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Fundamental Lab > 110 INTRO TO PROFESSIONALISM > Flashcards

110 INTRO TO PROFESSIONALISM Flashcards

1
Q

HIPAA

A

health insurance portability and accountability act

-protects sensitive patient health info from being disclosed

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2
Q

OSHA

A

occupational safety + health administration

-helps protect the safety of workers in the workplace

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3
Q

Nurse Practice Act

A

highlights the legal responsibilities, knowledge base, and skills of the RN specific to each state

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4
Q

California Board of Registered Nursing

[BRN]

A

regulates the nurse practice act in California

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5
Q

what CANNOT be delegated by an RN?

A

TAPE

T- teaching
A- assessment
P- planning
E- evaluating

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6
Q

UAP/CNA

A

unlicensed assistant personnel

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7
Q

LPN/LVN

A

licensed practical nurse

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8
Q

who can delegate?

A

RN
LPN/LVN (in some states)
never UAP/CNA

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9
Q

what can be delegated to UAP/CNA

A
  • ADL’s
  • ambulate
  • turning
  • bath/toilet
  • mouth care
  • linen
  • VS (stable)
  • I+O (except IV)
  • weight/measurement
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10
Q

what can be delegated to LVN/LPN

A
  • duties depend on state/facility
  • maybe delegate
  • stable patients w chronic + predictable outcomes
  • gather data to contribute to assessment (listen to lung/bowel/hrt sounds)
  • routine procedures (obtain EKG, glucose checks, insert catheters)
  • give medication (except IV)
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11
Q

UAP/CNA CANNOT…

A

delegate, provide medication, VT in unstable patients, IV

cannot take care of UNSTABLE patients
ex) post-op

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12
Q

LPN/LVN CANNOT…

A

have new admissions, fresh post ops, education, comprehensive assessment,
IV medication, interpret data, blood transfusions

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13
Q

SMART

A 
specific
measurable
attainable
relevant
time-bound
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14
Q

Change of Shift/Hand-Off Reports:

A
  • Basic identifying information about each patient: name, room number, bed designation, diagnosis, and attending and consulting physicians
  • Current appraisal of each patient’s health status
  • Current orders (especially any newly changed orders)
  • Abnormal occurrences during your shift
  • Any unfilled orders that need to be continued onto the next shift
  • Patient/family questions, concerns, needs
  • Reports on transfers/discharges
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15
Q

Nursing Diagnosis are composed of…

A

1 problem
2 etiology
3 definiting characteristics

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16
Q

“Problem” in nursing diagnosis

A

identifies what’s the problem

ex) insufficient air supply

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17
Q

“Etiology” in nursing diagnosis

A

identifies factors maintaining the unhealthy

ex) smoking (maintains breathing problems)

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18
Q

“Definining Characteristics” in nursing diagnosis

A

subjective + objective data

ex) increase bp, incr resp rate

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19
Q

Discharge Planning

A

-Planning for discharge begins on admission when information about the patient is collected and documented

20
Q

Against Medical Advice

A
  • patient is legally free to leave
  • patient is informed of risk prior to signing form, patient signature must be witnessed, release form is part of medical record
21
Q

ISBARQ method of hand-off

A 
I- introduction
S- situation
B - background
A - assessment
R -recommendation
Q - Q+A
22
Q

Primary Care

A

preventative screenings, no diagnosis yet

  • directed towards promoting health + preventing the development of disease processes or injury
    ex) immunization, family planning services, poison-control, accident prevention
23
Q

Secondary Care

A

checkups; focused on screening for early detection of disease w prompt diagnosis + treatment of any found
ex) assessing kids for normal growth + development, regular medical, dental, vision examination

24
Q

Tertiary Care

A

Tertiary care: already have a complex disease and now receiving treatments
-begins after an illness is diagnosed + treated, w goal of reducing disability + rehabilitation to a maximum level of functioning
ex) teaching patients w diabetes how to recognize + prevent complications.
using physical therapy to prevent contractures in patients w stroke or spinal cord injury.
Referring woman to support group after removal of a breast bc of cancer

25
Q

Levels of Healthcare

A

Primary Health Care- treatment of common health problems
Secondary Health Care- treatment of problems requiring more specialized clinical expertise
Tertiary Health Care- Mgmt of rare + complex disorders

26
Q

acronym for 5 rights of delegation

A

C PTSD

27
Q

CPTSD

A

circumstance, person, task, supervision, direction(communication)

28
Q

tort

A

intentional/nonintentional wrongdoing

  • NOT a crime
  • damages settled w money
29
Q

types of unintentional tort

A

negligence or malpractice, breach of duty, etc

30
Q

risk nursing diagnosis

A

describes human responses to health condition that may develop
-concerns w vulnerability

31
Q

health promotion nursing diagnosis

A

clinical judgment of motivation, desire, readiness to enhance well-being + actualize human health potential

32
Q

problem-focused nursing diagnosis

A

concerns w undersirable human response to health conditions that exist in individual, family, group

33
Q

medical diagnosis

A

id disease/problem

34
Q

types of records/documentation

A 
1 electronic health records [EHR]
2 personal health records [PHR] 
----type of EHR
3 health info exchange [HIE]
----EHR shared between diff providers
4 source oriented records (paper format)
5 problem oriented medical record [POMR]
6 PIE charting
7 Focus charting
35
Q

SOAP format

A

subjective data
objective data
assessment
plan

-used to organize entries in POMR progress nothes

36
Q

PIE Charting

A

problem, intervention, evaluating

  • focuses on current patient situation, saves time, old problems are moved away and new problems are prioritized
  • continuing problems are documented and numbered each day
37
Q

focus charting

A

brings focus back to patient + patient’s concerns instead of problem

contains DAR: data action response
-more holistic

38
Q

3 steps for credentials

A 
1 accreditation (education is eval. + recognd)
2 licensure (state determines minimum requirmt)
3 certification (person has met criteria)
39
Q

types of INTENTIONAL torts

A
  • assault/battery
  • defamation
  • invasion of privacy
  • false imprisonment
  • fraud
40
Q

just culture

A

encourage open reporting of errors

41
Q

human error

A

occurs unintentionally, w/o mal intent

42
Q

at-risk behavior error

A

acts designed to cut corners or save time

-seemingly justified

43
Q

reckless behavior error

A

acts that disregard all safety measures

44
Q

assault

A

threat or attempt to make bodily contact w another person WITHOUT THEIR CONSENT
ex)heart surgery w/o signed consent papers

45
Q

magnet status

A

decentralized decision-making process

-self-governing

46
Q

problem oriented medical records

A

organized by problem or diagnosis
-consist of database, problem list, care plan, + progress notes

ex) SOAP, PIE, DAR

Fundamental Lab (6 decks)

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