exam #1 Flashcards
nursing process
what does ADPIE stand for ?
- assesment
- diagnosis/ data collection
- planning
- implementation
- evaluation
nursing process
what is assesment used for in ADPIE?
subjective and objective
it is the patient interview, comprised of health history (subjective) and diagnostic test results (objective)
nursing process
what is diagnosis used for in ADPIE?
idetifies problem/ potential problem
diagnosis
what is the PES format?
-problem
- etiology
- syptoms
problem___ related to ____ etiology_____ as evidpenced by___ syptoms
what is the format of a two part nursing diagnosis?
RK, RS
- risk for ____ related to
- readiness for _____ as evidenced by
what is the diffrence between a risk for statement and a readiness for statement?
- risk for: is it used for potential problems, therfore will not have syptoms
- focuses more on primairy prevention
nursing process
what is planning used for in ADPIE?
establish goals in collab w/ pt
nursing process
what is implementation used for in ADPIE?
putting plan into action
nursing process
what is evaluation used for in ADPIE?
determining if plan is progressing and changing plan if not
medical records
what is the diffrence between a electronic medical record and a health record?
- MR: miniute clinic or 1 hospital visit
- HR: entirity of a health record
documentation
what is narrative charting?
paragraph charting
documentation
what are the diffrent forms of formatted charting?
PN, AN, SN, DN
- pie notes
- adpie
- soap
- dar
documentation
What does PIE stand for?
- problem
- intervention
- evaluation
documentation
what does SOAP stand for?
- subject
- objective
- assesment
- plan
documentation
why is charting important?
- No charting = it didn’t happen
- no charting = no pay
- can be used in a court of law as a legal document
documentation
if a nurse takes a verbal order what is required for documentation?
- date
- time
- physicians name
- RN signature
law
What is criminal law?
Renewal of license/ practicing w/o license
Intentional misconduct or a serious violation of professional standards of care
law
What are civil laws?
malpractice, slander, negligence, defamation
Court decisions which are created through precedents, rather than written statues
law
What is a tort?
Private civil action that causes personal injury to a private party
law
what is the diffrence between intentionl/ unintentional torts?
I: anger UI: wheelchair, giving celebrex to pt allergic to sulfa
intentional- assault, battery, defamation
unintentional- negligance and malpractice
saftey
what are the four D’s pg negligence/ malpratice?
- duty
- dereliction
- damages
- direct cause
when are potential problems a priority over real problems?
never
infection control
what are the 6 aseptic interventation/ infection control?
HH, P/I, PPE, I, M/SA, D/S
- hand hygiene
- precautions and isolation
- personal protective equipment
- immunizations
- medical and surgipcal asepsis
- disinfection and sterlization
assesment
what is a comprehensive assesment?
- a complete assesment that reviews health history and review all body systems ( head to toe)
assesment
when are comprehensive assesments preformed?
HA, APE
- hospital adminssion
- annual physical exam
assesment
what is an emergency assesment?
ABC
- focuses on the ABC’s
- airway, breathing, circulation
assesment
when is an emergency assesment completed?
PME, TMBI
- priorites must be established quickly
- treatment must begin immediatly
assesment
what is a focused assesment?
a brief individualized physical exam
assesment
when a focused assesment completed?
BOS, CIPC, DONC
- beginning of shift
- change in patient condition
- development of new condition
safety
what devices are used to promote saftey w/o the use of restraints?
R, B/CA, EV, MES, S, M, C/DT
- relocate pt closer to nursing station
- bed/ chair alarms
- encourage vistitors
- minimize envoirmental stimuli
- sitter
- mitts
- cover/ disguise tubes
what are the two reasons when physical restraints can be applied?
- harm to self or others
saftey
what are the two factors that affect safety?
IF, EF
- individual factors
- envoirmental factors
what are some examples of individual factors that affect safety?
BSI, LSF
- body system intergrity
- life span factors
safety
what are some examples of envoirmental factors that affect safety?
P, L, CD, WPH
- pollution
- lighting
- communicable diseases
- workplace hazards
saftey
What causes a risk for safety in the hospital?
F, UOR, ME, RE, DRM, PE
- falls
- use of restraints
- medication error
- radiation exposure
- drug resistant microorganisms
- procedural errors
safety
what is the hendrich II fall risk model?
- falls assesment tool
sterile
what are the characteristics of a sterile field?
- above the waist
- below elbows
- chest
- sterile touching sterile
- tables are sterile at waist level
sterile
What are characteritsics of a contaminated field?
- 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
