110 INTRO TO PROFESSIONALISM Flashcards
HIPAA
health insurance portability and accountability act
-protects sensitive patient health info from being disclosed
OSHA
occupational safety + health administration
-helps protect the safety of workers in the workplace
Nurse Practice Act
highlights the legal responsibilities, knowledge base, and skills of the RN specific to each state
California Board of Registered Nursing
[BRN]
regulates the nurse practice act in California
what CANNOT be delegated by an RN?
TAPE
T- teaching
A- assessment
P- planning
E- evaluating
UAP/CNA
unlicensed assistant personnel
LPN/LVN
licensed practical nurse
who can delegate?
RN
LPN/LVN (in some states)
never UAP/CNA
what can be delegated to UAP/CNA
- ADL’s
- ambulate
- turning
- bath/toilet
- mouth care
- linen
- VS (stable)
- I+O (except IV)
- weight/measurement
what can be delegated to LVN/LPN
- 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)
UAP/CNA CANNOT…
delegate, provide medication, VT in unstable patients, IV
cannot take care of UNSTABLE patients
ex) post-op
LPN/LVN CANNOT…
have new admissions, fresh post ops, education, comprehensive assessment,
IV medication, interpret data, blood transfusions
SMART
specific measurable attainable relevant time-bound
Change of Shift/Hand-Off Reports:
- 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
Nursing Diagnosis are composed of…
1 problem
2 etiology
3 definiting characteristics
“Problem” in nursing diagnosis
identifies what’s the problem
ex) insufficient air supply
“Etiology” in nursing diagnosis
identifies factors maintaining the unhealthy
ex) smoking (maintains breathing problems)
“Definining Characteristics” in nursing diagnosis
subjective + objective data
ex) increase bp, incr resp rate
Discharge Planning
-Planning for discharge begins on admission when information about the patient is collected and documented
Against Medical Advice
- 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
ISBARQ method of hand-off
I- introduction S- situation B - background A - assessment R -recommendation Q - Q+A
Primary Care
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
Secondary Care
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
Tertiary Care
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
Levels of Healthcare
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
acronym for 5 rights of delegation
C PTSD
CPTSD
circumstance, person, task, supervision, direction(communication)
tort
intentional/nonintentional wrongdoing
- NOT a crime
- damages settled w money
types of unintentional tort
negligence or malpractice, breach of duty, etc
risk nursing diagnosis
describes human responses to health condition that may develop
-concerns w vulnerability
health promotion nursing diagnosis
clinical judgment of motivation, desire, readiness to enhance well-being + actualize human health potential
problem-focused nursing diagnosis
concerns w undersirable human response to health conditions that exist in individual, family, group
medical diagnosis
id disease/problem
types of records/documentation
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
SOAP format
subjective data
objective data
assessment
plan
-used to organize entries in POMR progress nothes
PIE Charting
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
focus charting
brings focus back to patient + patient’s concerns instead of problem
contains DAR: data action response
-more holistic
3 steps for credentials
1 accreditation (education is eval. + recognd) 2 licensure (state determines minimum requirmt) 3 certification (person has met criteria)
types of INTENTIONAL torts
- assault/battery
- defamation
- invasion of privacy
- false imprisonment
- fraud
just culture
encourage open reporting of errors
human error
occurs unintentionally, w/o mal intent
at-risk behavior error
acts designed to cut corners or save time
-seemingly justified
reckless behavior error
acts that disregard all safety measures
assault
threat or attempt to make bodily contact w another person WITHOUT THEIR CONSENT
ex)heart surgery w/o signed consent papers
magnet status
decentralized decision-making process
-self-governing
problem oriented medical records
organized by problem or diagnosis
-consist of database, problem list, care plan, + progress notes
ex) SOAP, PIE, DAR
