Weeks 1 and 2- Nurse's Role, Documentation, Health Hx, Social/cultural Flashcards Preview

HAP FINAL - CK > Weeks 1 and 2- Nurse's Role, Documentation, Health Hx, Social/cultural > Flashcards

Flashcards in Weeks 1 and 2- Nurse's Role, Documentation, Health Hx, Social/cultural Deck (29)
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1

CAGE test

screening questionnaire to identify excessive drinking:

- C Cut down - Have you ever thought you should cut down your drinking?
- A Annoyed - Have you ever been annoyed by criticism of your drinking?
- G Guilty - Have you ever felt guilty about your drinking?
- E Eye-opener - Do you drink in the morning (i.e. an eye-opener?)

2

PES

problem- etiology - symptoms/defining characteristics
Diagnosis (P) r/t Etiology (E) aeb Characteristics (S)

3

disease condition based on specific evaluation of signs and symptoms

medical diagnosis

4

nursing diagnosis

judgment about the PT in response to an actual or potential health problem

5

an actual or potential physiological complication that nurses monitor to detect the onset of changes in patient's status

collaborative diagnosis

6

3 types of nursing diagnoses

actual
risk (potential)
wellness (health promotion)

7

Healthy People 2020

framework for health promotion efforts. Objectives address most significant preventable threats to health with goals to reduce threats

8

functional assessment

focuses on the functional patterns that all humans share: health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, cop- ing and stress tolerance, sexuality and reproduction, and values and beliefs

9

role of the professional nurse

to promote health, prevent illness, treat human responses, and advocate for patients.

10

SOAP

subjective-objective-assessment-plan

11

PIE

problem-intervention-evaluation

12

DAR

data-action-response

13

CBE

charting by exception

14

What is SBAR for?

it is a mental model for organizing verbal communication
**It does NOT replace written documentation!!

15

Computerized provider order entry (CPOE)

allows providers to enter all orders directly into the computer, electronically communicating orders to the laboratory, pharmacy, and nursing unit

16

purpose of auditing charting

To determine if staff members are providing and documenting standards of care

Agencies usually perform audits to look at systems, not individuals, and to determine whether staff members are meeting the standard of care

17

what are the 4 phases of an interview

preinteraction (always review the record chronologically)
beginning (introduce yourself)
working (assessing, asking questions, head to toe, etc)
closing (summarize!)

18

aphasia

name given to a collection of language disorders caused by damage to the brain

19

what does it mean to be culturally sensitive

Possessing basic knowledge of and constructive attitudes toward diverse cultural populations

20

what does it mean to be culturally appropriate

Applying underlying background knowledge necessary to provide the best possible health care

21

what does it mean to be culturally competent

Understanding and attending to the total context of the individual’s situation, including immigration status, stress factors, other social factors, and cultural similarities

22

Race

genetic in origin and includes physical characteristics:
 Skin color, bone structure, eye color, and hair color

23

What are the CLAS standards

There are 14 standards, made to ensure equitable and effective treatment

Organized around 3 themes:
1) Culturally Competent Care (Standards 1–3),
2) Language Access Services (Standards 4 –7), and
3) Organizational Supports for Cultural Competence (Standards 8–14).

24

Purnell model of cultural care

Addresses subjective (attitudes, beliefs, values, behaviors) culture and does not address objective (material) culture. This is NYU’s model for culturally competent care

25

The nurse assessing an older adult focuses the health history on

sensory deficits, illness history, and lifestyle factors

26

CAM therapies used ______of conventional treatments to restore health are often termed _______, whereas CAM therapies used _____conventional medicine are often labeled _______.

INSTEAD, alternative

WITH, complementary

27

Culture can be defined as

a shared, learned, and symbolic system of values, beliefs, and attitudes that shapes and influences the way people see and behave in the world

28

The purpose of comparing culture care needs of the specific individual to the general themes of people from similar cultural background is to:

provide a picture of the individual’s culture-based health care needs

29

With transcultural assessment, the nurse must

determine which questions to ask (the list is too extensive to ask everything!)