Concepts Exam 2 Flashcards
Documentation that tracks variances from the clinical pathway
case management system charting
Documentation of the nursing process, treatment, and associated care.
charting
Charting that focuses on deviations from predefined norms, using preset protocols and standards of care.
charting by exception
The entering of provider orders into the medical record via computer, eliminating translation error due to poor handwriting or due to human translation error.
computerized provider order entry (CPOE)
A health record entered into a computer’s software program that is updated via the computer.
electronic health record (EHR)
Charging that centers on the patient from a positive perspective and having three components data, action, and response.
focus charting
A record that contains all orders, tests, treatments, and care that occurred during the time a person was under the care of a health care provider.
medical record (chart)
A method of charting in which “P” means problem identification, “I” means interventions, and E” means evaluation
PIE charting
Charting that focuses on patient status, emphasizes the problem solving approach to patient care, and provides a method for communicating what, when, and how things are to be done in order to meet the patient’s needs.
problem oriented medical record (POMR) charting
Standard procedures.
protocols
Charting that is organized by the “source” or author of the documentation.
source oriented (narrative) charting
Listening with great concentration and focused energy
active listening
Standing up for your patient’s rights; acting in the patients behalf; being a representative of your patient.
advocate
Difficulty expressing or understanding language
aphasia
Nonverbal communication
body language
the exchange of information and ideas by speech, writing, gesture, expression, body posture, intonation, and general appearance
communication
kept private
confidentiality
in agreement
congruent
authorize another person to do something; entrust to another
delegate
the ability to understand by seeing the situation from another’s perspective
empathy
return of information and how it was interpreted
feedback
berbal and nonverbal messages that do not agree
incongruent
information put in
input
promotes understanding between the sender and the receiver.
therapeutic communication
encourages pt to continue or elaborate
general leads
encourages pt to elaborate rather than answer in one or two words
open ended questions or statements
shows caring, concern and readiness to hlep
offering self
restates in different words what the pt said; encourages further communication on that topic
restatement
reflects received message back to pt. also encourages further verbalization of feelings. reflects feelings. can also be used if pt is unable to verbalize or if nonverbal information is incongruent with verbal
reflection
seeks clarification about the source of the upset feeling. helps the pt clarify thoughts or ideas
seeking clarification
asking a goal directed question helps the pt focus on key concerns
focusing
helps the pt describe more fully the concern or problem under discussion
encouraging elaboration
provides the pt with information relevant to specific health care or situation
giving information
helps pts see options and consider alternatives to make their own decisions about health care
looking at alternatives
allows pt time to gather thoughts and sort them out
silence
sums up the important points of an interaction
summarizing
deprives the pt of the chance to verbalize concerns
changing the subject
negates the pts feelings and may give false hope, which, when things turn out differently can destroy trust in the nurse
giving false reassurance
nurse is judging the pts action. implies that the pt must take on the nurses values and is demeaning to the pt
judgmental response
nurse responds by defending the doctor. prevents pts from feeling free to express their feelings
defensive response
pries into the pts motives and therefore invades privacy
asking probing questions
negates the pts individual situation; stereotypes the pt this type of response sounds flippant and prevents the building of trust between pt and nurse
using cliches
tends to be controlling and diminishes pts responsibility for taking charge of their own health
giving advice
indicates that the pt is not important, that the nurse is bored, or that what is being said does not matter
inattentive listening
a social relationship differs from a therapeutic one in that…
the focus is on both participants and the usual goal is to meet ones own needs. Social relationship is established for mutual enjoyment with considerable sharing of experiences life events and thought.
characteristics in the nurse that facilitate a therapeutic nurse patient relationship include? 8
effective communications skills, empathy, a desire to help, honesty, a nonjudgmental attitude, genuineness, acceptance and respect.
what are the two keys to effective nurse pt communication
trust and understanding
ISBAR-R
introduction situation background assessment recommendation readback
can students legally take telephone orders?
No. they can take the order but they must have another nurse or instructor standing by to speak with the physician and take the order again including read back.
who is ultimately responsible for the outcomes of delegated tasks?
the person who delegates the certain task is ultimately responsible for the outcomes of that delegation
one characteristic differentiating source oriented (narrative) charting from POMR charting is?
the separation of notes on medical care and nursing care
when a pts medical record is needed as evidence for a legal action, you are aware that the record is the property of>
the health care agency
the advantage of POMR charting when using an interdisciplinary care system is that
it keeps all relevant data in one place
the assumption in charting by exception is that
unless otherwise documented, all standards have been met
an advantage of computer charting is that
is it cost effective because it saves nursing time compared with writing out notes
when charting the pts condition and nursing care, the nurse records?
the interventions performed and the pts responses
pt statements and behaviors that are observed
clinical data measurements
what are the 3 ways people learn?
visual learning, auditory learning, and kinesthetic learning
what are the 3 domains of learning?
1) cognitive domain - the learner takes in and processes information by listening to or reading the material.
2) affective domain - the material is presented in a way that appeals to the learner’s beliefs, feelings, and values. (pple must value cleanliness before they will wash hands)
3) psychomotor domain - the learner processes the information by performing an action or carrying out a task.
what are some situational factors that interfere with learning
pain, nausea, fatigue, a sense of being overwhelmed by all that is happening and multiple interruptions
what is the most commonly used nursing diagnoses?
deficient knowledge
behavioral objectives
represent the desired changes or additions to current behaviors and attitudes. They state what you are trying to teach the pt to do.
what is one way to evaluate that the pt is learning what is being taught
a return demonstration of the skill
the first step in teaching is?
to assess what the patient needs to know )learning needs, knowledge deficits)
what are some factors that affect learning?
physical limitations, situational factors (including pain) readiness to learn, personal values and expectations, age, attitude, and ability to comprehend.
what is essential in effective learning?
establishing rapport and mutual trust
how can you keep the pt involved in the educational plan?
including the pt in the development of the plan
evidence that the primary purpose of pt teaching has been achieved is that pts …
provide correct and safe self care after discharge
a pt newly diagnosed with diabetes has stated that he doesn’t understand why he needs insulin. his statement indicates a learning need regarding?
the disease process of diabetes
when starting the 2nd teaching session for a pt, the nurse should first
briefly review what was taught in the 1st session
when 1st teaching a young child about insulin injections, it is appropriate to
use a doll to demonstrate an insulin injection
when teaching the leery about a needed diet change, to reinforce the information
write down the diet instructions
an appropriate pt teaching plan
includes input from all disciplines involved in the care, as well as from the pt
to overcome barriers to learning for a hearing impaired person…
be certain the hearing aid is turned on and adjusted, eliminate other noise in the room as much as possible, gain the pts attention and speak in a normal low tone while facing him.
the most important objective for a pt who needs to learn about a dressing change is, the pt will…
use aseptic technique for the dressing change
who sets the standards for documentation
the joint commission
