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ADULT 1 > EXAM 2 - Pt. Edu/Doc > Flashcards

EXAM 2 - Pt. Edu/Doc Flashcards

1
Q

What is teaching/patient education?

A

This is a ongoing, interactive process that influences patient behavior, changes knowledge, attitudes, and skills and maintains and improves health

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2
Q

What is counseling?

A

A provision of resources and support that promotes/enhances self-care and effective coping

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3
Q

What does teaching and counseling aim to do?

A
  • Maintaining and promoting health
  • Preventing illness***
  • Restore health
  • Facilitate coping
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4
Q

What are the outcomes of providing patient teaching?

A
  • Disease prevention or early detection
  • Quick recovery from trauma or illness with minimal or no complications
  • Enhanced ability to adjust
  • High-level wellness & related self-care practices
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5
Q

What is a very important factor for successful patient outcomes after teaching has been provided?

A

Patient and family acceptance of lifestyle necessitated by illness or disability (support system must be understanding and supportive for the patient to succeed)

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6
Q

______ is acquiring or increasing knowledge or changing behavior in a measurable way as a result of the experience.

A

Learning

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7
Q

What factors should be considered when individualizing teaching and trying to maximize patient learning as a nurse?

A
  • age and developmental level
  • support networks
  • financial resources
  • cultural influences
  • language deficits & health literacy
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8
Q

What does the TEACH acronym stand for?

A

T – Tune into the patient (active listening)
E – Edit the patient information
A – Act on every teaching moment
C – Clarify often
H – Honor the pt as a partner in the education process

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9
Q

What does the COPE model represent?

A

family support

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10
Q

What does the COPE model stand for?

A

C: Creativity
O: Optimism
P: Planning
E: Expert information

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11
Q

What should you assess for when considering a patient’s family?

A
  • family function and style

- financial resources

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12
Q

When considering cultural beliefs, what should you do first?

A

Be aware of personal assumptions, biases, and prejudices

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13
Q

What reading level are hospital pamphlets?

A

6th or 8th grade reading level

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14
Q

What is health literacy?

A

The ability to read, understand, and act on health information

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15
Q

What should the patient and their families ask?

A
  • What is my main problem
  • What do I need to do?
  • Why is it important for me to do this?
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16
Q

What are the 3 different learning domains?

A
  • cognitive
  • psychomotor
  • affective
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17
Q

This domain stores and recalls new knowledge in the brain:

A

Cognitive

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18
Q

This domain is an integration of both mental and muscular activity to learning a physical skill:

A

Psychomotor

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19
Q

This domain produces changes in attitudes, values, and feelings:

A

Affective

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20
Q

What are some of the most important things to remember when practicing effective communication strategies?

A
  • be sincere and honest (don’t give false hope)
  • do not give more information than necessary
  • do not use medical jargon
  • practice active listening
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21
Q

What is the best way to go about assessing a patients learning needs?

A 
# 1 – Patient typically best source
#2 – Medical record, secondary 
#3 – Family
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22
Q

When preparing to educate a patient, the nurse should assess for:

A
  • Knowledge, Skills, and Attitudes
  • Learning readiness (motivation)
  • Ability to learn
  • Strengths
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23
Q

What is adherence?

A

Behavior consistent with agreed upon recommendations taking on a active role (patient is involved in POC and offers input)

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24
Q

What is compliance?

A

Behavior consistent with clinical advice taking on a passive role (patient has no role or input in POC)

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25
Q

Why does non-adherence and non-compliance occur? What strategies can help prevent the occurrences?

A

Because the patient is not apart of the treatment plan and does not understand the purpose of medication; provide education

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26
Q

What are some examples of cognitive teaching strategies?

A
  • Lecture/Discussion***
  • Panel
  • Discovery
  • Audiovisual
  • Printed Materials
  • Programmed instruction***
  • Computer-assisted***
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27
Q

What are some examples of psychomotor teaching strategies?

A
  • Role modeling***
  • Discussion
  • Panel
  • Audiovisual
  • Role playing***
  • Printed materials
28
Q

What are some examples of affective teaching strategies?

A

Demonstration***
Discovery
Audiovisual
Printed materials

29
Q

How should you schedule patient teachings?

A

make them short and frequent, lasting between 15-30 minutes in duration

30
Q

How often should a formal break be given when conducting long patient teachings?

A

every 50 minutes

31
Q

This portion of the nursing process measures the achievement of outcomes:

A

Evaluation

32
Q

____ is oral questioning

A

cognitive

33
Q

____ is return demonstration

A

psychomotor

34
Q

____ is the patients response

A

affective

35
Q

What action should be taken when desired

outcome not achieved?

A

change your teaching style, making it more individualized to the patient

36
Q

What does documentation include?

A
  • Learning need
  • Plan
  • Implementation
  • Evaluation
37
Q

What is the most important thing a nurse should do during the nurse coaching process?

A
  • Establishing relationships & identifying readiness for change (build rapport)***
  • Identify opportunities, issues, and concerns
  • Establish patient-centered goals
  • Create the structure of the coaching interaction
  • Empower and motivating patients to reach goals
  • Assist the patient to determine progress toward goals
38
Q

This type of counseling is done when there is a immediate concern that requires a fast response to care:

A

short term counseling

39
Q

This type of counseling is done for more than 3-6 months:

A

long term counseling

40
Q

What should always be included in motivational interviewing?

A

evident based research

41
Q

Why is effective documentation so important?

A

It is essential for coordination and continuity of care

42
Q

What are the 3 forms of communication?

A
  1. Documenting
  2. Reporting
  3. Conferring
43
Q

What are some ANA guidelines for effective documentation?

A
  • Consistent with professional and agency standards
  • Complete
  • Accurate
  • Concise
  • Factual
  • Organized and timely
  • Legally prudent
  • Confidential
  • Retrievable
44
Q

What are the patients rights when it comes to documentation and communication?

A
  • See and copy their health record
  • Update their health record
  • Get a list of disclosures
  • Request a restriction on certain uses or disclosures
  • Choose how to receive health information
45
Q

What are some examples of confidential information?

A
  • Name, address, phone, fax, social security number
  • Reason the person is sick
  • Treatments patient receives
  • Information about past health conditions
46
Q

When should you chart on a patient?

A

As soon as you have carried out a task

47
Q

What are some examples of potential breeches of patient information?

A
  • Displaying information on a public screen
  • Sending confidential e-mail messages via public networks
  • Sharing printers among units with differing functions
  • Discarding copies of patient information in trash cans
  • Holding conversations that can be overheard
  • Faxing confidential information to unauthorized persons
  • Sending confidential messages overheard on pagers
48
Q

What should you do when collecting verbal orders from the physician?

A
  • Record the orders in patient’s medical record.
  • Read orders back to practitioner to verify accuracy.
  • Date and note the time orders were issued.
  • Record telephone orders, and full name and title of physician or nurse practitioner who issued orders***
  • Sign the orders with name and title.
49
Q

What is the purpose of patient records?

A
  • Communication
  • Diagnostic and therapeutic orders
  • Care planning
  • Quality process and performance improvement
  • Research; decision analysis (QI)
    Education
  • Credentialing, regulation, and legislation
  • Reimbursement***
  • Legal and historical documentation
50
Q

What are stand alone personal health records?

A

Patients fill in information from their own records and the information is stored on patients’ computers or the Internet.

51
Q

What are tethered/connected personal health records?

A

Linked to a specific health care organization’s electronic health record (EHR) system or to a health plan’s information system (EPIC) * gold standard*

52
Q

What is the biggest benefit of health information?

A

It creates a potential loop for feedback between health-related research and actual practice

53
Q

What does the SOAP format stand for?

A
  • Subjective
  • Objective
  • Application
  • Plan
54
Q

What is the main thing you should have in your nursing documentation?

A

your OWN assessment (always do your own assessment)

55
Q

What is Medicare’s requirements for home health?

A
  • Patient is homebound and still needs skilled nursing care.
  • Rehabilitation potential is good (or patient is dying).
  • The patient’s status is not stabilized.
  • The patient is making progress in expected outcomes of care.
56
Q

What is the purpose of recording data?

A
  • Facilitate quality, evidence-based patient care
  • Serve as a financial and legal record
  • Help in clinical research
  • Support decision analysis
57
Q

How soon should new orders be completed?

A

within 60 minutes

58
Q

What should be included in your telemedicine report?

A
  • Identify yourself and the patient and state your relationship to the patient.
  • Report concisely and accurately the change in the patient’s condition that is of concern and what has already been done in response to this condition.
  • Report the patient’s current vital signs and clinical manifestations.
  • Have the patient’s record at hand to make knowledgeable responses to any physician’s inquiries.
  • Concisely record time and date of the call, what was communicated, and physician’s response.
59
Q

What does the discharge summary summarize? What is included in the discharge summary?

A

It summarizes the reason for treatment and includes:

  • Significant findings
  • Procedures performed
  • Treatment rendered
  • Patient’s condition on discharge or transfer
  • Specific pertinent instructions given to the patient and family
60
Q

Who does an incident report document cover?

A

harm to a patient, employee, or visitor

61
Q

What is a incident report used for?

A

quality improvement

62
Q

What are consultations?

A

Inviting another to evaluate and make recommendations

63
Q

What are referrals?

A

Sending or guiding the patient to another source for assistance

64
Q

What are the 8 behaviors of purposeful rounding?

A
  • Use Opening Key Words (C-I-CARE) with PRESENCE.
  • Accomplish scheduled tasks.
  • Address four Ps.
  • Address additional personal needs, questions.
  • Conduct environmental assessment.
  • Ask “Is there anything else I can do for you? I have time.”
  • Tell the patient when you will be back.
  • Document the round.
65
Q

What are the four Ps?

A
  • Pain
  • Personal needs (toileting)
  • Positioning
  • Fall prevention

ADULT 1 (9 decks)

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