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Nurs. 301 > Exam 2 > Flashcards

Exam 2 Flashcards

0
Q

What is a source oriented record?

A

A source oriented record is one in which each healthcare group keeps data on it’s own separate form. Sections of the record are designated for nurses, physicians, laboratory, x-ray personnel. Notations are entered chronologically with the most recent entry being the nearest to the front of the record. The advantage of the source oriented record is that each discipline can easily find and chart data

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1
Q

What is the only permanent legal document that details the nurses interactions with the patient and is the nurses best defense if a patient alleges nursing negligence?

A

The patient record

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2
Q

Progress notes written by nurses and the source oriented record are called what?

A

Narrative notes

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3
Q

What is the problem oriented medical record (POMR) ?

A

The POMR is organized around the patients problems rather than around sources of information. With POMRs all healthcare professionals record information on the same forms. The advantage of this type of record are that the entire healthcare team works together in identifying a master list of patient problems

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4
Q

What is the SOAP format?

A

Subjective data
Objective data
Assessment
Plan

The SOAP format is used organize data entries in the progress notes of the POMR. Caregivers select number of problems from the master list on the front of the patient record and then work out the problem or SOAP it on the progress sheet

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5
Q

What is PIE charting?

A

The PIE charting system is unique in that it is not developed a separate plan of care. The plan of care is incorporated into the progress notes in which the problems identified by number

Problem
Intervention
Evaluation

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6
Q

What is focus charting?

A

The purpose of focus charting is to bring the focus of care back to the patient and the patient’s concern. The narrative portion of focus charting uses the DAR format

Data
Action
Response

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7
Q

What is charting by exception?

A

Charting by exception is a shorthand documentation method that makes use of well-defined standards of practice, only significant findings or exceptions to these standards are documented in narrative notes. Benefit includes decreased charting time

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8
Q

What are collaborative pathways?

A

Collaborative pathways are used in the case management model. The collaborative pathway specifies the plan of care linked to expected outcomes along the time

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9
Q

What is variance charting?

A

The usual format for variance charting is the unexpected event, the cost of the event, actions taken in response to the event, and discharge planning when appropriate. The variances most likely to be documented are those that effect quality, costs, or length of stay

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10
Q

What are flowsheets?

A

Flowsheet are documentation tools used to record routine aspects of nursing care

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11
Q

The outcome and assessment information set, or oasis, is a group of data elements that…

A
  1. Represent core items of a comprehensive assessment for an adult homecare patient
  2. Form the basis for measuring patient outcomes for purposes of outcome based quality improvement

The oasis is a key component of Medicare’s partnership with the homecare industry

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12
Q

What is criteria?

A

Criteria are measurable qualities, attributes, characteristics of specify skills, knowledge, our health states. They described acceptable levels of performance by stating the expected behaviors of the nurse or patients

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13
Q

What are standards?

A

Standards are the levels of performance excepted and expected by the nursing staff. They are established by authority, custom, or consent

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14
Q

What are the four crucial steps in improving performance?

A
  1. Discover a problem
  2. Plan a strategy
  3. Implement a change
  4. Asses the change
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15
Q

What is peer review?

A

Peer-review, the evaluation of one staff member by another staff member on the same level in the hierarchy of the organization, is an important mechanism nurses can use to improve their professional performance

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16
Q

Specially designed programs that promote excellence in nursing are called what?

A

Quality assurance programs

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17
Q

The American nurses Association developed a model quality assurance program consisting of seven steps…..

A
  1. Identify value
  2. Identify structure, process, outcomes standards, criteria
  3. Measure the degree of attainment of criteria and standards
  4. Identify possible courses of action
  5. Choose a course of action
  6. Take action
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18
Q

What is the structure evaluation?

A

The structure evaluation or audit focuses on the environment in which the care is provided.

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19
Q

What is a process evaluation

A

The focus of the process evaluation is the nature and sequence of activities carried out by the nurse implementing the nursing process

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20
Q

What is outcome evaluation?

A

Outcome evaluation focuses on measurable changes in the health status of the patient or the and result of nursing care

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21
Q

What is a nursing audit?

A

A nursing audit is a method of evaluating nursing care that involves reviewing patient records to assess outcomes of nursing care or the process by which these outcomes were achieved.

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22
Q

What is concurrent evaluation?

A

Concurrent evaluation is conducted by using direct observation of nursing care, patient interview, and chart review to determine whether the specified design criteria.

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23
Q

What is retrospective evaluation?

A

Retrospective evaluation may use the post discharge questionnaires, patient interviews, our chart review to collect data.

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24
Q

The following are all classic elements of evaluation. Which item below places them in the correct sequence?

A
  1. Identifying evaluative criteria and standards
  2. Collecting data to determine whether going to criterion standards are met
  3. Interpreting and summarizing findings
  4. Documenting your judgment
  5. Terminating, continuing, or modifying the plan
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25
Q

When a new nurse is oriented to the subacute unit, she is told every nurse is expected to observe her patients at least every hour, and more if their condition warrants extra Monitoring. This expectation is best termed as what?

A

A standard

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26
Q

One of the outcomes Jean and the nurse planned that Jean appreciates and values a healthy body sufficiently to try the new behaviors. Which of the following best describes this type of outcome?

A

Affective, affective outcomes pertain to changes in patient values, beliefs, and attitudes

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27
Q

Another of outcomes Jean and the nurse plan is that jean can explain the relationship between weight-loss, increased exercise, and decreased caloric intake. Which is fine best describes this type of outcome?

A

Cognitive, cognitive outcomes involved increases in patient knowledge

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28
Q

A quality assurance program reveals a higher incidence of falls and other safety violations on a particular unit. The nurse manager states we better find the folks responsible for these errors and see if we can’t replace them. This is an example of which of the following?

A

Quality by inspection, focuses on finding deficient workers and removing them

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29
Q

One nursing unit with an excellent safety record needs to review the findings of the audit and the nurse manager states were doing well but we can do better. Who’s got an idea to foster increased patient well-being and satisfaction? This is an example of leadership that values which of the following?

A

Quality improvement, is internally driven and focuses on patient care rather than organizational structure, focuses on processes rather than individuals, and has no endpoints. It’s outcome is improving quality rather than assuring quality

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30
Q

What is allopathic medicine?

A

Allopathic medicine has been dominant for over hundred years and has spearheaded remarkable advances in biotechnology, surgical interventions, pharmaceutical approaches, and diagnostic tools. Allopathic medicine is particularly effective when aggressive treatment is needed in emergency and acute situation. It has not been effective in dealing with chronic illness however… CAT come in

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31
Q

What is holism?

A

Holism is a theory and philosophy that focuses on connections and interactions between parts of the whole

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32
Q

What is integrative care?

A

A person who uses integrative carried to some combination of allopathic medicine and CAT

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33
Q

NCCAM classifies the major CAT into five categories

A
  1. Whole medical systems
  2. Mind-body therapies
  3. Energy medicine
  4. Biologically-based practices
  5. Manipulative and body-based practices
34
Q

What is Ayurveda?

A

Ayurveda is the science of life that delineates the diet, medicines, and behaviors are beneficial or harmful for life. Ayurveda considers a balance among people the environment and the larger cosmos is integral to the human health

35
Q

What are the 3 doshas of Ayurveda ?

A

Vata (changeable)
Pitta (intense)
Kapha (relaxed)

36
Q

What is the definition of culture and subculture?

A

●Culture – is the total sum of beliefs , values, norms, and traditions that are learned, shared, and transmitted by groups from and across generations guiding thinking, decisions, and behavior
●Subculture – groups within distinct characteristics from the dominant culture

37
Q

Ethnicity Vs.race

A

●
Ethnicity

Shared characteristics of a group
●Primary characteristics
●Race, color, national or geographic origin, religious beliefs, cultural origin
●Share a common heritage
●Secondary characteristics
●Sense of identity, distinctive customs, language, attitudes, health care practices, socioeconomic, immigration status, political orientation

●Race

●Common biological attributes (specific physical characteristics)
●Skin pigmentation, body stature, facial features, hair texture
●Categories: American Indian/Alaska Native, Asian, Black or African American, Native Hawaiian/Pacific Islander, White (non-Hispanic), White (Hispanic origin)

38
Q

Enculturation vs. Acculturation

A

●Enculturation – socialization into primary culture as a child

●Acculturation – process of adapting and adopting dominant culture characteristics

39
Q

What is cultural assimilation vs bicultural ism

A

●Cultural Assimilation – individual gradually adopts and incorporates values of the dominant culture

●Biculturalism – Individual equally identifies with 2 or more cultures

40
Q

Culture shock vs. Culture conflict

A

●Culture Shock – feelings a person experiences when placed in a different culture perceived as strange

●Cultural Conflict – when people become aware of cultural differences, feel threatened, and act negatively

41
Q

What is ethnocentrism?

A

●Ethnocentrism - occurs when a people believe their own way of life is superior to others. This causes bias and prejudice.

42
Q

What is allopathic medicine?

A

●Allopathic:
●Illness occurs in either the mind or body, which are separate entities.
●Health is the absence of disease.
●Illness is an event caused by an external agent.
●Curing is accomplished by external agents.
●Curing occurs more quickly if we destroy the invading organism or repair the affected part.

43
Q

What is CAT?

A

●Complimentary/Alternative
●Mind, body, and spirit are integrated and contribute to health and illness.
●Health is a state characterized by a dynamic balance of mind, body, and spirit.
●Illness is a manifestation of imbalance or disharmony.
●Healing is done by the patient.
●Health is a natural, slow process involving the mind, body, and spirit.

44
Q

Traditional Chinese medicine

A

●Believes that the interaction of people with environment creates health
●Central concept is qi or chi, yin/yang
●Uses acupuncture, diet, herbs, massage, and energy exercises
●Yin = cool, moist, dark
●Yang = hot, dry, light
●Yin and yang must be in balance

45
Q

What is Qi Gong

A

●System of posture
●Exercise—gentle and dynamic
●Breathing techniques
●Visualization that regulates the qi gong

46
Q

Shamanism

A

●It is the most widely practiced medical system.
●Illness is thought to originate in the spirit world.
●The shaman or medicine man/woman accesses the spirit world to obtain information on the proper treatment.
●Treatment may consist of retrieving lost soul energy, restoring the individual to right relationship with the spirit world, and treating symptoms.
●Healing techniques involve native plants and herbs, animals, rituals, ceremonies, and purification techniques.

47
Q

Define homeopathy

A

●Support the body while symptoms run their course
●Based on Law of Similars and Law of Infinitesimals
●Looks for individual patterns
●Treatment consists of matching patterns with remedies

48
Q

Define naturopathy

A

●Began in early 1900s in the United States
●A way of life
●Belief in the vitalist doctrine
●Health is a dynamic state of being, providing energy to deal with life
●Illness can be attributed to ignoring natural laws
●Therapies support the self-healing mechanism of the body

49
Q

What is chakra ?

A

●Chakra—concentrated areas of energy aligned vertically in the body that relate to each other as well as specific areas of the body/mind/spirit

50
Q

How many layers does your aura have?

A

●Etheric body (aura)—consists of at least seven layers of energy surrounding the body

51
Q

Healing touch vs. Therapeutic touch

A

●Therapeutic Touch—use of hands on or near the body with intent to heal

●Healing touch—use of a collection of energy techniques to assess and treat the human energy system

52
Q

What are the 4 scientific premises of therapeutic touch

A

●A human being is an open energy system.
●Anatomically, a human being is bilaterally symmetrical.
●Illness is an imbalance in an individual’s energy field.
●Human beings have a natural ability to transform and transcend their conditions of living.

53
Q

True or false
Nursing is a subculture of the larger healthcare system culture, and teenagers and older adults are often regarded as subcultures of the general population in the United States

A

True

54
Q

Nurse states I know I’m cleaner than most of my patients. What does this statement indicates?

A

Ethnocentrism, this occurs when one believes that one’s own ideas and practices are superior to those of other

55
Q

The nurse wants to acquire knowledge of the specific culture. What could be done first?

A

Review literature

56
Q

Which of the following documentation guidelines are correct? Select all that apply.

A. Enter information in a complete, accurate, concise, factual and organized manner
B. Wait until end of shift the document nursing interventions to ensure comprehensive chart
C. Date and time each entry

A

A. Enter information in a complete, accurate, concise, factual and organized manner

C. Date and time each entry

57
Q

Which of the following documentation guidelines are correct ?

A. Erase or he’s correcting fluid to completely delete mistaken entry
B. Document nursing interventions as closely as possible to the time of their execution
C. Note problems as they occur in an orderly sequential manner
D. Carefully document all the factors the compromise patient safety and contribute to patient hot

A

B. Document nursing interventions as closely as possible to the time of their execution

C. Note problems as they occur in an orderly sequential manner

58
Q

If you’re looking for a trend in patient’s vital signs what form should you consult first?

A

Graphic sheet

59
Q

This method of documentation uses the categories data, action, and response to facilitate charting (DAR)

A

Focus charting

60
Q

A nurse is describing which type of CAT as involving the use of Meriden energy circuits to nursing support all cells and organs of the body?

A

Acupuncture

61
Q

After reviewing the different complementary and alternative therapies a group of students demonstrate understanding when they identify which of the following is reflecting CAT?

A

It’s recognized by half of the state boards of nursing

62
Q

Which CAT uses the law of similars and law of infinitestimonials?

A

Homopathy, the law of similar states the natural substance that produces a given symptom in a healthy person will curate in a sick person. The law of in a infintestials states that the smallest dose possible will have the desired effect

63
Q

Which CAT is most similar to the current health promotion/disease prevention models

A

Naturopathic medicine

64
Q

Neuropeptide messenger molecules for which type of CAT?

A

Mind body modalities

65
Q

Which of the following is a CAT that involves active participation by the patient is often used in pre/post op pain control?

A

Guided imagery

66
Q

The relaxation response is opposite of which persons ideas?

A

HAns Selye , he developed the term Gen. adaptation syndrome to describe the general holistic pattern emerges when people experience stress or illness. The relaxation answers and alert, hypometabolic state of decreased sympathetic nervous energy arousal.

67
Q

Who developed the theory of energy?

A

Einstein developed a theory of energy.

68
Q

What was Descartes theory?

A

He separated mind and body

69
Q

What did kabot zinn do?

A

He developed the mindfulness-based stress reduction concept

70
Q

Which of the following is true of energy healing approaches?

A

They have a North American nursing diagnosis Association recognize nursing diagnosis. Disturbed energy field and excepted nursing diagnosis

71
Q

Although the nursing process is presented as an orderly progression of steps in reality there’s great interaction and overlapping among the five steps. Which of the following describes his characteristic of the nursing process?

A

Dynamic

72
Q

An actual nursing diagnosis has four components, what are they?

A

Label, definition, defining characteristics, and related factor

73
Q

What to queues must be present for a valid wellness diagnosis

A

A desire for a higher level of wellness

An effective present status or function

74
Q

Which of the following is an optional element in a measurable outcome?

A

Conditions

75
Q

What is the most common mistake nurses make in acute care setting?

A

The most common mistake nurses make when evaluating an acute care settings is waiting until the day the patient is to be discharged before evaluating outcome achievement. At that point it is too late to revise the plan of care

76
Q

What is an advantage of a source oriented record?

A

An advantage of the source oriented record is that each discipline can easily find and chart pertinent data.

A disadvantage is that data are fragmented, making it difficult to track problems chronologically with input from different groups of professionals

77
Q

Notes written to inform caregivers of the progress the patient is making toward achieving expected outcomes are called what

A

Progress notes

78
Q

The narrative portion of focus charting uses what format

A

The DAR format, data, action, response

79
Q

What is the advantage of focus charting?

A

The principal advantage of focus charting is a holistic emphasis on the patient and the patient’s priorities

80
Q

Kardex cards

A

Outside of the card contains basic info such as the patient profile, diagnosis, diet, vital signs, medications. Inside of the Cardex contains the nursing care plan specify nursing diagnosis and health problems

81
Q

What are some examples of energy healing?

A

Acupuncture
Acupressure
Chi gong
Reiki

82
Q

What are the common types of yoga?

A

Ashtanga, focuses on synchronizing breath with a fast-paced series’

Bikram, Hot yoga

Iyengar, proper alignment and holding poses for a long time

Kripaula, gentle yoga relaxation

Nurs. 301 (4 decks)

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