Exam 1 Flashcards
Documentation that tracks variances from the clinical pathway
Case management system charting
Documentation of the nursing process, treatment, and associated care
Charting
Documentation that focuses on deviations from predefined norms, using preset protocols and standards of care
Charting by exception
Documentation in which data are input via the computer
Computer-assisted charting
The entering of provider orders into the medical record via computer
Computerized provider order entry (CPOE)
Health record entered into a computers software program that is updated via the computer
Electronic health record (EHR)
Documentation that centers on the patient from a positive perspective; this form of documentation has three components: data, action, and response
Focus charting
Paper or electronic 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
Method of documentation in which “P” means problem identification, “I” means interventions, and “E” means evaluation
PIE charting
Documentation 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 to meet the patients needs
Problem-oriented medical record (POMR) charting
Standard procedures
Protocols
Documentation that is organized by the “source” or author of the documentation
Source-oriented (narrative) charting
The written document that contains the patients information
Medical record
Organizations outside of the health facility that are usually allowed access to patient information
Insurance companies
The results of the patients skull x-ray findings may be found with which forms
Radiology report
Focus charting utilizes what
DAR: date, action, response
Written documentation is also known as
Charting
The form used to obtain authorization for a surgical procedure
Consent form
The military time for 3:00 PM is
1500
When using a computerized documentation system, the date and … are automatically entered with each notation
Time
Nonverbal communication is usually referred to as…
Body language
A nurse who is actively listening implements which of the following behaviors
Nods slightly at regular intervals
A question that allows for a yes or no answer is known as what kind of question
Closed-ended
If a patient focuses too long on a single topic, it is appropriate to implement which of the following
Redirct
When a patient is ambivalent, the best therapeutic communication technique is to
Examine alternatives
The practice of eye contact, personal space, and certain gestures is based on an individuals
Culture
When verbal and nonverbal messages do not agree, they are
Incongruent
Perceiving a situation through the patients eyes is know as what
Empathy
When a patients medication dose needs to be clarified, it is best to telephone the…
Physician
If a patient does not speak English, efforts should be made to enlist the services of an
Interpreter
Discharge orders are written by the…
Primary care provider
Prior authorization is not needed for admissions for…
Emergency care
What is a typical responsibility of the admitting department
Collecting personal and insurance information
The governments health insurance program for older adults is
Medicare
Health maintenance organizations (HMOs) provide
Prepaid health insurance for health plan members
Patients who are discharged against medical advice
Must be informed of risks to their health and safety
What does the county medical officer (coroner) do
Investigates unexplained deaths to find the cause
The nursing assessment on hospital admission and transfer should include
A list of medications (prescribed and over-the-counter) taken by the patient
Listening with great concentration and focused energy
Active listening
Standing up for your patients rights; acting in the patients behalf; being a representative of your patient
Advocate
Difficulty expressing or understanding language
Aphasia
Examination of the body organs and tissues to determine the cause of death
Autopsy
Focusing on the moment
Being present
Nonverbal communication
Body language
The exchange of information and ideas by speech, writing, gesture, expression, body posture, intonation, and general appearance
Communication
The principle of keeping private all information about a patient
Confidentiality
In agreement
Congruent
The amount an insurance carrier requires the patient to pay for care
Copayment
Person with legal authority to determine cause of death
Coroner
The amount an insurance carrier requires the patient to pay for care before beginning to pay expenses
Deductible
Authorize another person to do something; entrust to another
Delegate
Registered nurse or social worker who implements and organizes the plan for patient discharge
Discharge planner
Order written by a physician or other authorized provider when the patient has indicated a desire to be allowed to die if breathing ceases or the heart stops
Do not resuscitate (DNR) order
Admission for which there is no prior planning
Emergency admission
The ability to understand by seeing the situation from another’s perspective
Empathy
Return of information and how it was interpreted
Feedback
Type of group practice that enrolls patients for a set fee per month and provides a limited network of doctors, hospitals, and other health care providers from which to choose
Health maintenance organization (HMO)
Verbal and nonverbal messages that do not agree
Incongruent
Information put in
Input
Technique for communication between members of the health care team
ISBAR-R
What is the acronym ISBAR-R
Introduction, Situation, Background, Assessment, Recommendation, Readback
Health care plan in which all medical care is managed by the insuring group
Managed care plan
State medical care coverage for individuals and families with reduced or poverty -level income
Medicaid
Individual who provides counseling and information on long-term planning, financial assistance, or available community services
Medical social worker (MSW)
Health care provided through the Social Security Administration primarily for the retired older adult
Medicare
Being highly aware and alert to another’s feelings; considerate
Mindful
Refraining from judgement; an attitude of openness
Nonjudgmental
Without words
Nonverbal
Recognizing the patient as the source of control and full partner in providing compassionate and coordinated care based on respect for the patients values, needs, and preferences
Patient-centered care
Being aware of something through the senses of seeing, hearing, feeling, tasting, and smelling
Perception
Relationship of mutual trust or affinity
Rapport
Admission that is scheduled in advance
Routine admission
Report on the details of a patients condition and treatment
Shift report
Having medical or healing properties
Therapeutic
Communication that promotes understanding between the sender and the receiver
Therapeutic communication
In words; expressed orally
Verbal
When the nurses perform shift report by off going and oncoming nurses walking together, room to room
Walking rounds
Organic compound; protein is composed of 20 of these
Amino acid
Disorder in which the focus is on remaining thin, causing restriction of food intake to the point of danger
Anorexia nervosa
The accumulation of fatty deposits on the walls of blood vessels
Atherosclerosis
Episodes of continuous eating, often followed by purging
Binge eating
Ratio that uses height and weight to estimate fat values at which the risk for disease increases
Body mass index (BMI)
Eating disorder characterized by episodic binge eating, followed by behaviors designed to prevent weight gain, including purging, fasting, laxative use, and excessive exercise
Bulimia nervosa
Chemical substance containing only carbon, oxygen, and hydrogen; category of food
Carbohydrate
Antioxidants that protect cells and tissues from damage by free radicals; shown to increase immunity, improve vision, and have a role in cancer prevention
Carotenoids
Metabolic process of breaking down complex substances into simple compounds
Catabolism
Component of fat found only in animal products
Cholesterol
The first breast fluid
Colostrum
Protein from plant sources
Complementary protein
One that contains all 9 essential amino acids
Complete protein
Disturbance of the metabolism of carbohydrates and the use of glucose by the body
Diabetes mellitus
The process of converting food into chemical substances that can be absorbed into the blood and used by the body tissue
Digestion
Difficulty swallowing
Dysphagia
Within the small intestine
Enteral
Amino acid that must be consumed through food sources
Essential amino acid
Essential nutrient made up of fatty acids and glycerol that supplies a concentrated form of energy
Fat
Pump used in continuous feedings that pumps the liquid formula, drop by drop, into the feeding tube
Feeding pump
That portion of carbohydrate that cannot be broken down by intestinal enzymes and juices
Fiber
Fruit sugar
Fructose
Feeding tube placed directly into the stomach through the abdominal wall
Gastrostomy tube
The metabolized form of sugar in the body
Glucose
Ranking of foods based on the response of postprandial blood glucose as compared with a reference food, usually white bread or glucose
Glycemic index
Glucose in the urine
Glycosuria
Pump failure of the right or left ventricle associated with abnormal retention of fluid
Heart failure
Tendency of biologic systems to maintain stability in their internal environment while continually adjusting to changes necessary for survival
Homeostasis
Increased concentration of solutes with the fluid
Hyperosmolality
Blood pressure elevated above the normal range
Hypertension
One that does not contain all essential amino acids
Incomplete protein
Feeding tube placed directly into the intestines through the abdominal wall
Jejunostomy or duodenal tube
Properly prepared in accordance with Jewish dietary laws
Kosher
Condition occurring in infants and young children soon after weaning from breast milk, due to severe protein deficiency
Kwashiorkor
Diet consisting of dairy products, eggs, and plant foods
Lacto-ovo-vegetarian
Sugar derived from milk
Lactose
Diet consisting of dairy products and plant foods
Lactovegetarian
Poor nourishment resulting from improper diet or from some deficit in nutrition that prevents the body from using its food properly
Malnutrition
Form of protein-calorie malnutrition occurring chiefly in the first year of life, characterized by growth retardation and wasting of subcutaneous fat and muscle
Marasmus
Cellular chemical reactions in the body
Metabolism
Inorganic substance contained in animals and plants
Mineral
Loss of blood supply to the heart muscle, causing tissue damage; also know as a heart attack
Myocardial infarction (MI)
The US Department of Agriculture (USDA) schematic and description of recommended foods and exercise for a healthy diet and lifestyle
MyPlate
Type of tube that is placed through the nose into the stomach
Nasogastric (NG) tube
Amino acid that can be manufactured by the liver
Nonessential amino acid
NPO
No food or fluids by mouth
Biochemical substance used by the body that must be supplied in adequate amounts from foods consumed
Nutrient
The sum of processes involved in taking in nutrients and absorbing and using them
Nutrition
Excessive accumulation of body fat
Obesity
Fatty acid with a double bond at the third carbon; appear to have protective functions against formation of blood clots and coronary heart disease
Omega-3 fatty acid
Introduction of a substance into the body by some means other than the gastrointestinal tract
Parenteral
Feeding tube placed directly into the stomach
Percutaneous endoscopic gastrostomy (PEG)
Nutrition delivery using a peripheral vein
Peripheral parenteral nutrition (PPN)
After surgery
Postoperative
Before surgery
Preoperative
One of a class of complex nitrogenous compounds that occur naturally in plants and animals and yield amino acids when hydrolyzed
Protein
Remains after digestion or evaporation
Residue
Fatty acids that come from animal food sources, coconut oil, and palm oil
Saturated fats
Table sugar
Sucrose
The technique of providing needed nutrients intravenously
Total parenteral nutrition (TPN)
Vegetarian diet in which all animal food sources are excluded
Vegan
Fatty acids that come from vegetables, nuts, or seeds
Unsaturated fats
One whose diet is lacto-ovo-vegetarian, lactovegetarian, or vegan
Vegetarian
Essential nutrient that must be taken in through food sources or supplements
Vitamin
A postoperative patient may be advanced from a clear liquid diet to a full liquid diet
When clear liquid is tolerated
A common medical condition that may exist with the diagnosis of bulimia is
Peptic ulcer
When liver function is severely impaired, foods containing what will likely be restricted
Fats
What is regarded as “good” cholesterol
HDL
The condition that may require the use of insulin is
Diabetes mellitus
A nutritional therapy for what condition includes a reduction of protein
Kidney failure
What is the range for gastric juices
2-4
A feeding tube may be appropriately placed in the
Jejunum
How often should tube placement be checked
Before infusing anything through the tube
What food group makes up half of the USDA MyPlate
Fruits and vegetables
A starvation condition common in children after weaning is known as
Kwashiorkor
A body mas index above 30 is categorized as
Underweight
An excess of which mineral causes hyperkalemia, with cardiac disturbances
Potassium
The body’s use of protein and muscle breakdown to combat starvation is known as
Marasmus
The food source that provides the most saturated fatty acids is
Animal food sources
Vitamins absorbed in the small bowel are know as
Fat-soluble
A serum lab value that indicates the patients protein level is the
Serum albumin
Periodontal disease may be an indication of lack of vitamin
D
