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Nur 170 Exam 1 > Ethical and Legal Standards, Patient Centered Care & Evidence Based Practice > Flashcards

Ethical and Legal Standards, Patient Centered Care & Evidence Based Practice Flashcards

1
Q

To do good

A

Beneficence

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2
Q

to do no harm

A

Nonmaleficence

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3
Q

Treated all fairly

A

Justice

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4
Q

Truthful

A

Veracity

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5
Q

A way for citizens to feel safe. Laws regulating professional development

A

Nurse Practice Act

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6
Q

National League of Nursing;

A

NLN

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7
Q

Making sure standards are up to date

A

Joint Commission

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8
Q

Standards of right vs. wrong
Based on a specific group’s standards
Relates to the rights of clients and their families
The development of ethical standards of an individual, community, or a profession

A

Ethics

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9
Q

Distinguishing between right or wrong based on your own personal standards. Focus is more on a social aspect and involves personal awareness of feelings

A

Morality

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10
Q

A set of professional principles and standards designed to help guide professional behavior and relationships through specific nursing beliefs and values

A

Nursing Ethics

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11
Q

Comfort
Teaching & Learning
Communication
Advocacy

A

Concepts Related to Nursing Ethics

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12
Q

Personal ideas about the worthiness of importance of something known through socialization

A

Values

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13
Q

Ideas that one holds to be fact based on experiences and personal knowledge. One’s values often reflect their beliefs.

A

Beliefs

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14
Q 
Altruism
Autonomy
Human dignity 
Integrity
Social Justice
A

5 essential values of nursing

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15
Q

Necessary for the nurse to help them maintain client-centered care
Necessary for clients to help the nurse learn their values and distinguish them from their own
Therefore, assists with effective plan of care
Also, helps the nurse know whether values clarification is necessary
**The nurse is to NEVER impose his/her own personal values on a client and must be careful with offering opinions*

A

Clarifying Values

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16
Q

A set of ethical standards and behaviors that are expected in the nursing profession
Help guide nurses in the profession
The 2 major codes the nursing profession follows are the American Nurses Association (ANA) and the International Council of Nurses (ICN)

A

Nursing Code of Ethics

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17
Q

The nurse has certain obligations to address such as the client’s best interests and following facility’s policies

The first step is to consider whether a moral dilemma exists
Maximize the client’s well being.
Balance the clients need for autonomy with family members’ responsibilities for the clients well being.
Support ea. family member and enhance the family support system.
Carry out hospital policies.
Protect other clients’ well-being.
Protect the nurses’s own standards of care.

Become aware of their own values and the ethical aspects of nursing.
Be familiar with nursing codes of ethics.
Seek cont. education
Respect values, opinions, and responsibilities of other healthcare professionals

A

Ethical Decision Making

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18
Q

problem oriented medical record

A

POMR

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19
Q

subjective data
objective data
assessment
plan of care

A

SOAP

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20
Q 
subjective data
objective data
assessment 
plan of care
interventions
evaluations
revision
A

SOAPIER

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21
Q

problems
interventions
evalutations

A

PIE

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22
Q

intended to make the client and the clients concerns and strengths the focus of care.

A

Focus charting

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23
Q

only abnormal or significant findings or exceptions to norms are recorded.

A

CBE-Charting by exception

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24
Q

Health Insurance Portability Accountability Act of 1996
privacy and security rule which applies to us all.
Logging off of computers
Can send an email as long as it is encrypted and subject box has “confidential” in it.

A

HIPPA

25
Q

Population/Patient Problem-Who is your pt?
Issue/Intervention-What do you plan to do for this pt?
Comparison-Whats the alternative plan?
Outcome-What outcome do you seek?
Time-What is the time frame?

Your PICOT question will fall under one of these types:
Therapy/Prevention
Diagnosis
Etiology
Prognosis
A

PICOT Format

26
Q

using one’s expertise and knowledge to assist in gathering information related to professional practice. The data collected is a result of best current practices. This process is continuous because old evidence needs to be replaced with updated information.

A

Evidence based practice

27
Q

Best evidence is from current research
Based on nurse’s clinical expertise
Should reflect clients’s preferences, values, needs, interests, and choices

A

Components of EBP Framework

28
Q 
Clinical decision making
Advocacy
Quality Improvement
Accountability
Professional behaviors
A

Concepts related to EBP

29
Q

Evidence: increased staph infections to wounds noticed per hospital reports
Research can be conducted within the facility to determine possible causes
Once all evidence is collected and evaluated, changes can be made for improvement

A

Benefits of EBP

30
Q

Implementing the scientific process
All information gathered is OBJECTIVE & FACTUAL
The overall goal is to improve client care
Careful consideration of funding, participants, ethical/legal issues, and implications for practice

A

Clinical Research

31
Q

Precision of measurement is used; statistical data collected

A

Quantitative Research

32
Q 
Meta-analysis
Case study
Cohort study
Case-control study
Randomized control trial
A

Types of Research Studies

33
Q

A group of studies on a given topic are examined, and their results are combined and analyzed as if they were from one large study.

A

Meta-analysis

34
Q

A case study is specific to one individual, issue or event.

A

Case study

35
Q

A longitudinal study follows two groups and measures the outcomes of an exposure group with those of a non-exposure group.

A

Cohort Study

36
Q

This study compares individuals with and without a specific condition to identify predictive variables.

A

Case-Control Study

37
Q

This is the strongest type of study. RCT’s are designed to illustrate a cause and effect relationship by using a control group and an experimental group.

A

Randomized Control Trial (RCT)

38
Q

Provide best evidence for EBP.
Support nursing as a professional discipline.
Define current best practice standards of nursing care.

A

Implications for Nursing Practice. Three main benefits of clinical research.

39
Q
  1. Develop a clinical question (determine the type)
    - Diagnosis
    - Etiology
    - Therapy
    - Prognosis
  2. Retrieve the evidence
  3. Evaluate the evidence
  4. Apply the evidence
A

Steps to Developing EBP

40
Q 
Communication
Planning client care
Auditing health agencies (The Joint Commission)
Research
Education
Reimbursement (from insurance/government)
Legal Record (admissible in court)
Healthcare analysis
A

Purposes of Maintaining Client Records

41
Q

document helps clients understand their treatment choices and risks that maybe involved.
Not nurses Duty. Can be a witness; Physicians duty

A

Informed Consent

42
Q 
Assessments
Change in conditions
Objective descriptions
Statements
Nursing action
Use of safety equipment
Deviations or achievement of outcomes
MD notification
Procedures
Consultations
Involvement of family/others 
Activities
A

What to Document

43
Q

Also referred to as charting, recording or documenting onto a client’s chart or clinical record.
The main purpose is for effective communication among healthcare professionals.

A

Nursing Documentation

44
Q

Referred to as POMR or POR;

Advantage;
Encourages collaboration among healthcare team and care is organized based on problem list

Disadvantage:
Requires frequent updating

Four Components include:

  1. Database
  2. Problem list
  3. Plan of care
  4. Progress notes
    - SOAP
    - SOAPIER
A

Problem-oriented medical record

45
Q

Source-oriented
Problem-oriented
3. Problems, interventions, evaluations (PIE)
4. Focus charting
5. charting by exception (CBE)
6. Electronic (to be discussed in Class 2)

A

Documentation Systems

46
Q

Also known as PIE=
consists of a formatted flow sheet and progress notes

Advantage;
Organized flow sheet of information
Creates an ongoing care plan

Disadvantage:
All notes must be reviewed prior to the nurse giving care (time consuming)

A

Problems interventions evaluations

47
Q

source-oriented

Advantages:
Easy for healthcare team members to locate different sections of the chart
Each disipline’s charting is clearly identified

Disadvantages:
Client information is scattered throughout the chart

A

Source oriented

48
Q 
Do's of charting
Be prompt
Be accurate
Be detailed
Be neat!
Check spelling
Chart chronologically
Date & Time
Use black or blue pen
Be objective
Record you signature
A

Do’s of charting

49
Q 
Dont's of Charting
Forget
Falsify
Use white out
Scribble
Chart for someone else
Stereotype
Wait until the end of the shift
Chart ahead of time!
A

Don’t’s of charting

50
Q

Usually contains 3 components

  1. Date and time
  2. focus (condition, nursing diagnosis, behavior, etc)
  3. progress notes
A

Focus charting

51
Q

Written in Dar format
D=data (what was assessed/found)
A=action (what was done about it)
R=response (how did the client respond to treatment)

Advantage:
Client-centered providing holisitic care
Provides a framework for nursing progress notes

Three components do not have to be in any particular order

A

Focus charting

52
Q

Admissions (nursing history, initial database, nursing assessment)
Care Plans
Kardexes
Flow sheets (includes graphs, intake and output, med administration, and skin assessment)
Progress Notes
Discharge/Referral Summaries

Long-term Care-
requirements for documentation depend on facility policy, federal and state regulations, and professional standards

Home Care-
documentation must meet standards for Medicare and Medicaid and facilities must maintain:

  1. home health certification & plan of care
  2. medical update and client info form
A

Special Considerations for charting

53
Q 
Used only to document deviation from the expected finding
Three components:
1. Flow sheets
2. standards of nursing care
3. Bedside access to chart forms

Advantages:
Charting is simplistic with no repetition
Changes to clients condition stand out

Disadvantage:
Some nurses are not comfortable with this charting system

A

Charting by Exception (CBE)

54
Q

Provide citizens with protection from harm.

Mandatory duties to report; unsafe working conditions, child abuse and medical practioner

A

Nurse Practice Act

55
Q

Protecting is
defends another’s cause
represents clients needs, wishes to others
positive experience for nurses & clients

A

advocacy

56
Q

Navigate complex health care system
Educate clients about their rights, health care options
-provide info
-support client in making informed decisions
-work with client who lack decision-making capacity

A

Advocate’s Role

57
Q

Nurse maintains professional boundaries

  • being client advocate
  • following through or following up
  • providing resources
  • going above and beyond
A

Four Dimensions of Advocacy

58
Q

Protecting an individual by expressing and defending the individuals cause on his or her behalf.

An individual who expresses and defends the cause of another.

Whats best for the patient, children, elderly, mentally handicapped, not able to advocate for themselves, next of kin that can

A

Advocate/Advocacy

Nur 170 Exam 1 (3 decks)

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