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Flashcards in Unit Exam 1 Deck (90):
1


List/Explain Benner’s levels of proficiency

Novice-Student, no experience

Advanced beginner- Some experience

Competent- 2-3 years experience

Proficient- Years of applicable experience

Expert- Diverse Experience, Intuition

2

Torts

A tort is a civil wrong or omission made against a person or property

There are three kinds, intentional, quasi-intentional, and unintentional

3

Intentional Torts

Deliberate acts that violate another’s rights.
Assault, battery, false imprisonment
Examples: Assault, a threat of harmful, imminent, unwanted contact. NO CONTACT REQUIRED. (Threats to give injection against will, restraint)
Battery: Intentional offensive touching without consent or lawful justification. PATIENT CONSENT. Without consent, injection is battery.
False imprisonment: Patient must be conscious and aware they are being kept.

4

Quasi-intentional torts

Intent is lacking but violational action and direct causation occur such as invasion of privacy and defamation of character.

Example: Accidentally telling the family without patient permission about PHI

5

Unintentional Torts

Negligence and malpractice

In negligence care falls below standard

Malpractice care falls below standard, the patient was injured, and the patient was injured as a result of the below-standard care.

6

Code of ethics

A set of guiding principles that all members of a profession accept as the expectations and standards for behavior, the ANA created the code of ethics for nursing.

7

SMART goals

Part of the planning aspect of the Nursing Process

Specific
Measurable
Attainable
Realistic
Timed

8

The nursing process: Planning

Establishing a plan of care that prioritizes diagnoses and establishes interventions, patient-centered goals, and expected outcomes. Planning must be individualized. Use SMART acronym. Interventions planned should include actions, frequency, quantity, method, and who’s performing them.

9

The Nursing process: Assessment

Learn as much as you can about the patient. Collection of data comes from primary patient source, and secondary (friends, family, health care providers) sources. Establishment of the therapeutic relationship. Subjective and objective data is collected.

10

Normal Temperature

36 to 38 Celsius

96.8 to 100.4 Fahrenheit

Oral 37
Rectal 37.5
Axillary 36.5

11

Normal pulse

60-100 bpm

12

Normal pulse oximetry

Greater than or equal to 95%

13

Normal respirations

12-20 breaths/min

14

Normal BP

120/80 mmHg

15

Diaphoresis

Visible sweating

16

10 guidelines for collecting vitals

1. Collection is your responsibility
2. Make sure equipment is working
3. Make sure it’s the correct equipment (cuff size)
4. Know patients normal ranges
5. Know patients history, any factors to affect vitals
6. Control relevant environmental factors
7. Use organized, systematic methods for collection
8. Determine how often vitals are to be collected
9. Use vitals to determine med admin
10. Verify and communicate vitals

17

Pulse point: Dorsalis Pedis

Along top of foot

18

Statutory Law

Elected legislative bodies (state legislature) and the U.S. congress create these laws

Example: Nurse Practice Acts describe and define legal boundaries of nursing practice within each state.

19

Nurse Practice Acts

Describe and define the legal boundaries of nursing practice within each state.

Defines scope, role, education requirements, and distinguishes between nursing and medical practice.

20

The Nursing Process

ASSESSMENT

NURSING DIAGNOSIS

PLANNING/OUTCOMES I.D.

IMPLEMENTATION

EVALUATION

21

Standards of care

Legal requirements for nursing practice that describe the minimum acceptable nursing care.
Standards reflect knowledge and skills ordinarily possessed by those who are currently practicing.

22

The 5 preparatory activities BEFORE implementation of interventions

1.Anticipate complications

2.Assess patient

3. Review care plan

4. Organize resources

5. Delivery of care

23

Common Law

Common law results from judicial decisions made by courts when individual cases are decided.

Common laws include: Informed Consent, patients right to refuse, negligence, malpractice.

24

Hypertension BP

140/90 mmHg or higher

25

Regulatory or Administrative Law

Reflects decisions made by administrative bodies such as the state boards of nursing when rules and regulations are passed.

Example: Requirements to report incompetent or unethical nursing conduct

26

American Nursing Association (ANA) standards of professional performance

Ethics
Education
Evidence based practice
Quality
Communication
Leadership
Collaboration
Evaluation
Resources
Environmental healt

27

Nurse Practice Act

Varies by state, outlines licensure laws for nurses and creates State boards of nursing that create and enforce rules consistent with the practice act, investigating and deciding cases that violate the act, and licensure. They establish scope, educational, examination, and competency requirements.

28

Americans with Disabilities act

Prevents discrimination and refusal to care for patients with disabilities. It also ensures accommodations are made so that disabled patients have access to care.

29

Emergency medical treatment and Active labor act (EMTLA)

Protects patients and ensures medical treatment was not denied to a patient simply because of their inability to pay. Legally, hospitals under this act must treat and stabilize a patient before transfer. ESPECIALLY for private hospitals, who would turn patients away and transfer them to tax supported, public hospitals at the taxpayer expense. (Known as patient-dumping).

30

Health Insurance Portability and Accountability Act (HIPAA)

PORTABILITY CLAUSE

Allows for the portability of health insurance when an individual loses or changes a job and has pre-existing conditions. I.e. they will not lose their previous coverage when switching to new benefits after a job loss or change simply because of a pre-existing condition. AS LONG AS they have had 12 months of continuous group health insurance coverage.

31

Health insurance Portability and Accountability Act (HIPAA)

The privacy part of the clause is most relevant to practice. It ensures the legal right of the PATIENT to expect privacy and confidentially of PERSONAL HEALTH INFORMATION. Right to privacy protects the disclosure of PHI, while confidentiality protects PHI after it has been disclosed in clinical settings. (Minimum, need-to-know basis). The HITECH Act was created in conjunction with HIPAA and provides protection from deliberate or accidental disclosure of PHI online

32

Patient self-determination Act

PSDA, advance directives are covered by the guidelines of this act. It requires facilities such as hospitals and nursing homes to provide patients upon admission with info related to their preferences for end of life care. Patients may or may not choose to accept all life-saving measures. The facilities must inform the patient of their right to decide, and they must respect these wishes. Documentation in medical chart of wishes is also required.

33

Legal concepts of standards of care

Basic guidelines for the minimum amount of care a nurse is legally obligated to provide under their scope of practice. Standards reflect the knowledge and skill of nurses actively practicing in the profession. The nurse Practice Act defines the standards of every state, as well as the federal and state laws that regulate hospitals and other health care agencies, and by the policies and procedures established by the facility where the nurse practices. Failure of providing standard care is negligence and malpractice

34

Sources for standards of care

Nurse Practice acts

The joint commission

ANA code of ethics

Currently practicing nurses

35

DNR orders

Nurses should have a discussion with the patient about his or her wishes regarding a DNR order. Letting them know their options is part of the patient self-determination act. This discussion falls under the duty of advocacy. Documentation is required.

36

Clinical judgement

Interpretation or conclusion about a patients needs, concerns, or health problems and or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patients response.

37

Critical thinking

Individualized responses for the betterment of the patient condition. Holistic and continuous consideration of care, a nurse must consider multiple complex variables

38

Noticing

A nurse notices things about a patient in the context of the nurses background, experience, context of environment, and knowledge of the patient. Looking for patterns that are consistent with previous experience and using that information to guide care is important in the concept of noticing.

39

Interpreting

The process of assembling information to make sense of it

Novice nurses tend to be analytic in their reasoning, while expert nurses tend to draw from a variety of reasoning patterns-analytic, intuitive, and narrative.

40

Reflecting

Thinking and learning from experiences

1. Reflection in action: happens in real time while care is occurring

2. Reflection on action: happens after the patient receives care.

Reflection is important for the development of knowledge and reasoning improvement.

41

Responding

Implementation of actions and interventions based on patient needs. Depending on the level of expertise, a nurse may or may not be able to determine the effectiveness of an intervention before implementation.

42

Data collection

Interview: (nursing health history obtained)

Nurse health history (obtained during interview)

Physical exam (gathering objective and observable data)

Diagnostic and lab data (nurse reviews and identifies alterations, lab data as compared to present condition.)

43

Nursing health History

Biographical info, reason for seeking care, past health history, environmental history, spiritual health , patient expectations, present illness or health concerns, family history, psych history, review of systems, DOCUMENTATION.

44

Priority establishment

Determining urgency and importance to establish a preferential order for nursing actions. Use maslows hierarchy.

High
Intermediate
Low

45

Purposes of documentation

Legal documentation
Communication
Financial billing
Education
Assessment
Research
Auditing- proof quality care was delivered

46

Guidelines for reporting and recording

Consistent with professional and agency standards.
Complete. Confidential
Factual Legally prudent
Accurate
Concise
Thorough
Current
Organized

47

Legal guidelines for reporting and recording

No erasure, no correction fluid, no blanks

Must use ink, acceptable abbreviations, chart only for yourself, begin every entry with date and time, and end every entry with signature and title.

48

Sources for standards of care

ANA code of ethics

Currently practicing nurses

Joint commission

Nurse Practice Acts

49

Review chapter 23 for full legal issues (potter/Perry

Review chapter 23 potter Perry

50

Identify ethical components of professional practice (General)

Autonomy
Beneficence
Nonmaleficence
Justice
Fidelity

51

ANA code of ethics

Advocacy

Responsibility

Accountability

Confidentiality

52

Autonomy

Patient autonomy refers to including patients in decision about their care, protecting independence.

Provider autonomy refers to policies that allow providers to conflict with assignments and systems, as well as practices and policies, whether it be disagreeing with beliefs or due to a concern that something is unsafe.

53

Beneficence

Taking positive actions to help others. The best interests of the patient remain more important than the interest of self. It implies that nurses work primarily as a service to others.

54

Nonmaleficence

Avoidance of harm, DO NO HARM. The balancing of risk and benefit. A procedure may offer a cure, but it may also be impossible in the specific case of the patient and may cause more unnecessary suffering.

55

Justice

Fairness. Access to healthcare and equal distribution of resources. Just culture refers to the allowance of open discussion without fear of punishment whenever mistakes or adverse events occur or nearly occur. This allows learning and improvement opportunity for others to prevent future harm.

56

Fidelity

Keeping promises. Following through on actions and interventions, monitoring patient response to implementations to ensure intent is achieved. (Is the pain med working?) unwillingness to abandon patient regardless of circumstances.

57

Advocacy

Nurses advocate for the health, safety, and rights of patients. (Including privacy and right to refuse) Relationships with patients by nurses provide a unique understanding for patient view.

58

Responsibility

Willingness to respect ones professional obligations and follow through.

59

Accountability

Answering for ones actions, ensuring your actions are explainable.

60

Confidentiality

Nurses should not share PHI with anyone not involved in patient care.

61

Body Temperature

Effected by age, exercise, hormones, circadian rhythms and the environment.

36.5-37.5

98.6-100.4

62

Pulse

60 to 100 bpm

Effected by exercise, temperature, emotion, medications, hemorrhage, posture, pulmonary conditions.

63

Respirations

12-20 breaths/min, measured in rate,depth,rhythm.

Effected by exercise, pain, anxiety, smoking, body position, medications, neurological injury, hemoglobin function.

64

Blood Pressure

120/80 mmHg. (Pulse pressure is the difference between so 40)

Effected by age, stress, ethnicity, gender, daily variation, medications, activity, weight, smoking.

65

Pulse oximetry (SpO2)

Greater than or equal to 95%, anything lower than 90 is an emergency.

66

Pain as the fifth vital

Scale of 1 to 10 if it is included in vital collection

67

BP ERRORS

Bladder cuff too wide
Bladder cuff too narrow/short
Cuff wrapped too loosely or uneven
Deflating too quickly
Deflating too slowly

False low

False high

False high

False low systolic, false high diastolic

False high diastolic


68

BP errors

Arm below heart level
Arm above heart level
Arm not supported
Impairment of hearing the sounds
Stethoscope too firm against fossa

False high
False low
False high
False low systolic, false high diastolic
False low diastolic

69

BP ERRORS

Inflating too slowly
Repeating assessments too quickly
Inadequate inflation level
Multiple examiners using different sounds for diastolic readings

False high diastolic
False high systolic
False low systolic
False high systolic, false low diastolic

70

Purpose of hygiene

Opportunity to assess patient condition (physical and emotional)
Enhance therapeutic communication
Provide opportunity for patient teaching


Always consider the clients own beliefs, values, and habits. Maintain and promote privacy during hygiene.

71

Purpose of bathing

Cleanse skin
Enhance circulation
Improve self image
Reduces body odor
Promote ROM
Provide comfort and relaxation
Prevents dangerous skin breakdown

72

Mobility

The state or quality of being mobile or movable. Complete, partial, or full mobility. Includes body mechanics, which are the coordinated efforts of the musculoskeletal and nervous systems to produce movement. Alignment and posture.

73

Influences on mobility

Trauma to brain, spinal cord, bones, joints, muscles.

Congenital or acquired postural abnormalities

Damage to the CNS

Musculoskeletal trauma or abnormalities

Neurological conditions

74

Interventions for maintaining/improving/preventing complications for mobility:

Musculoskeletal

Ambulation with Dr. orders

Passive ROM

Strength training, isometrics

Nutrition

Patient teaching

75

Interventions for maintaining/improving/preventing complications for mobility:

Metabolic

Implement a high-protein, high calorie diet to rebuild protein stores.

B and C supplementation, B for metabolism, C for skin

Enteral or parenteral nutrition

76

Interventions for maintaining/improving/preventing complications for mobility:

Respiratory

Deep breathing exercises, the use of incentive spirometer.

Controlled coughing 1, 2, 3, cough

Fluids

Encourage ambulation

77

Interventions for maintaining/improving/preventing complications for mobility:

Cardiovascular

Movement ASAP

Isometrics to improve activity tolerance

Fluids and anticoagulants

Ambulation of legs-prevent DVT

Position changes and compression stockings

78

Interventions for maintaining/improving/preventing complications for mobility:

Elimination

Hydrate
Diet
Toileting opportunities
Stool softeners

79

Interventions for maintaining/improving/preventing complications for mobility:

Integumentary

Turning, repositioning
Skin care
Shifting
Support devices

80

Interventions for maintaining/improving/preventing complications for mobility:

Psychosocial

Interaction

Don’t interrupt sleep, wake cycle

Encourage verbalization of feelings.

81

Identify changes in function associated with immobility:

Musculoskeletal

Loss of endurance, strength, mass, atrophy

Increased fatigue

Joint instability and or contracture; foot drop

Impaired metabolism of calcium

Bone atrophy (disuse syndrome)

82

Identify changes in function associated with immobility:

Metabolism

Endocrine metabolism, calcium resorption, reduced GI function, decreased basal metabolic rate, fluid, electrolyte imbalance, decreased appetite, negative nitrogen balance, tissue catabolism, hypercalcemia.

83

Identify changes in function associated with immobility:

Respiratory

Atelectasis-collapsed alveoli- lung collapse, hypostatic pneumonia, decreased diffusion and perfusion and oxygenation.

84

Identify changes in function associated with immobility:

Cardiovascular

Orthostatic hypotension

Increased cardiac workload

Reduced cardiac output

Thrombus formation

85

Identify changes in function associated with immobility:

Elimination

Decreased peristalsis

Urinary stasis

Dehydration

Renal calculi-exacerbated by hypercalcemia

UTI

Decreased urine output day 5/6

86

Identify changes in function associated with immobility:

Integumentary

Pressure ulcers

Prolonged ischemia

Skin breakdown

87

Identify changes in function associated with immobility:

Psychosocial

Isolation

Depression

Anxiety

Withdrawal

88

Care plans and interventions for patients with limited or no mobility

Prevention: regular ambulation, protection from injury, nutrition, and fall prevention.

Frequent turning(q2h), skin assessment/care, ROM, deep breathing, weight bearing, nutrition, elimination optimization.

Collaborative: exercise(p.t.), meds, surgery,assistive devices, immobilization of injury.

89

Hypothalamus

Thermostat of the body, creates set point

90

Phrenic nerve

Controls diaphragm