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Fundamentals > exam #1 > Flashcards

exam #1 Flashcards

1
Q

nursing process

what does ADPIE stand for ?

A
  • assesment
  • diagnosis/ data collection
  • planning
  • implementation
  • evaluation
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2
Q

nursing process

what is assesment used for in ADPIE?

subjective and objective

A

it is the patient interview, comprised of health history (subjective) and diagnostic test results (objective)

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3
Q

nursing process

what is diagnosis used for in ADPIE?

A

idetifies problem/ potential problem

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4
Q

diagnosis

what is the PES format?

A

-problem
- etiology
- syptoms

problem___ related to ____ etiology_____ as evidpenced by___ syptoms

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5
Q

what is the format of a two part nursing diagnosis?

RK, RS

A
  • risk for ____ related to
  • readiness for _____ as evidenced by
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6
Q

what is the diffrence between a risk for statement and a readiness for statement?

A
  • risk for: is it used for potential problems, therfore will not have syptoms
  • focuses more on primairy prevention
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7
Q

nursing process

what is planning used for in ADPIE?

A

establish goals in collab w/ pt

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8
Q

nursing process

what is implementation used for in ADPIE?

A

putting plan into action

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9
Q

nursing process

what is evaluation used for in ADPIE?

A

determining if plan is progressing and changing plan if not

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10
Q

medical records

what is the diffrence between a electronic medical record and a health record?

A
  • MR: miniute clinic or 1 hospital visit
  • HR: entirity of a health record
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11
Q

documentation

what is narrative charting?

A

paragraph charting

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12
Q

documentation

what are the diffrent forms of formatted charting?

PN, AN, SN, DN

A
  • pie notes
  • adpie
  • soap
  • dar
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13
Q

documentation

What does PIE stand for?

A
  • problem
  • intervention
  • evaluation
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14
Q

documentation

what does SOAP stand for?

A
  • subject
  • objective
  • assesment
  • plan
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15
Q

documentation

why is charting important?

A
  • No charting = it didn’t happen
  • no charting = no pay
  • can be used in a court of law as a legal document
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16
Q

documentation

if a nurse takes a verbal order what is required for documentation?

A
  • date
  • time
  • physicians name
  • RN signature
17
Q

law

What is criminal law?

Renewal of license/ practicing w/o license

A

Intentional misconduct or a serious violation of professional standards of care

18
Q

law

What are civil laws?

malpractice, slander, negligence, defamation

A

Court decisions which are created through precedents, rather than written statues

19
Q

law

What is a tort?

A

Private civil action that causes personal injury to a private party

20
Q

law

what is the diffrence between intentionl/ unintentional torts?

I: anger UI: wheelchair, giving celebrex to pt allergic to sulfa

A

intentional- assault, battery, defamation
unintentional- negligance and malpractice

21
Q

saftey

what are the four D’s pg negligence/ malpratice?

A
  • duty
  • dereliction
  • damages
  • direct cause
22
Q

when are potential problems a priority over real problems?

A

never

23
Q

infection control

what are the 6 aseptic interventation/ infection control?

HH, P/I, PPE, I, M/SA, D/S

A
  • hand hygiene
  • precautions and isolation
  • personal protective equipment
  • immunizations
  • medical and surgipcal asepsis
  • disinfection and sterlization
24
Q

assesment

what is a comprehensive assesment?

A
  • a complete assesment that reviews health history and review all body systems ( head to toe)
25
Q

assesment

when are comprehensive assesments preformed?

HA, APE

A
  • hospital adminssion
  • annual physical exam
26
Q

assesment

what is an emergency assesment?

ABC

A
  • focuses on the ABC’s
  • airway, breathing, circulation
27
Q

assesment

when is an emergency assesment completed?

PME, TMBI

A
  • priorites must be established quickly
  • treatment must begin immediatly
28
Q

assesment

what is a focused assesment?

A

a brief individualized physical exam

29
Q

assesment

when a focused assesment completed?

BOS, CIPC, DONC

A
  • beginning of shift
  • change in patient condition
  • development of new condition
30
Q

safety

what devices are used to promote saftey w/o the use of restraints?

R, B/CA, EV, MES, S, M, C/DT

A
  • relocate pt closer to nursing station
  • bed/ chair alarms
  • encourage vistitors
  • minimize envoirmental stimuli
  • sitter
  • mitts
  • cover/ disguise tubes
31
Q

what are the two reasons when physical restraints can be applied?

A
  • harm to self or others
32
Q

saftey

what are the two factors that affect safety?

IF, EF

A
  • individual factors
  • envoirmental factors
33
Q

what are some examples of individual factors that affect safety?

BSI, LSF

A
  • body system intergrity
  • life span factors
34
Q

safety

what are some examples of envoirmental factors that affect safety?

P, L, CD, WPH

A
  • pollution
  • lighting
  • communicable diseases
  • workplace hazards
35
Q

saftey

What causes a risk for safety in the hospital?

F, UOR, ME, RE, DRM, PE

A
  • falls
  • use of restraints
  • medication error
  • radiation exposure
  • drug resistant microorganisms
  • procedural errors
36
Q

safety

what is the hendrich II fall risk model?

A
  • falls assesment tool
37
Q

sterile

what are the characteristics of a sterile field?

A
  • above the waist
  • below elbows
  • chest
  • sterile touching sterile
  • tables are sterile at waist level
38
Q

sterile

What are characteritsics of a contaminated field?

A
  • broken seals/ packaging
  • wet or damp surface
  • sterile touching clean
  • outside 1 in
  • if it flaps back
  • below the wasit
  • above elbows
  • back
  • reaching over field

Fundamentals (4 decks)

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