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Fundamentals > Exam 1 N320 Fundamentals > Flashcards

Exam 1 N320 Fundamentals Flashcards

1
Q

4 modes of Roy’s Adaptation theory

A
  1. Physiologic
  2. Self-Concept
  3. Role Function
  4. Interdependence
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2
Q

Roy’s Adaptation Theory
Describe Physiologic Mode

A

-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

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3
Q

Roy’s Adaptation Theory
Describe Self-Concept Mode

A

-Beliefs & feelings an individual holds about self
-components: body sensation/body image; personal self including self consistency, self ideal, & moral ethical spiritual self

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4
Q

Roy’s Adaptation Theory
Describe Role Function Mode

A

-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

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5
Q

Roy’s Adaptation Theory
Describe Interdependence Mode

A

-interactions related to the giving & receiving of love, respect, & value
-EX: loss, grief

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6
Q

Describe the nature of clinical judgements in nursing practice

A

-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

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7
Q

Explain how questioning promotes critical thinking

A

-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

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8
Q

Discuss how reflection improves a nurse’s capacity for making future clinical decisions

A

When a nurse reflects on the service they give, it helps them identify their mistake & how to improve next time

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9
Q

Compare/contrast the 3 levels of critical thinking

A
  1. Basic: the early stage of critical thinking- inexperienced nurse follows guides & trusts older nurses as experts
  2. Complex: rely less on experts & instead trust their own decisions (critical thinking & creativity)
  3. Commitment: the nurse anticipates when to make choices without assistance from others & accepts accountability for decisions made
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10
Q

Explain the importance of problem solving practice

A

-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

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11
Q

Describe the processes of inductive & deductive reasoning in decision making

A

-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

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12
Q

Describe the components of a critical thinking model for clinical decision making

A
  1. Competence- ability to perform nursing skills, cognitive processes that guide nurses in applying nursing process in making accurate clinical judgements
  2. Knowledge base- varies on educational experience, nursing education, continuing education courses, & additional college degrees
  3. Experience- clinical learning experiences are necessary to acquire decision making skills & to gain competence in performing nursing skills
  4. Environment- the context of the pt’s condition & environmental factors, task complexity, time pressure, work setting & interruptions
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13
Q

Describe approaches for developing critical thinking skills

A

Approach critical thinking with confidence, thjnking independently, fairness, responsibility, authority, risk taking, discipline, perseverance, creativity, curiosity, integrity & humility

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14
Q

Explain the two steps involved in nursing assessment

A
  • 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
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15
Q

Describe the 3 types of nursing assessments

A
  1. pt centered interview: conducted during a nursing hx (comprehensive nursing hx)
  2. Periodic assessment: conducted during ongoing contact with pts
  3. Physical exam (conducted during a nursing hx & at any time a pt presents a symptom)
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16
Q

Explain principles to follow in the use of data sources during the assessment

A

*pt: best sources of information
*Family caregivers & significant other
*health care team
*medical records
*other records & the scientific literature
*nurse’s experience

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17
Q

Explain the importance of building a nurse-pt relationship before a formal nursing assessment

A

-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

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18
Q

describe skills to apply when conducting pt interview during nursing hx

A

-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

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19
Q

explain communication approaches to use during the working phase of a pt centered interview

A

-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

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20
Q

explain how to maintain professionalism during hx taking

A

-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

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21
Q

identify components of nursing health hx

A

-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

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22
Q

describe elements of assessment process

A

-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)

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23
Q

nursing diagnosis vs. medical diagnosis vs. collaborative problem diagnosis

A
  1. nursing diagnosis- clinical judgment made by RN to describe pt’s response or vulnerability to health conditions or life events that RN can treat
  2. medical diagnosis- identification of disease condition based on specific assessment of physical signs/symptoms , pt’s medical hx, & results of tests/procedures
  3. collaborative problem- requires BOTH medical & nursing interventions to treat
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24
Q

describe importance of having standardized language of nursing diagnoses

A

ppl can understand across all disciplines and care settings

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25
Q

describe the diagnostic reasoning process

A

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

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26
Q

describe components of a nursing diagnostic statement

A

-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

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27
Q

explain the difference between finding data patterns & data interpretation

A

-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

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28
Q

how to form a nursing diagnosis statement

A

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

29
Q

identify sources of nursing diagnostic errors

A

during data collection, analysis of data clusters/patterns, & interpretation in choosing a nursing diagnostic statement

30
Q

explain the relationship of planning to nurse diagnosis

A

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

31
Q

discuss criteria used in priority setting

A

priorities are based on pt’s current condition and desired outcomes, NOT ordering of list of care tasks

32
Q

discuss the difference between a goal and expected outcome

A

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

33
Q

discuss difference between independent vs dependent nursing interventions

A

independent- nurse initiates in response to nursing diagnosis without supervision
dependent- requires an order from provider

34
Q

discuss benefits of nursing care plans

A

-promotes continuity of care/better communication bc it informs all providers about a pts needs/interventions.
-reduces risk of incomplete, incorrect, inappropriate care

35
Q

describe consultation process

A

seek expertise of a specialist to identify ways to handle specific problems in pt management or planning/implementing therapies

36
Q

explain process of inter professional collaboration

A

complex process involving 2+ people from various professional fields to achieve common outcomes for pt

37
Q

explain the relationship between nursing interventions & nursing’s scope of practice

A

-nursing intervention depends on the nurse’s scope of practice!
-nursing scope of practice describes what a nurse is licensed to perform

38
Q

explain benefits of standard nursing interventions

A

-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

39
Q

describe implications for use of standard care bundles

A

-interventions when implemented together can result in better pt outcomes than doing it individually
-improve quality of care, prevents complications

40
Q

describe the association between critical thinking and selecting nursing interventions

A

critical thinking helps nurses select the right nursing intervention for pt and rule out possible errors

41
Q

explain a nurse’s role in the implementation process

A

to reassess the pt before a procedure, review nursing care plan (possible revision), organize resources, prevent complications, implement the interventions correctly

42
Q

explain how a nurse balances organizational & pt priorities in time management

A

-be aware of agency’s goals of efficiency and cost
-provide timely, safe, efficient care
-time management

43
Q

describe how nurses anticipate/prevent complications

A

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!

44
Q

define 2 implementation skills as they relate to direct and indirect nursing interventions

A
  1. cognitive skills; ensure no nursing action is automatic, it needs to be thoughtful and pt centered
  2. interpersonal communication skills; develop trust, express care, and communicate clearly to pt
  3. psychomotor skills; requires cognitive and motor actives.. access your level of competency, obtain resources to ensure pt has safe treatment
45
Q

describe relationship between critical thinking and evaluation

A

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

46
Q

explain difference between evaluative measures and assessment

A

-evaluative measures are at the end; after nursing interventions
-assessment starts the very first time you meet pt before intervention

47
Q

explain relationship among goals of care, expected outcomes, and evaluative measures when evaluating nursing care

A

they work together to determine how pt is going/how care plan is being effective

48
Q

explain how evaluation reveals errors or omissions in care

A

evaluation involves observation skills, critical thinking, intellectual standards, knowledge, & reflection to see errors so changes can be made

49
Q

compare constitutional, civl, & criminal law

A

-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

50
Q

describe scope of nursing practice & standards of nursing care

A

-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)

51
Q

define the standard of proof required to establish a nurse’s negligence

A

it’s the degree to which the evidence must show that a duty of care was violated, resulting in harm to the pt

52
Q

examples of federal statues that affect nursing practice

A

-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

53
Q

analyze under what circumstances a pt can be chemically or physically restrained

A

-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

54
Q

explain what a nurse’s witnessing of a pt’s informed consent indicates

A

it indicates that the pt voluntarily gave consent, the pt’s signature is authentic, & the pt appears to be competent to give consent

55
Q

list the elements needed to establish negligence & malpractice

A
  1. professional duty owed to the pt
  2. breach (did not carry out) of such duty
  3. injury caused by the breach
  4. resulting damages
56
Q

determine nursing actions most often associated w/ a breach of nursing practice

A

-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

57
Q

identify proactive measures nurses can take to help reduce their legal risks

A

-identify potential hazards/risks & eliminate them before harm occurs

58
Q

identify the purposes of a health record

A

-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

59
Q

discuss the relationship between documentation & financial reimbursement for health care

A

-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

60
Q

discuss legal guidelines for documentation

A

-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

61
Q

identify ways to maintain the confidentially of heath care record data

A

-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

62
Q

describe guidelines for quality documentation

A

-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

63
Q

identify appropriate & inappropriate use of abbreviations in health care documentation

A

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

64
Q

describe the different methods used in record keeping

A

-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

65
Q

identify elements to include when documenting a pts discharge plan

A

-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

66
Q

describe elements to include in the documentation of telephone conversations w/ providers

A

-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

67
Q

medication: Warfarin (Coumadin)

A

-blood thinner
-oral, prevents blood clots
-vit k is an antagonist
-monitor through proton

68
Q

medication: Heparin

A

-blood thinner
-IV/Sub Q, injectable
-protamine sulfate is an antagonist

Fundamentals (5 decks)

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