EXAM 2 - Pt. Edu/Doc Flashcards
What is teaching/patient education?
This is a ongoing, interactive process that influences patient behavior, changes knowledge, attitudes, and skills and maintains and improves health
What is counseling?
A provision of resources and support that promotes/enhances self-care and effective coping
What does teaching and counseling aim to do?
- Maintaining and promoting health
- Preventing illness***
- Restore health
- Facilitate coping
What are the outcomes of providing patient teaching?
- 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
What is a very important factor for successful patient outcomes after teaching has been provided?
Patient and family acceptance of lifestyle necessitated by illness or disability (support system must be understanding and supportive for the patient to succeed)
______ is acquiring or increasing knowledge or changing behavior in a measurable way as a result of the experience.
Learning
What factors should be considered when individualizing teaching and trying to maximize patient learning as a nurse?
- age and developmental level
- support networks
- financial resources
- cultural influences
- language deficits & health literacy
What does the TEACH acronym stand for?
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
What does the COPE model represent?
family support
What does the COPE model stand for?
C: Creativity
O: Optimism
P: Planning
E: Expert information
What should you assess for when considering a patient’s family?
- family function and style
- financial resources
When considering cultural beliefs, what should you do first?
Be aware of personal assumptions, biases, and prejudices
What reading level are hospital pamphlets?
6th or 8th grade reading level
What is health literacy?
The ability to read, understand, and act on health information
What should the patient and their families ask?
- What is my main problem
- What do I need to do?
- Why is it important for me to do this?
What are the 3 different learning domains?
- cognitive
- psychomotor
- affective
This domain stores and recalls new knowledge in the brain:
Cognitive
This domain is an integration of both mental and muscular activity to learning a physical skill:
Psychomotor
This domain produces changes in attitudes, values, and feelings:
Affective
What are some of the most important things to remember when practicing effective communication strategies?
- be sincere and honest (don’t give false hope)
- do not give more information than necessary
- do not use medical jargon
- practice active listening
What is the best way to go about assessing a patients learning needs?
# 1 – Patient typically best source #2 – Medical record, secondary #3 – Family
When preparing to educate a patient, the nurse should assess for:
- Knowledge, Skills, and Attitudes
- Learning readiness (motivation)
- Ability to learn
- Strengths
What is adherence?
Behavior consistent with agreed upon recommendations taking on a active role (patient is involved in POC and offers input)
What is compliance?
Behavior consistent with clinical advice taking on a passive role (patient has no role or input in POC)
Why does non-adherence and non-compliance occur? What strategies can help prevent the occurrences?
Because the patient is not apart of the treatment plan and does not understand the purpose of medication; provide education
What are some examples of cognitive teaching strategies?
- Lecture/Discussion***
- Panel
- Discovery
- Audiovisual
- Printed Materials
- Programmed instruction***
- Computer-assisted***
What are some examples of psychomotor teaching strategies?
- Role modeling***
- Discussion
- Panel
- Audiovisual
- Role playing***
- Printed materials
What are some examples of affective teaching strategies?
Demonstration***
Discovery
Audiovisual
Printed materials
How should you schedule patient teachings?
make them short and frequent, lasting between 15-30 minutes in duration
How often should a formal break be given when conducting long patient teachings?
every 50 minutes
This portion of the nursing process measures the achievement of outcomes:
Evaluation
____ is oral questioning
cognitive
____ is return demonstration
psychomotor
____ is the patients response
affective
What action should be taken when desired
outcome not achieved?
change your teaching style, making it more individualized to the patient
What does documentation include?
- Learning need
- Plan
- Implementation
- Evaluation
What is the most important thing a nurse should do during the nurse coaching process?
- 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
This type of counseling is done when there is a immediate concern that requires a fast response to care:
short term counseling
This type of counseling is done for more than 3-6 months:
long term counseling
What should always be included in motivational interviewing?
evident based research
Why is effective documentation so important?
It is essential for coordination and continuity of care
What are the 3 forms of communication?
- Documenting
- Reporting
- Conferring
What are some ANA guidelines for effective documentation?
- Consistent with professional and agency standards
- Complete
- Accurate
- Concise
- Factual
- Organized and timely
- Legally prudent
- Confidential
- Retrievable
What are the patients rights when it comes to documentation and communication?
- 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
What are some examples of confidential information?
- Name, address, phone, fax, social security number
- Reason the person is sick
- Treatments patient receives
- Information about past health conditions
When should you chart on a patient?
As soon as you have carried out a task
What are some examples of potential breeches of patient information?
- 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
What should you do when collecting verbal orders from the physician?
- 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.
What is the purpose of patient records?
- 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
What are stand alone personal health records?
Patients fill in information from their own records and the information is stored on patients’ computers or the Internet.
What are tethered/connected personal health records?
Linked to a specific health care organization’s electronic health record (EHR) system or to a health plan’s information system (EPIC) * gold standard*
What is the biggest benefit of health information?
It creates a potential loop for feedback between health-related research and actual practice
What does the SOAP format stand for?
- Subjective
- Objective
- Application
- Plan
What is the main thing you should have in your nursing documentation?
your OWN assessment (always do your own assessment)
What is Medicare’s requirements for home health?
- 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.
What is the purpose of recording data?
- Facilitate quality, evidence-based patient care
- Serve as a financial and legal record
- Help in clinical research
- Support decision analysis
How soon should new orders be completed?
within 60 minutes
What should be included in your telemedicine report?
- 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.
What does the discharge summary summarize? What is included in the discharge summary?
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
Who does an incident report document cover?
harm to a patient, employee, or visitor
What is a incident report used for?
quality improvement
What are consultations?
Inviting another to evaluate and make recommendations
What are referrals?
Sending or guiding the patient to another source for assistance
What are the 8 behaviors of purposeful rounding?
- 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.
What are the four Ps?
- Pain
- Personal needs (toileting)
- Positioning
- Fall prevention
