Exam 2 Flashcards
Collaboration (3)
-development of partnerships to achieve the best possible outcomes that reflect the particular needs of the patient, family, or community
-requires an understanding of what others have to offer
- to labor together or to work with others in an intellectual endeavor.
4 Attributes of Collaboration
- Values and ethics (mutual respect and trust)
- Teams and teamwork
- Roles and Responsibilities (know yours and others)
- Communication (use common language, responsible and responsive)
Kim’s Theory of Collaboration
Collaborative decision making is assessed on a continuum:
-lowest level of collaboration is expressed as complete domination of decision making by the nurse
- highest level of collaboration is expressed as an equally influencing joint decision making (this is where we want to function)
How is Collaboration addressed as a professional standard?
-ANA includes it in the code of ethics
-Complexity of healthcare delivery system requires multidisciplinary approach
What is the economic impact of collaboration?
-positive impact at organizational level
-Cowan’s study found collaboration is linked to decreased length of stay for patients and increased economic benefits for health care organizations
How is Collaboration changing in research?
Health sciences research is moving away from the private investigator model to a collaborative model represented by interprofessional collaborators.
What does QSEN say has a positive impact on length of hospital stay and total charges?
Daily interprofessional rounds in inpatient, acute hospital settings
What are situations of Nurse-Nurse (Intraprofessional) Collaboration?(3)
-patient care handoff (bedside report)
-Mentoring
-Shared Governance
Patient Care Hand-Off (2)
*A transfer and acceptance of patient care responsibility using effective communication.
*High-quality hand-off is complex and structured. (a Joint Commission Standard)
8 Contributing factors to hand-off communication breakdowns
- Insufficient or misleading information
- Lack of safety culture
- Ineffective communication methods
- Lack of time
- Poor follow-up between sender and receiver
- Interruptions or distractions
- Lack of standardized discharge and transfer procedures
- Insufficient staffing
I in IPASStheBATON for Handoffs
Introduction (Introduce yourself and your role or job (include patient)); write name on whiteboard
P in IPASStheBATON
Patient (Name, identifiers, age, sex, location)
A(1st) in IPASStheBATON
Assessment (Present chief complaint, vital signs, symptoms, and diagnosis)-new nurse quickly assesses
S (1st) in IPASStheBATON
Situation (Current status or circumstances, including code status, level of (un)certainty, recent changes, and response to treatment)
S (2nd) in IPASStheBATON
SAFETY Concerns (Critical lab values or reports, SES factors, allergies, and alerts (falls, isolation))
What is SBAR? What does it improve? What does it stand for? (3)
- A common language and tool for communicating critical information to healthcare providers in a standardized, structured, and timely manner.
- Improves perception of communication and information about patients between health care professionals.
- Situation, Background, Assessment, and Recommendation
B in IPASStheBATON
Background ( Comorbidities, previous episodes, current medications, and family history)
A(2nd) in IPASStheBATON
Actions (What actions were taken or are required? Provide brief rationale)
T in IPASStheBATON
Timing (Level of urgency and explicit timing and prioritization of actions)
O in IPASStheBATON
Ownership (Who is responsible (person or team) including patient or family?)
N in IPASStheBATON
Next (What will happen next? Are there anticipated changes? What is the plan?
Are there contingency plans?)
Shared Governance (3)
-decentralized management style which creates an environment of empowerment via involving all staff in decision making
-Managers are facilitative versus controlling
-Increases collaborative effort, professional accomplishment, competence, and satisfaction
What are 4 situations of Interprofessional Collaboration?
-Patient rounding
-Rapid Response Team
-SBAR
-Interprofessional education
3 Challenges of IPC
-power and authority imbalances
-tension with boundaries
-confusion of roles and responsibilities
5 strategies to improve IPC
- Address colleague by name
- Be prepared with patient’s record
- Share expectations of what, when , and how to communicate
- Focus on patient problem
- Be professional and assertive (not aggressive or confrontational)
What is the interprofessional purpose of patient rounding? What is the Intraprofessional purpose of patient round?
- Interprofessional goal is to monitor progress and communicate clear goals and a plan of care for each patient.
- Intraprofessional goal is to check on patients on a predetermined timeframe assess the patient’s need such as pain level and assisting with basic needs.
What is the difference in team members between the Medical Response Team and Rapid Response Team?
Medical Response Team: respond to emergencies (includes nurses and physicians)
Rapid Response Team: Respond to emergencies, Follow up on patients discharged from ICU, Proactively evaluate high-risk patients, Educate and act as liaison to unit staff (critical care nurse, respiratory therapist, and physician)
S in ISBAR
Situation (concise statement of the problem)
B in ISBAR
Background
- Pertinent and brief information related to the situation.
- Diagnosis and co-morbidities
- Relevant background clinical information (i..e. medications, specialists, procedures)
A in ISBAR
Assessment
- Analysis and considerations of options
- What are your assessment findings?
- What do you think the problem is?
R in ISBAR
Recommendation
- Action requested/recommended
- What do you suggest needs to be done?
- What are you requesting?
- Is everyone clear about what needs to be done?
What is TeamSTEPPS in IPC? What are the 5 principles?
-evidence based team work (increases team awareness and communication; decreases barriers to patient safety)
-Principles: team structure, communication, leadership, situation monitoring, mutual support
CUS Tool in IPC
I am Concerned
I am Uncomfortable
This is a Safety Issue
SACCIA in IPC
- Sufficiency-enough detail
- Accuracy- include physical physiological, & behavioral facts
- Clarity - concise w/ essential info
- Contextualization & Interpersonal adaptation – adjust explanations to experience level of who you are talking to
4 ways to reduce Lateral Violence
- Zero tolerance policy
- Develop conflict management and assertive communication
- Mentors (can help and be personal support)
- Don’t retaliate , stay calm , report incidences
5 examples of Clinical Information Systems (CIS)
Examples include:
* Electronic health records
* Clinical data repositories
* Decision support programs
* Handheld devices
* Communication tools: electronic messaging systems and patient portals
5 links of Standardized Information Systems
- Efficiency
- Cost containment
- Codified terminology
- Taxonomies and nomenclature
- care communication
Meaningful use criteria (4)
requires that use of tech results in:
- improved quality, safety, and efficiency of health care
- increases coordination of health care delivery
- advances public health
- protects the privacy of personal health records
The application and utilization of technology in healthcare must demonstrate: (3) per HITECH
- Meaningful use criteria
- Certification standards
- Practices to reduce barriers for information exchange
Nurse Informaticians: (3)
*Use their knowledge of patient care combined with understanding of informatics concepts, methods, and tools to analyze, design, implement, and evaluate information and communication systems
*Advanced education and training
*Collaboration with other health care professionals and IT specialists
HIPPA Privacy vs Security rule
Privacy rule: requires disclosures of PHI be limited to specific info required for particular purpose
Security rule: specifies administrative, physical/ and technical safeguards for 18 elements of PHI in electronic form
What did Florence Nightingale say about health informatics?
To Err Is Human: Building a Better Health System: appropriate technologies can help to reduce errors and ensure patient safety
Translational bioinformatics
focuses on preventive measures as it relates to health information
Electronic Health Records (EHR)
- Documentation systems used to record the process and outcome of delivered patient care
- It is comprehensive of Multiple records from multiple providers
Documentation
- A written account of pertinent patient data, clinical decisions and interventions, and patient responses to care in a health record
- Available for all members of the health care team to revive, document, and receive data
6 Purposes of Health Care Record
- Auditing and Monitoring
- Reimbursement (via diagnosis-related groups)
- Interprofessional Communication
- Education
- Research (w/ de-identification of PHI)
- Legal documentation (confidential and permanent info related to patient care)
5 Documentation mistakes that can lead to malpractice
- failure to record pertinent health or med info
- failure to record nursing actions ( including medication admin)
- failure to record medication reactions or changes in patient condition
- failure to document discontinued medications
- incomplete or illegible records
11 legal Guidelines for Documentation
- No retaliatory comments or opinions about HCP or patient
- Correct all errors promptly
- Record facts
- Discuss communication you initiated for orders or clarification
- Document only for yourself
- Avoid generalized statements “status unchanged” or “tolerated well”
- Begin with date and time, end with signature and credentials
- Password protection
- Do not leave blank spaces or lines
- Do not erase or scratch out errors made while recording
- Record all written entries legibly using black ink and not felt tip pen or erasible ink
4 Guidelines for Quality Documentation
- Only include facts
- Write in short sentences
- Use simple, short words
- Avoid the use of jargon or abbreviations
6 standards for Quality Documentation
-Factual (avoid opinions and vague terms; only subjective data should be from patient
-Accurate (avoid irrelevant details)
-Appropriate Usage of Abbreviations
-Current (document right after things occur)
-Organized
-Complete (appropriate and essential info)
How Documentation is used for Research?
De-identified data can be used for statistical analysis of: Frequency of clinical conditions, Complications, Use of specific medical and nursing therapies, and Clinical outcomes
Analysis of the data contributes to evidence-based practice and quality care
5 Error-prone abbreviations
- U, u for unit
- QD or QOD for daily or every other day
- IU for international unit
- trailing and leading zeros
- MS , MSO4, MgSO4 for morphine sulfate and magnesium sulfate
5 Benefits of CPOE
- Reduces safety issues and medication errors related to illegible handwriting and transcription errors
- Increases the implementation time of ordered diagnostics test and treatments
- Improves reimbursement
- Increases productivity
- Cost effective
Point of Care Testing (POCT) and 4 examples
-quick lab tests near the patient which reduces time for clinical decision making
- glucose monitoring
- arterial blood gas (ABGs) monitoring
-pregnancy test
-rapid strep test
Flow Sheets (2)
-Documentation method used to document patient assessment data, routine care, repetitive care (hygiene, ambulation, safety checks)
- photos and graphics organized by body system so quick and easy
Narrative (What is it? What are the disadvantages? What are the advantages)
- Traditional, Story-like, Free text or menu selection documentation method
- Time consuming and Repetitious
- Enhances clinical communication and interdisciplinary understanding of patient care
SOAP
-Documentation Method to identify interprofessional problems
Subjective, Objective, Assessment, Plan
PIE
-Documentation Method with specific nursing focus
* Problem: Nursing problem or diagnosis
* Intervention: Interventions that will be used to address the problem
* Evaluation: Nursing evaluatione
Focused Charting
Documentation method used to report problems and address patient concerns
* Data: subjective and objective
* Action: nursing intervention
* Response: response of the patient
Problem-Oriented Medical Record Documentation method includes:(4)
- Database
- Problem list
- Progress notes
- Standardized care plans or clinical practice guidelines (CPGs)
Charting by Exception (4)
- Documentation Method which says Patient meets all standards unless otherwise documented
- Uses standards of care and EBP
- Usually there are drop-down menus with defined criteria to document “normal” i.e WDL or WNL
- When the patient’s status changes, or selections are not available, include a nurse’s note (narrative note)
Critical Pathways (2) in Case management model
- Interprofessional care plan that identifies patient problems, pertinent interventions, and expected outcomes within an identified time frame
- Variance may occur when the tasks on the critical pathway are not completed or patient does not meet outcomes as expected
6 Guidelines for Telephone and Verbal Orders
- Verbal order only in emergencies
- Only authorized staff receive and record telephone and verbal orders.
- Clearly identify the patient’s name, room number, and diagnoses.
- Document “TO” (telephone order) or “VO” (verbal order), including date and time, name of patient, the complete order; the name and credentials of the health care provider giving the order(s); and your name and credentials as the nurse taking the order.
- Read back all orders prescribed to the health care provider who gave them and document “TORB” (telephone order read back) when signing your name and credentials.
- Have another nurse listen, repeat details of prescription, obtain provider signature within 24 hrs
Acuity Rating Systems
Determines the hours of care and number of staff required for a given group of patients every shift or every 24 hours
-patient acuity level based on type and # of nursing interventions required in 24 hrs
What is the Rationale and Correct Action for the following documentation Guideline:
Do not document retaliatory or critical comments about a patient or care provided by another health care professional. Do not enter personal opinions.
Rationale: Statements can be used as evidence for nonprofessional behavior or poor quality of care.
Correct Action: Enter only objective and factual observations of a patient’s behavior or the actions of another health care professional. Quote all patient statements.
What is the Rationale and Correct Action for the following documentation Guideline:
Correct all errors promptly.
Rationale: Errors in recording can lead to errors in treatment or may imply an attempt to mislead or hide evidence.
Correct Action: Avoid rushing to complete documentation; be sure that information is
What is the Rationale and Correct Action for the following documentation Guideline:
Record all facts.
Rationale: Record must be accurate, factual, and objective.
Correct Action: Be certain that each entry is thorough. A person reading your documentation needs to be able to determine that a patient received adequate care.
What is the Rationale and Correct Action for the following documentation Guideline:
Document discussions with providers that you initiate to seek clarification regarding an order that is questioned.
Rationale: If you carry out an order that is written incorrectly, you are just as liable for prosecution as the health care provider.
Correct Action: Do not record “physician made error.” Instead document that “Dr. Smith was called to clarify order for analgesic.” Include the date and time of the phone call, with whom you spoke, and the outcome.
What is the Rationale and Correct Action for the following documentation Guideline:
Document only for yourself.
Rationale: You are accountable for information that you enter into a patient’s record.
Correct Action: Never enter documentation for someone else (exception: if professional has went home and forgot to document something)
What is the Rationale and Correct Action for the following documentation Guideline:
Avoid using generalized, empty phrases such as “status unchanged” or “had good day.”
Rationale: This type of documentation is subjective and does not reflect patient assessment.
Correct Action: Use complete, concise descriptions of assessments and care provided so that documentation is objective and factual.”
What is the Rationale and Correct Action for the following documentation Guideline:
Begin each entry with date and time and end with your signature and credentials.”
Rationale: Ensures that the correct sequence of events is recorded; signature documents who is accountable for care delivered.
Correct Action: Do not wait until the end of shift to record important changes that occurred several hours earlier; sign each entry according to agency policy (e.g., M. Marcus, RN).
4 mechanisms of Disrupted Fluid Electrolyte balance
- Normal output but deficient intake or absorption—Children
- Increased output not balanced by increased intake—BP pills, hemorrhage, diarrhea
- Output less than excessive or too rapid intake-IV (crackles in lungs)
- Decreased output not balanced by decreased intake—Urinary retention/oliguria
4 forces of filtration
- Capillary Hydrostatic Pressure (strong, outward - force) → strongest @ arterial end and weakest @ venous end
- Blood colloid osmotic pressure (inward - force) - stronger @ venous end
- Interstitial fluid hydrostatic pressure (weak)
- Interstitial fluid osmotic pressure (very small)
What is the Rationale and Correct Action for the following documentation Guideline:
Do not erase or scratch out errors made while recording.
Rationale: Charting becomes illegible: it appears as if you were attempting to hide information or deface a written record.
Correct Action: Draw single line through error, write word “error” above it, and sign your name or initials and date it. Then record note correctly.
What is the Rationale and Correct Action for the following documentation Guideline:
Do not leave blank spaces or lines in a written nurse’s progress note.
Rationale: Allows another person to add incorrect information in open space.
Correct Action: Chart consecutively, line by line; if space is left, draw a line horizontally through it and place your signature and credentials at the end.
What is the Rationale and Correct Action for the following documentation Guideline:
Record all written entries legibly using black ink. Do not use pencils, felt-tip pens, or erasable ink.
Rationale: Illegible entries are easily misinterpreted, causing errors and lawsuits; ink from felt-tip pen can smudge or run when wet and may destroy documentation; erasures are not permitted in clinical documentation; black ink is more legible when records are photocopied or scanned.
Correct Action: Write clearly and include appropriate abbreviations using black ink
Why are infants at greater risk of fluid imbalance? (4)
Ø High metabolic rate
Ø Immature kidneys
Ø More rapid respiratory rate
Ø Proportionately greater BSA compared to adults
Why are older adults at greater risk of fluid imbalance? (3)
Ø Thirst and taste sensation blunted
Ø Kidneys less able to respond to ADH
Ø Impaired ability to conserve water (low body weight)
What are some red flags of health history related to fluid imbalance?
Ø Vomiting, diarrhea, organ failure (kidney, heart, liver)
Ø Unexplained nausea, fatigue, dizziness, shortness of breath, muscle cramping, edema, sudden changes in weight
7 nursing interventions related to fluid balance
- Patient Teaching
- Daily weight (1st thing in morning with same amount of clothes; if increase or decrease for by ≥5 pounds then fluid loss or gain)
- Monitoring fluid intake and output (can delegate to UAP)
- Safety risk assessments (Fluid imbalance can cause orthostatic hypotension, dizziness)
- Comfort measures
- Oral hygiene
- Assess vitals
BUN and Creatinine normal range
BUN-6-24
Creatinine-0.6-1.2
When does BUN increase? What does it mean if BUN and creatinine are high?
BUN increases with dehydration and decreases with ECF excess. If BUN and Creatinine are high, there may be dehydration and kidney failure
Hematocrit and Hemoglobin normal range
Hematocrit (% of RBC in blood)-36-48
Hemoglobin (amount of protein in RBC)—12-16
Hematocrit to Hemoglobin ratios
Normal 3:1
Dehydration/Hypovolemia: >3:1
Fluid Overload: <3:1
Differentiate isotonic, hypotonic, hypertonic solutions
Isotonic solution has the same number of solutes as human intravascular fluid so the red blood cell stays the same.
Hypotonic solution: solutes in solution are dilute so the red blood cell in the intravascular space swells.
Hypertonic solution: solutes in solution concentrated so the red blood cell in the intravascular space shrinks.
When someone is dehydrated what does Gatorade, Water, and Pedialyte do?
Gatorade is hypertonic so is draws water from cells; good for prevention
Water is hypotonic so it pulls water from intravascular compartment; good for prevention
Pedialyte is isotonic and will increase circulating volume to nourish all cells; good for treatment
Purpose and 2 examples of Isotonic fluids
-increase ECV but do not enter cells; given for dehydrated, hypotensive, or hypovolemic shock
- Normal Saline (0.9%)
- Lactated Ringers-includes Na+, K+, Ca2+, Cl−, and lactate, which liver metabolizes to HCO3−
10 Signs of Hypovolemia
- sudden weight loss (overnight)
- decreased skin turgor (elasticity)/tenting
- postural hypotension
- no tears or sweat, dry mucus
- Tachycardia
- Rapid Thready pulse (comes and goes; difficulty finding)
- Flat neck veins
- Restlessness/decreased LOC
- Sunk eyes
- Oliguria (less than 30 mL/hr)
6 causes of hypovolemia
- Abnormal GI losses: vomiting, diarrhea, GI suction,
- Abnormal Skin losses: diaphoresis, prolonged fever, wound drainage
- Abnormal renal losses: diuretic therapy
- Third space shifting: peritonitis (inflammation of belly abdomen), ascites (fluid shift in abdomen), burns
- Hemorrhage: blood loss after surgery, GI bleed
- Enteral feeding without sufficient free water
9 signs of hypervolemia
- Sudden weight gain (overnight)
- Confusion
- Orthopnea (unable to breathe laying down)
- Hypertension
- Tachypnea (fast breathing
- Crackles in lower bases of longs
- Bounding pulse
- Distended neck veins
- Pulmonary edema
7 causes of Hypervolemia
- Congestive heart failure
- Liver cirrhosis
- Increased glucocorticoids
- Kidney failure
- Excess Sodium intake
- Water replacement with no electrolyte replacement
- Excess IV
Purpose and 5 Examples of Hypertonic fluids
§ Used to draw water from cells.
§ 3% or 5% NS
§ D10W (becomes hypotonic in body)
§ D5 ½ NS (becomes hypotonic after D5 absorbed)
§ D5 NS (becomes isotonic after D5 absorbed)
§ D5 LR (becomes isotonic after D5 absorbed)
Purpose and 2 Examples of Hypotonic fluids
§ Used to expand ECV and hydrate cells before surgery
§ 0.225% NS
§ 0.45% NS
When to use hypertonic solutions? (3)
§ Dextrose rapidly enters cells. D5 is isotonic for patient’s not eating
§ 3 or 5% NS if pulling fluid off of brain after stroke
§ D10 if insulin shock
3 Types of IV devices
- Central Venous Catheters (CVCs) – catheter tip in central circulatory system (used for high osmolality, irritating fluids, large volumes)—includes PICCs
- Peripheral IVs- catheter tip in vein of one of the extremities (used for low osmolality)
6 notes on Venipuncture Sites
- Inner arm=most common
- No hands on older adults or ambulatory individuals
- Feet only in children
- Avoid areas of flexion and compromised veins
- No sites on chest, breast, abdomen, or trunk
- No sites of infection, infiltration or thrombosis
Infiltration and Extravasation Assessment Findings (3)
- Skin around catheter site taut, blanched, cool to touch, pitting edema;
- may be painful as infiltration or extravasation increases
- infusion may slow or stop
Infiltration and Extravasation Nursing Intervention (5)
§ Stop infusion (discontinue if not vesicant; if vesicant disconnect and aspirate) and call HCP
§ Remove the IV site
§ Prop the arm
§ Do not apply heat or cold unless ordered, (can react with substance)
§ Do not apply pressure (can cause more contact with skin)
Phlebitis (vein inflammation) Assessment Finding
hard, red, painful, hot lump where IV site is ; may or may not have red streak or palpable cord along vein
Phlebitis Nursing Interventions (5)
§ Take out IV and call doctor.
§ Elevate affected extremity
§ Do not apply heat or cold without order.
§ May need IV antibiotics.
§ Start new IV line proximal or in other extremity
Infection of IV site Assessment Finding
Redness, burning ,swelling, weeping or discharge; not hard
Infection of IV site Nursing Intervention (4)
§ Remove catheter and contact HCP
§ Need antibiotics to prevent sepsis
§ Clean skin with alcohol and culture drainage if ordered
§ Initiate appropriate wound care
4 Types of circulatory overload of IV Solution Assessment Findings
- Na+-containing isotonic fluid (crackles in parts of lungs, shortness of breath, edema)
- Hyponatremia with hypotonic fluid (confusion, seizures)
- Hypernatremia with hypertonic fluid (confusion, seizures)
- Hyperkalemia from K+ fluid (cardiac dysrhythmias, muscle weakness, abdominal distention)
Circulatory overload of IV solution Nursing Interventions (3)
§ Reduce IV flow rate and notify HCP
§ With ECV excess, raise head of bed; administer oxygen and diuretics if ordered.
§ Monitor vital signs and laboratory reports of serum levels.
Air embolism Assessment Finding (7)
Sudden onset of dyspnea, coughing, chest pain, hypotension, tachycardia, decreased level of consciousness, possible signs of stroke
Air embolism Nursing Interventions (3)
- Prevent further air from entering the system by clamping or covering the leak.
- Place patient on left side, preferably with head of bed raised, to trap air in the lower portion of the left ventricle.
- Call emergency support team and notify HCP
Bleeding at venipuncture site Assessment Finding
Oozing or slow, continuous seepage of blood; sometimes pooling under extremity
Bleeding at venipuncture site Nursing Interventions (3)
- Assess whether IV system is intact.
- If catheter is within vein, apply pressure dressing over site or change dressing.
- Start new IV line in other extremity or proximal to previous insertion site if VAD is dislodged, IV is disconnected, or bleeding from site does not stop
Barriers to establishing therapeutics relationships and interpersonal connections with patient: (5)
- Institutional Demands
- Time constraints
- Reliance on technology and cost-effective health care strategies
- Efforts to standardize and refine work
- Nurses torn b/w human caring model and the task-oriented biomedical model
Caring relationships require (4):
- Sincerity (respect and accepting)
- Presence
- Availability
- Engagement (listening)
