurate * complete * current * organized
211
SOAP
``` •method of recording Subjective Objective Assessment Plan ```
212
SOAPIE
``` •method of recording Subjective Objective Assessment Plan Intervention Evaluation ```
213
PIE
•method of recording Problem Intervention Evaluation
214
DAR
•method of recording Data Action Response
215
nursing informatics
* A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice * facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in decision making in all roles and settings * Ex: using decision support system
216
nursing process design
* NIS that organizes documentation within well-established formats * admission and postoperative assessment problem lists * care plans * discharge planning instructions * intervention lists or notes
217
clinical decision support system
* is based on “rules” and “if-then” statements * links info and provides alerts/warnings * emphasis on pt safety * Ex: notifies provider of allergies before ordering a medication
218
Clinical Information System (CIS)
•provide information about patients in an organized and easily accessible fashion 1. ) monitoring systems 2. ) order info systems 3. ) pharm, radio, lab systems
219
monitoring systems
•record biometric measurements in critical care areas
220
order info systems
•allow nurses to order supplies/services from other areas
221
computerized provider order entry (CPOE)
* provider directly enters orders into hospital info system | * orders sent to appropriate departments (lab, pharm, etc)
222
importance of medical record
•serves as financial record for reimbursement
223
problem-oriented medical records
•organized by pt's problem
224
hand-off report
* purpose is for continuity of care * report given during pt transfer * pt info given to new caregiver * must give receiver chance to ask ??? * Ex: Sally breathes better when on right side
225
flow sheet
•shows pt trends over time
226
Kardex
* kept at nurses station | * contains pt info so don't have to look through all charts
227
most important aspect of hand hygiene
•friction
228
negative response question
•correct answer is pt's incorrect response
229
nursing process
* blueprint for how to care for pts * dx and tx to health problems * continuous * critical thinking * promotes organization and efficiency
230
stages or nursing process
1. ) assessment 2. ) nursing diagnosis 3. ) planning 4. ) implementation 5. ) evaluation
231
assess
* gathering and analysis of information about the patient’s health status * collecting info from primary source (pt) and secondary source (care giver, record, med prof) * then interpreting and documenting data
232
when assess
•within the 1st hour of your shift | *begins right when you walk in the door
233
cue
•info you obtain through senses
234
inference
•judgment or interpretation of cues
235
bedside reporting
* previous nurse gives detailed report of pt that is now yours * both of you go do a quick assessment before shift * look at IV line to make sure flowing and inserted correctly * determine current condition * brief interview and then come back for thorough assessment
236
how to assess
* interview/observe pt * talk to caregivers and team members * look at medical record * scientific literature
237
interview
* introduce self and role * focus on pt * use open ended ??? * be attentive- don't rush * observe verbal cues * remember culture * promise to return and follow through
238
abnormal findings
* list on back of care plan sheet | * categorize each- Gordon's
239
card list
* gives list of nursing diagnoses | * based on gordon's 11 fxnal health problems
240
documentation
* timely, thorough, accurate * be factual * "subjective data"- pt states, "..." * electronic health records * HIPPA
241
who can assess
``` •nurse •student nurse •physician •APRN *techs can only observe ```
242
nursing diagnosis
* not a medical diagnosis * nursing language * classifies health problems * use card- *be sure def. is same as your dx * look at symptoms listed in book * use interventions from book
243
types of nursing diagnoses
* actual diagnosis * potential for risk * health promotion
244
NANDA
* North American Nursing Diagnosis Association | * common lang. for understanding pt needs
245
read p. 244
•select diagnosis and read def
246
risk for
•always document risk for fall/injury *when writing diagnosis, priority is not usually "risk for" •pt are in hospital for real problem, so need to find real problem
247
incontinent pt
•risk for dehydration •risk for skin breakdown- soiled *your responsibility to prevent b/c hospital has to pay for developed issue
248
As evidenced by (AEB)
* subjective and objective data | * defining characteristics
249
Recipe for nursing diagnosis
1. ) NANDA diagnosis 2. ) related factors 3. ) AEB
250
related factors
``` •reason for nursing diagnosis •pathophysiological (bio/psych) •treatment related •situational •maturational *not a medical diagnosis ```
251
key for writing good diagnosis
* use more than one symptom * don't be judgmental * never assume * remember it's not a medical diagnosis
252
plan
•what do you want for your pt •goals must be SMART *ALWAYS start with "pt will...."
253
SMART
``` Specific Measurable Attainable Realistic Timed ```
254
Ex: timed
Pt will maintain an oxygenation status of 95% or better this shift
255
short term goal
* before discharge | * within your shift
256
interventions
* you don't make them up * all are evidence based * look in Doenges book under nursing dx
257
independent interventions
* actions that nurse initiates | * don't require and order from another HCT
258
dependent
•require an order from physician or HCT member
259
collaborative intervention
•therapies that require the combined knowledge, skill, and expertise of multiple health care professionals
260
listing interventions
•list 4 in care plan 1. ) assess 2. ) administer- *be specific 3. ) ... 4. ) ... * make sure interventions focus on ONE specific goal
261
ex: specific administer
•Inhale 4 puffs of albuterol inhaler every 3-4 hours when oxygenation less than 90%
262
on intervention list
* don't do more than one of assess/monitor/evaluate/determine/ascertain * think about what you did with nurse * give rationale for each intervention
263
rationale for medication
* action listed in drug book | * reference book
264
implementation
* direct/indirect care * use good judgment/decision making * remember pt status can change often * consider consequence * prepare self and pt * explain everything to pt * think of previous interventions for pt and those w/ same condition
265
direct care
* care of a patient provided personally by a staff member * treatments * counseling * self-care, patient education * administration of medication
266
indirect care
•non-nursing tasks
267
5 prep activities
1. ) reassess pt 2. ) review care plan 3. ) organize resources 4. ) anticipate complications (Ex: rxn) 5. ) implement interventions
268
evaluation
* examination to see if change occurred * did you reach your goal? * positive outcome if goal met * if goal unmet, reevaluate care plan and implement new changes * communicate results to family
269
why do a care plan
•prioritize •organize *identify nursing actions to be delivered
270
standardized care plan
•typical nursing dx and intervention
271
HIPPA
•right for sensitive health care info to be kept confidential
272
oriented times 3
* awake * alert * oriented to person, place, time
273
components of nursing diagnosis
* diagnostic label | * related factor (etiology)
274
diagnostic label
* pt response to health conditions | * includes descriptors to give more detain
275
descriptors examples
* impaired * compromised * decreased * deficient * delayed * effective * imbalanced * impaired * increased * acute
276
etiology (related factor)
``` •reason pt is displaying nursing diagnosis •4 categories 1.) pathophysiological- bio/psych 2.) treatment related 3.) situational- environmental/personal 4.) maturational ```
277
risk nursing diagnosis
* human responses to health conditions or life processes that may develop in a vulnerable individual * risk factor is the related factor * don't have related factors b/c they have not occurred yet * Ex: risk for infection; risk for loneliness, risk for acute confusion
278
risk factors
•environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem

Foundations 1 (3 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions