Exam 1 N320 Fundamentals Flashcards
4 modes of Roy’s Adaptation theory
- Physiologic
- Self-Concept
- Role Function
- Interdependence
Roy’s Adaptation Theory
Describe Physiologic Mode
-Physical
-5 basic needs: oxygen, elimination, activity & rest, protection
-4 complex processes: the senses; fluid, electrolyte, & acid base balance; endocrine function
-EX: impaired skin integrity, decreased cardiac output
Roy’s Adaptation Theory
Describe Self-Concept Mode
-Beliefs & feelings an individual holds about self
-components: body sensation/body image; personal self including self consistency, self ideal, & moral ethical spiritual self
Roy’s Adaptation Theory
Describe Role Function Mode
-Focuses on the roles that the individual occupies in society
-EX: no income coming in & they’re the sole provider for their family, social isolation
Roy’s Adaptation Theory
Describe Interdependence Mode
-interactions related to the giving & receiving of love, respect, & value
-EX: loss, grief
Describe the nature of clinical judgements in nursing practice
-Clinical judgments made by thinking critically & making sound decisions are the core of professional nursing competence
-it’s the observed outcome of critical thinking & decision making
Explain how questioning promotes critical thinking
-it helps nurses face personal biases & examine information for answers & deeper meaning to understand their patients
-when fire critical thinking competencies are applied, the complex & continuous nature of decision making & clinical judgment becomes clear
Discuss how reflection improves a nurse’s capacity for making future clinical decisions
When a nurse reflects on the service they give, it helps them identify their mistake & how to improve next time
Compare/contrast the 3 levels of critical thinking
- Basic: the early stage of critical thinking- inexperienced nurse follows guides & trusts older nurses as experts
- Complex: rely less on experts & instead trust their own decisions (critical thinking & creativity)
- Commitment: the nurse anticipates when to make choices without assistance from others & accepts accountability for decisions made
Explain the importance of problem solving practice
-it requires you to obtain information that clarifies the nature of a person, suggest possible solutions, & by the solution over time to evaluate if it’s effective
Describe the processes of inductive & deductive reasoning in decision making
-inductive: moves from reviewing specific data elements to making inferences by forming a conclusion about the related pieces of evidence.. previous experience with the evidence is also considered
-deductive: moves from general to specific. Nurse analyzes facts from a conceptual viewpoint. After collecting data based on conceptual view, the nurse forms an interference & eventually interprets the pts condition with respect to the conceptual view
Describe the components of a critical thinking model for clinical decision making
- Competence- ability to perform nursing skills, cognitive processes that guide nurses in applying nursing process in making accurate clinical judgements
- Knowledge base- varies on educational experience, nursing education, continuing education courses, & additional college degrees
- Experience- clinical learning experiences are necessary to acquire decision making skills & to gain competence in performing nursing skills
- Environment- the context of the pt’s condition & environmental factors, task complexity, time pressure, work setting & interruptions
Describe approaches for developing critical thinking skills
Approach critical thinking with confidence, thjnking independently, fairness, responsibility, authority, risk taking, discipline, perseverance, creativity, curiosity, integrity & humility
Explain the two steps involved in nursing assessment
- collection of information from a primary source (a pt) & secondary sources (e.g. family, caregiver, friends, health professional, medical record)
*the interpretation and validation of data to determine whether more data are needed, or the database is complete
Describe the 3 types of nursing assessments
- pt centered interview: conducted during a nursing hx (comprehensive nursing hx)
- Periodic assessment: conducted during ongoing contact with pts
- Physical exam (conducted during a nursing hx & at any time a pt presents a symptom)
Explain principles to follow in the use of data sources during the assessment
*pt: best sources of information
*Family caregivers & significant other
*health care team
*medical records
*other records & the scientific literature
*nurse’s experience
Explain the importance of building a nurse-pt relationship before a formal nursing assessment
-effective communication is foundation for creating nurse-pt relationships that enable pts to tell their stores while nurses understand them.
-helps build trust and nurses will gain more knowledge
describe skills to apply when conducting pt interview during nursing hx
-courtesy: greet pts by name they prefer, introduce yourself, ask pts permission to interview if a visitor is present
-comfort: maintain privacy, select quiet room free of distractions, avoid making pt tired
-connection: make good 1st impression, begin w/ open ended questions, be observant, ask if pt needs anything before leaving, respect silence and be open minded
-conformation: at end of interview, ask pt to summarize discussion so there are no uncertainties. tell pt you will FU if you don’t know the answer
explain communication approaches to use during the working phase of a pt centered interview
-this phase fathers accurate, relevant, & complete info about pt’s condition
-ask pt to describe what they know about their health problems & health care expectations
-don’t rush to an opinion, don’t rush pt
-verbal cues pts express will help you stay focused
-organize your time with pt & focus on priority areas to assess
explain how to maintain professionalism during hx taking
-have caring approach, look at pt- not the computer
-ask pt to explain why them came here & listen
- ask open ended questions & speak at reasonable pace
identify components of nursing health hx
-biographical info such as age, gender, address, insurance, occupation, marital status
-chief concern
-pt expectations
-illness/health concerns
-past health hx and family hx
-psychosocial hx & spiritual health
-review of systems (subjective data)
-observation of pt behavior
describe elements of assessment process
-collect data, recognizing & confirming cues that begin to form picture of pt health care problems/needs
-clinical inference: occurs before you determine pts problems (interpretation of the cues/collection of data which involves clinical judgement)
nursing diagnosis vs. medical diagnosis vs. collaborative problem diagnosis
- nursing diagnosis- clinical judgment made by RN to describe pt’s response or vulnerability to health conditions or life events that RN can treat
- medical diagnosis- identification of disease condition based on specific assessment of physical signs/symptoms , pt’s medical hx, & results of tests/procedures
- collaborative problem- requires BOTH medical & nursing interventions to treat
describe importance of having standardized language of nursing diagnoses
ppl can understand across all disciplines and care settings
describe the diagnostic reasoning process
data cluster is a set of signs/symptoms found during assessment that help you group them. compare a pt’s data with info that’s consistent w/ nominal healthy patterns
describe components of a nursing diagnostic statement
-diagnostic label/diagnosis: name of nursing diagnosis approved by NANDA, ICNP, or any other system used in your institution that offers definitions for each diagnosis
-related factors: a pt’s response to a health problem is related to conditions that caused or influenced the response
-major assessment findings: optional, further clarity can be added
explain the difference between finding data patterns & data interpretation
-patterns: critically organizing all data elements into patterns called data clusters
-interpretation: placing labels on data patterns/clusters to identify a pt’s response to health care problem
how to form a nursing diagnosis statement
Each type of diagnosis is different
-Problem focused diagnosis has 3 parts; diagnostic label, related factors, major defining characteristics
-Risk nursing diagnosis has 2 parts; diagnosis and associated risk factors (“as evidenced by”)
-health promotion diagnosis has 2 parts; diagnosis. level and defining characteristics/assessment findings
identify sources of nursing diagnostic errors
during data collection, analysis of data clusters/patterns, & interpretation in choosing a nursing diagnostic statement
explain the relationship of planning to nurse diagnosis
planning is a conscious process that occurs quickly (automatic) when nurses are familiar with pt’s diagnoses & have experience in observing how pts respond to interventions
discuss criteria used in priority setting
priorities are based on pt’s current condition and desired outcomes, NOT ordering of list of care tasks
discuss the difference between a goal and expected outcome
Expected outcomes: use SMART
-Specific, measurable, attainable, realistic, timed
nursing goals are specific expected outcomes related to nursing diagnosis
EX: goal is oral health, expected outcome is knowledge of infection management/self care oral hygiene
discuss difference between independent vs dependent nursing interventions
independent- nurse initiates in response to nursing diagnosis without supervision
dependent- requires an order from provider
discuss benefits of nursing care plans
-promotes continuity of care/better communication bc it informs all providers about a pts needs/interventions.
-reduces risk of incomplete, incorrect, inappropriate care
describe consultation process
seek expertise of a specialist to identify ways to handle specific problems in pt management or planning/implementing therapies
explain process of inter professional collaboration
complex process involving 2+ people from various professional fields to achieve common outcomes for pt
explain the relationship between nursing interventions & nursing’s scope of practice
-nursing intervention depends on the nurse’s scope of practice!
-nursing scope of practice describes what a nurse is licensed to perform
explain benefits of standard nursing interventions
-allows nurses to deliver the most clinically effective care to improve pt outcomes
-captures pt care info that can be shared across disciples/care settings to make it easier to measure quality of care/support ongoing research
describe implications for use of standard care bundles
-interventions when implemented together can result in better pt outcomes than doing it individually
-improve quality of care, prevents complications
describe the association between critical thinking and selecting nursing interventions
critical thinking helps nurses select the right nursing intervention for pt and rule out possible errors
explain a nurse’s role in the implementation process
to reassess the pt before a procedure, review nursing care plan (possible revision), organize resources, prevent complications, implement the interventions correctly
explain how a nurse balances organizational & pt priorities in time management
-be aware of agency’s goals of efficiency and cost
-provide timely, safe, efficient care
-time management
describe how nurses anticipate/prevent complications
know the risks, be knowledgable of pt’s condition, adapt your choice of interventions depending on the situation… CRITICAL THINKING IS KEY TO PREVENT COMPLICATIONS!
define 2 implementation skills as they relate to direct and indirect nursing interventions
- cognitive skills; ensure no nursing action is automatic, it needs to be thoughtful and pt centered
- interpersonal communication skills; develop trust, express care, and communicate clearly to pt
- psychomotor skills; requires cognitive and motor actives.. access your level of competency, obtain resources to ensure pt has safe treatment
describe relationship between critical thinking and evaluation
critical thinking- influences nurse’s workplace performance and reflects ability to resolve a pts problem
evaluation- final step of nursing process that determines a pt’s condition after nursing interventions were delivered
explain difference between evaluative measures and assessment
-evaluative measures are at the end; after nursing interventions
-assessment starts the very first time you meet pt before intervention
explain relationship among goals of care, expected outcomes, and evaluative measures when evaluating nursing care
they work together to determine how pt is going/how care plan is being effective
explain how evaluation reveals errors or omissions in care
evaluation involves observation skills, critical thinking, intellectual standards, knowledge, & reflection to see errors so changes can be made
compare constitutional, civl, & criminal law
-constitutional law: devised from federal & state constitutions
-civil law: statutory law that protects right of individuals & provides for fair & equitable treatment when civil wrongs or violations occur
-criminal law: statutory law that protects society & provides punishment for crimes defined by municipal, state, & federal legislation
describe scope of nursing practice & standards of nursing care
-scope of nursing practice defines nursing & reflects the values of the nursing profession
-the standard of nursing care reflects the knowledge & skill ordinarily possessed/used by nurses to perform within the scope of practice. (derived from health care Laws, guidelines, professional organizations, evidence based nursing, citizen advocacy groups)
define the standard of proof required to establish a nurse’s negligence
it’s the degree to which the evidence must show that a duty of care was violated, resulting in harm to the pt
examples of federal statues that affect nursing practice
-PPACA (pt protection & affordable care act) ; later changed to Affordable Care Act (ACT) that has 4 themes including consumer rights/protection, affordable health care, increase access to care & quality of care that meets the need of pts ; it’s intended to reduce overall medical costs
-EMTALA (emergency medical treatment & active labor act) ; prohibits transfer of pts from private to public hospitals without appropriate screening & stabilization to prevent pt dumping
-HIPPA (health insurance portability & accountability act) ; provides rights to pts & protects employees
-HITECH (health information technology act) ; privacy regarding technology, never post pt info on social media
-ADA (Americans w/ disability act) ; protects right of ppl w/ physical or mental disabilities
-MHPAEA (mental health parity & addiction equity act) ; requires health insurance companies to provide coverage for mental health substance use disorder
-PSDA (pt self determination act) ; requires healthcare institutions to provide written info to pts concerning their rights to make dickens about their care including right to refuse treatment & to formulate an advance directive
-UAGA (uniform anatomical gift act) ; provides foundation for national organ donation system
-OBRA (omnibus budget reconciliation act) ;focuses on pt rights, quality of life/care, physical environment in which pts live ; addresses the use of physical & chemical restraint use
analyze under what circumstances a pt can be chemically or physically restrained
-when they want to ensure physical safety of pt or other pts
-when less restrictive interventions are unsuccessful
-when only on the written order of a health care provider
explain what a nurse’s witnessing of a pt’s informed consent indicates
it indicates that the pt voluntarily gave consent, the pt’s signature is authentic, & the pt appears to be competent to give consent
list the elements needed to establish negligence & malpractice
- professional duty owed to the pt
- breach (did not carry out) of such duty
- injury caused by the breach
- resulting damages
determine nursing actions most often associated w/ a breach of nursing practice
-failure to follow the standard of care
-failure to communicate abnormal assessment date
-failure to document care & evaluation of care
-failure to act as the pt’s advocate
-failure to follow policies & procedures
identify proactive measures nurses can take to help reduce their legal risks
-identify potential hazards/risks & eliminate them before harm occurs
identify the purposes of a health record
-health care documentation consists of all info entered into health record, which may be electronic, paper, or combination of both formats
-nursing documentation systems should reflect current standards of nursing practice & minimize risk of errors ; documentation systems need to be flexible enough allow members of health care to efficiently document & retrieve clinical data, track pt outcomes, facilitate continuity of care
discuss the relationship between documentation & financial reimbursement for health care
-documentation: key communication strategy that produces a written account of pertinent pt data, clinical decisions, interventions, & pt responses in a health record
-financial reimbursement: insurance companies look at documentation to determine payment or reimbursement for health care services (Ex: HACs - hospital acquired condition such as pressure injuries, falls, catheter associate UTIs, CLABSIs -central line associated blood stream infections)
**diagnosis-related groups (DRGs) = classifications based on pts primary & secondary medical diagnosis that are used as the basis for establishing Medicare reimbursement for pts provided by health care agencies
discuss legal guidelines for documentation
-don’t document retaliatory or critical comments about a pt or care provided by another healthcare professional, don’t document opinions
-correct all errors promptly, record all facts, protect the security of your password for computer documentation
-avoid using generalized empty phrases such as “status unchanged” or “had a good day”
-document only for yourself, document discussions you had with providers to seek clarification regarding order in question
-begin each entry w/ time & date, end w/ signature & credentials, don’t erase/scratch out errors while recording (only do single line through & write “error” with your signature, date)
-don’t leave blanks in nurse’s progress note, record all written entries legibly using black ink, no pencils/felt pens/erasable ink
identify ways to maintain the confidentially of heath care record data
-auto sign off
-a firewall: combination of hardware/software that protects private network resources from outside hackers, network damage, theft, misuse of information
-a password: collection of alphanumeric characters & symbols that a user types into a computer sign-on screen before accessing a program after the entry & acceptance of an access code or username
describe guidelines for quality documentation
-5 important characteristics: factually accurate, current, organized, complete
**achieve these by sticking to the facts, writing in short sentences, using simple/short words, avoid us of jargon or abbreviations
identify appropriate & inappropriate use of abbreviations in health care documentation
Do not use:
-U for unit, write out “unit” instead
-IU for international unit, write it out instead
-Q.D, QD, q.d., qd (daily), QOD, qod (every other day)… write out “daily” or “every other day” instead
-trailing zeros or lack of leading zeros
-MS, MSO4, MgSO4… write out morphine sulfate & magnesium sulfate instead
describe the different methods used in record keeping
-Flow sheets: graphic records that are organized by body system & navigated using the computer mouse w/ a series of tabs & rows
-narrative documentation: story-like format, traditionally used by nurses/health care providers to record pt assessment, clinical decisions, & care provided
-PIE: P for nursing problems or diagnosis, I for interventions that will be used to address the problem, E for nursing evaluation
-focus charting: uses DAR.. D for date (subjective or objective), A for action/nursing intervention, R for response of the pt
-SOAP note: used by all heath care disciplines .. S for subjective, O for objective, A for assessment, P for plan
identify elements to include when documenting a pts discharge plan
-clear/concise description in pts language
-step by step description of how to perform a procedure
-detailed list of all prescribed meds
-precautions to follow when performing self care or procedures
-pts restrictions
-review signs/symptoms to report to provider it it comes up at home
-list names/phone numbers of health care providers
-unsolved problems
-actual time of discharge, mode of transpiration, who accompanied the pt
describe elements to include in the documentation of telephone conversations w/ providers
-only authorized staff receive & record telephone & verbal orders
-identify pt info
-use clarifying questions to avoid misunderstandings
-document TO (telephone order or verbal order)
-read back of all orders prescribed to health care provider & document TORB (telephone order read back)
-follow agency policies
-healthcare provider cosigns
medication: Warfarin (Coumadin)
-blood thinner
-oral, prevents blood clots
-vit k is an antagonist
-monitor through proton
medication: Heparin
-blood thinner
-IV/Sub Q, injectable
-protamine sulfate is an antagonist
