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Final Flashcards

1
Q

How to safety handle patients and protect yourself from injury?

A
  • High incidence of work-related injuries
  • Evidence based interventions
  • Ergonomics: equipment
  • protect your back!
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2
Q

prevention of work related musculoskeletal injuries

A
  • Weight to be lifted close to body-maintains center of gravity
  • Bend at knees-maintains center of gravity and uses strong leg muscles
  • Tighten abdominal muscles and tuck pelvis-balance and protects the back
  • Do not twist at trunk
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3
Q

types of transfers

A 
Bed to chair
Bed to commode
Bed to wheelchair
Bed to stretcher
Logrolling
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4
Q

gait belt

A

used to transfers people from one position to another or from one thing to another
- gives us a steady set of hands

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5
Q

transferring and positioning patients

A

Use gait belts
Assess patient: strength, orientation status, pain
Move item to transfer to as close to patient as possible
Stand opposite of patient’s hips
Use pivot techniques to move
Obtain appropriate amount of staff
Raise the bed to a comfortable working height

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6
Q

patients falls

A 
Fall risk assessment
Risk of falling increases as number of risk factors increases:
Follow fall protocols
Patient-centered care
Assistive aids
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7
Q

what can be done to prevent falls?

A
  • Side rails up on beds and stretchers
  • Remove excess furniture or equipment in room
  • No skid slipper socks
  • Hourly rounding
  • Make sure assistive walking devices are used properly and in good condition: Physical Therapy department (PT)
  • Fall prevention wrist band
  • Low safety bed
  • Gait belt for ambulating
  • Call light within reach before leaving patient’s room
  • Location of patient’s room
  • Use of family members/support personnel
  • Bed/chair alarm
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8
Q

the 4 P’s

A

Pain
Potty
Positioning
Personal belongings

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9
Q

assistive devices: walker

A

Handles of walker go to greater trochanter (wrist height)

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10
Q

assistive devices: wheelchair

A

Use locks, armrests and foot rests

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11
Q

assistive devices: canes

A

Canes-Can be single or quad
Handle should be at wrist crease
Should be on stronger side of body
not typically used in hospitals

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12
Q

assistive devices: crutches

A

Crutches-Can be forearm or axillary
3-4 Finger width, elbows at 30 degrees
Do not lean on the axillae: It can put a lot of pressure on nerves in armpit
Temporary need for pt

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13
Q

Risk for disability related to immobility depends on

A

the extent and duration of immobilization

overall health of the patient

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14
Q

nature of mechanics

A

body mechanics: Force of weight is down
alignment & balance: your center of gravity is stable and balanced
gravity: Have a good center of gravity so we can protect ourselves
friction & shear: the greater the surface area of an object that is moving the greater the friction; force exerted against skin while skin remains stationary: shear

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15
Q

immobility onset

A

temporary: knee surgery
permanent: paraplegia
sudden: car accident where pt broke leg
slow: arthritis

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16
Q

pathological influences on mobility

A

Postural abnormalities: Congenital or acquired postural abnormalities affect the efficiency of the musculoskeletal system and body alignment, balance, and appearance.
Muscle abnormalities: Injury and disease lead to alterations in musculoskeletal function.
Damage to central nervous system (CNS): Impaired body alignment, balance, and mobility.
Musculoskeletal trauma: Results in bruises, contusions, sprains, and fractures.
(any injury with one system will cause problems with the other)

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17
Q

Nursing Process: Assessment Mobility

A 
Focuses on ROM, Gait, exercise and activity tolerance, and body alignment. 
Gait
ADL
Activity tolerance:
Physiological
Emotional
Developmental
(as age progresses the less things people can do)
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18
Q

Nursing Process: Assessment of body system changes

A

Metabolic: Measure height, weight, and skinfold thickness. I&O, food intake, elimination, wound healing.
Respiratory: Ever 2 hours, inspect chest wall movements, auscultate lungs.
Cardiovascular: BP, apical and peripheral pulses, signs of venous stasis.
Musculoskeletal: Decreased muscle tone and strength, loss of muscle mass, reduced ROm, and contractures.
Integumentary: Assess for skin breakdown and color changes.
Psychosocial
Developmental

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19
Q

metabolic

A 
Altered endocrine system:
Decreased basal metabolic rate
Changes in protein, carbohydrate and fat metabolism
Alterations in calcium, fluid and electrolytes
Assessment:
Decreased Intake and Output
Altered urinary and bowel elimination
Monitor Lab values
can lead to: Muscle loss
Weight loss
Hypercalcemia
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20
Q

respiratory

A

Decreased respiratory movement:
Secretions accumulate in the dependent areas of the lungs.
Decreased cough response
Decreased oxygenation
Atelectasis and pneumonia
Assessment:
inspecting the chest for movement
auscultating the lungs for decreased breath sounds, crackles, and wheezes.
Perform assessment at least every 2 hours for patients with restricted activity
*** use incentive spirometer

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21
Q

cardiovascular

A 
Decreased cardiac output and effectiveness:
Blood stasis
Decreased fluid volume
deep vein thrombosis (DVT)
Orthostatic hypotension
Assessment:
Blood pressure monitoring
evaluation of pulses
signs of venous stasis
***  use TED hose, Get patients up slowly for the first time , Sit them up and let them dangle at the side of the bed
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22
Q

musculoskeletal

A 
Decreased muscle endurance, strength, and mass:
Muscle atrophy
Impaired balance
Impaired calcium absorption
Joint abnormalities and fractures
Assessment:
ROM capability
Muscle tone and mass
Monitor gait
Monitor nutritional intake of Calcium
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23
Q

why do pts need to move their muscles?

A

they will lose them!!
Foot drop: permanent
Contracture: fixation of the joint caused by shortened muscles

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24
Q

muscular reconditioning and disuse atrophy

A

The effects of muscular deconditioning associated with lack of physical activity are often apparent in a matter of days.
Higher Risk for falls
lose 3% a day

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25
Q

integumentary

A

Decreased circulation to tissue and increased pressure on skin can lead to pressure ulcers
Assess:
skin for breakdown and color changes such as pallor or redness.
Assess at least every two hours
Observe for urinary or bowel incontinence
Pressure ulcer
Ischemia
*** Make sure pt are clean and dry

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26
Q

elimination

A

Decreased fluid intake, poor perineal care and decreased peristalsis:
Urinary stasis
Renal calculi
Constipation/fecal impaction
Assess:
elimination status on each shift and total intake and output every 24 hours.
Bladder distention
adequacy of dietary choices, bowel sounds, and the frequency and consistency of bowel movements.
*** watch for kidney stones & impacted bowel

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27
Q

psychosocial

A

Altered sensory perception and ineffective coping:
Depression and anxiety
Loneliness and social isolation
changes in the sleep/wake cycle
Assessment:
Focus on the patient’s emotional state, behavior, and sleep-wake cycle.
Ineffective coping
Support systems
*** If immobile probably lacking socialization

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28
Q

immobility across the lifespan: infants toddlers, preschoolers

A

Prolonged immobility delays gross motor skills, intellectual development, musculoskeletal development.
Usually because of trauma or the need to correct a congenital skeletal abnormality.

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29
Q

immobility across the lifespan: adolescents

A

Delayed in gaining independence and in accomplishing skills

Social isolation can occur

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30
Q

immobility across the lifespan: adults

A

Physiological systems are at risk

Changes in family and social structures

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31
Q

immobility across the lifespan: older adults

A

Decreased physical activity
Hormonal changes
Bone reabsorption

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32
Q

nursing diagnosis for immobility

A
  • Impaired physical mobility
  • Risk for Disuse Syndrome
  • Ineffective Airway Clearance
  • Ineffective Coping
  • Impaired Urinary Elimination
  • Risk for impaired Skin integrity
  • Social Isolation
  • Risk for Falls
33
Q

planning: immobility

A 
Goals and outcomes
Setting priorities
Teamwork and collaboration
Make sure immediate needs are met first, prioritize
Individualize plan of care
Age appropriate
34
Q

implementation: metabolic

A

Provide high-protein, high-calorie diet with vitamin B and C supplements.
If the patient is unable to eat, nutrition can provided parenterally or enterally

35
Q

implementation: respiratory

A

Cough and deep breathe every 1 to 2 hours
Adequate fluid intake(2,000 mL per day)
Reposition every 1-2 hours
Monitor ability to expectorate secretions

36
Q

implementation: cardiovascular

A 
Increase activity as soon as possible: 
Change positions as often as possible
ROM exercises
Orthostatic Blood pressure measurement:
Lying to sitting to standing
37
Q

Prevention of complications from immobilityDVT Prophylaxis

A
  • Sequential Compression Devices (SCD): help promote venous return by squeezing leg
  • TED Hose(anti-embolitic stockings): promote venous return
  • Medication
  • ** do these things before there is a problem
38
Q

implementation: musculoskeletal

A

ROM exercises
Assistive devices(cane, crutches, walker)
Change position in bed at least every 2 hours
Shift weight when sitting every 15 minutes
Assist with ambulation
Physical therapy

39
Q

implementation: integumentary

A 
Positioning and Skin Care:
Reposition every 1 to 2 hours
Use of therapeutic devices to relieve pressure: Trapeze bar
Limit sitting in chair to 1 hour
Provide skin and perineal care
Good skin assessment skills
40
Q

implementation: elimination

A

Provide adequate hydration(2,000 mL/day)
Serve a diet rich in fluids, fruits, vegetables, and fiber.
Medications such as stool softeners, laxatives or enema

41
Q

implementation: psychosocial

A 
Routine and informal socialization
Involve in daily care activities
Help maintain body image
Scheduling therapies
Encourage visitors
Might have a roommate if in rehab
42
Q

implementation: developmental

A

Family involvement
Provide mental and physical stimulation
Play therapist in children’s hospitals
Teach families activities

43
Q

evaluation of immobility

A

Patient outcomes:
Evaluate effectiveness of specific interventions
Evaluate patient’s and family’s understanding of all teaching provided

44
Q

what is communication?

A

The process of sending and receiving messages both verbal and nonverbal
Allows for exchange of information, feelings, needs and preferences
Goal is to have a mutual understanding of the meaning of the message and receive feedback that indicates the meaning of the message was communicated as intended
Communication can result in harm or good
Metacommunication: Term that refers to all factors that influence communication

45
Q

emotional intelligence

A

Assessment and communication technique that allows nurses to better understand and perceive the emotions of themselves and others
Enables the nurse to use self awareness, motivation, empathy, and social skills to build therapeutic relationships with patients.

46
Q

electronic communication

A

Electronic communication is a constantly growing form of communication. Most people use the form of communication numerous times a day thru email, texting, cell phones, etc
Nurses need to be able to utilize technology to create ongoing relationships with patients and their health care team(example-nurses using iphones for patient communication, patients being able to view their medical information online)

Secure messaging provides an opportunity for frequent and timely communication with a patient’s physician or nurse via a patient portal

47
Q

levels of communication

A

Intrapersonal communication-occurs within the individual, inner thought, used to develop self awareness
Interpersonal communication-one on one interaction that occurs face to face, used most frequently and is at the heart of nursing practice, meaningful exchange results in an exchange of ideas, problem solving, expression of feelings, decision making, goal accomplishment, team building and personal growth
Transpersonal communication-used when addressing spiritual needs, nurses need to assess a patient’s spiritual needs and intervene to meet those needs
Small group communication-usually goal directed, working in committees, most effective when they are cohesive
Public communication-interaction with an audience

48
Q

communication cycle (circular transactional model)

A

The referent motivates one person to communicate with another. In a health care setting sights, sounds, sensations, perceptions, and ideas are examples of cues that initiate the communication process.
The sender is the person who encodes and delivers a message, and the receiver is the person who receives and decodes the message. The more the sender and receiver have in common and the closer the relationship, the more likely they will accurately perceive one another’s meaning and respond accordingly.
The message is the content of the communication. It contains verbal and nonverbal expressions of thoughts and feelings. Effective messages are clear, direct, and in understandable language.
Communication channels are means of sending and receiving messages through visual, auditory, and tactile senses. Facial expressions send visual messages; spoken words travel through auditory channels. Touch uses tactile channels. Individuals usually understand a message more clearly when the sender uses more channels to send it.
Feedback is the message a receiver receives from the sender. It indicates whether the receiver understood the meaning of the sender’s message.
Interpersonal variables are factors within both the sender and receiver that influence communication. Perception provides a uniquely personal view of reality formed by an individual’s culture, expectations, and experiences. Each person senses, interprets, and understands events differently.
The environment is the setting for sender-receiver interaction. An effective communication setting provides participants with physical and emotional comfort and safety.

49
Q

types of communication

A

Verbal communication-includes use of spoken and written words, can be altered by vocabulary-use of medical terminology, understanding the meaning of the word used(can have more than one meaning), the pace of the conversation, the tone of the message, clarity and timing of the message delivered(if a patient is in pain or emotionally distressed they may not be able to process what is being communicated to them)
Vocabulary, timing and relevance is very important for nurses(this takes time and practice to be an effective communicator)

Nonverbal-includes the five senses and nonverbal messages can be easily misinterpreted(what does personal appearance say about the nurse or the patient)?
Examples-What does showing up in wrinkled clothes say to you patient?
What does poor posture and slow slumped gait suggest?
Facial expression-face is the most expressive part of the body, people are sometimes unaware of the their facial expressions
Nurses need to make sure they are using appropriate eye contact, use of gestures, sounds(such as sighing) and personal space can all impact how the message is received

50
Q

professional nursing relationships

A

Nurse-patient-helping relationships are the foundation of clinical nursing practice. Nurse assumes role of the helper and recognizes the patient as an individual with unique health needs, human responses and patterns of living. Therapeutic relationships promote a climate that facilitates positive change and growth

Nurse-family-form relationship with the entire family

Nurse-healthcare team-communication with the team can affect patient care/safety and the work environment and how to interact with coworkers, accurate communication is essential to preventing errors

Nurse-community-communication providing education on health promotion to the community

51
Q

phases of the helping relationship

A

Preinteraction phase-reviewing patient data including history, previous notes, previous assessments and any other pertinent data
Orientation phase-the phase when the patient and nurse get to know each other, initial relationship is superficial, expect the patient to test your competence and commitment
Working phase-nurse and patient work together to solve problems, nurses need to encourage expression of feelings and use therapeutic communication
Termination phase-ending of the relationship, evaluate goal achievement with the patient, and the nurse relinquishing responsibility of care

52
Q

Developing communication skills

A

Each individual bases his or her perceptions about information received through the five senses of sight, hearing, taste, touch, and smell.
An individual’s culture and education also influence perception. People often incorrectly assume that they understand an individual’s culture. They tend to distort or ignore information that goes against their expectations, preconceptions, or stereotypes.
Critical thinking helps nurses overcome perceptual biases or stereotypes that interfere with accurately perceiving and interpreting messages from others.
By thinking critically about personal communication habits, you learn to control these tendencies and become more effective in interpersonal relationships.
You learn to integrate communication skills throughout the nursing process as you collaborate with patients and health care team members to achieve goals.

53
Q

basics of professional communication

A

Professional appearance for a nurse is the expectation to be clean, neat, well groomed, conservatively dressed, and odor free.
Professional behavior reflects warmth, friendliness, confidence, and competence. Professionals speak in a clear, well-modulated voice; use good grammar; listen to others; help and support colleagues; and communicate effectively.
Professional appearance, demeanor and behavior communicate that you have assumed the professional helping role, are clinically skilled, and are focused on your patient
Common courtesy is part of professional communication. To practice courtesy, say hello and goodbye to patients and knock on doors before entering.
Always introduce yourself. Failure to give your name and status or to acknowledge a patient creates uncertainty about the interaction and conveys an impersonal lack of commitment or caring.
To foster trust, communicate warmth and demonstrate consistency, reliability, honesty, competence, and respect.
Autonomy is being self-directed and independent in accomplishing goals and advocating for others. Professional nurses make choices and accept responsibility for the outcomes of their actions.
Assertiveness allows you to express feelings and ideas without judging or hurting others. Assertive behavior includes intermittent eye contact; nonverbal communication that reflects interest, honesty, and active listening; spontaneous verbal responses with a confident voice; and culturally sensitive use of touch and space.

54
Q

why should nurses use critical thinking with communication?

A

Nurses who develop critical thinking skills make the best communicators
Integrate knowledge, analyze content and evaluate effect
Using critical thinking helps nurse to make decisions about what, when, where, and how to best convey a message

Patients are more likely to communicate with a nurse who expresses an interest in them

55
Q

factors influencing communication

A

Psychophsiological context-internal factors that influence communication such as pain, hunger, emotional status, developmental level, unmet needs, perceptions and personalities, self-esteem
Relational context- is the nature of the relationship. It is the level of trust and caring expressed, balance of power and control between the nurse and the patient
Situational context-is the reason for communication-Is the nurse/patient using it for information exchange, problem resolution, expression of feelings
Enviromental context-is the physical surroundings- What is the privacy level, noise level, comfort and safety level, or distraction level
Cultural context-what is the education level of participants, language, customs and expectations

56
Q

challenging communication situations

A

pts that are silent, withdrawn or have difficulty expressing feelings
pts that are sad or depressed
pts with special needs
pts that are angry or confrontational
pts that are uncooperative
pts that are talkative and want someone to be with them all the time
pts that are demanding and expect others to meet their requests
pts that have difficulty seeing and hearing
pts who are confused and disoriented
pts with English as a second language
pts who are sexually inappropriate
pts that are frightened, anxious, and having difficulty coping

57
Q

assertive communication

A

Assertiveness allow you to express feelings and ideas without judging or hurting others
Increases self esteem and self-confidence, increases the ability to develop satisfying interpersonal relationships and increases goal attainment
Make decisions and control their lives effectively
Deal with criticism and manipulation, learn to say no, set limits and resist intentionally imposed guilt
Responses include “I” messages
“I” want, need, think, feel

58
Q

assessment: communication

A

During the assessment process, thoroughly assess each patient and critically analyze findings to ensure that you make patient-centered clinical decisions required for safe nursing care.
Patient-centered care requires careful assessment of a patient’s values; preferences; and cultural, ethnic, and social backgrounds. If the nurse cannot resolve his or her bias related to a patient, care should be transferred to another individual.
Internal and external factors can also affect a patient’s ability to communicate.
It is especially important to assess the psychophysiological factors that influence communication. Many altered health states and human responses limit communication. Review of a patient’s medical record provides relevant information about his or her ability to communicate.
Aspects of a patient’s growth and development also influence nurse-patient interaction. Adapt communication techniques to the special needs of infants and children and their parents.
Age alone does not determine an adult’s capacity for communication.
Hearing loss and visual impairments are changes that may occur during aging that contribute to communication barriers.
Simple measures facilitate communication with older individuals who have hearing loss.
[Review Box 24-7, Focus on Older Adults” Tips for Improved Communication with Older Adults Who Have Hearing Loss]
Culture influences thinking, feeling, behaving, and communicating. Be aware of the typical patterns of interaction that characterize various ethnic groups, but do not allow this information to bias your response.
[Review Box 24-8, Cultural Aspects of Care: Communication with Non-English-Speaking Patients.]
Gender influences how we think, act, feel, and communicate.
Men tend to use less verbal communication but are more likely to initiate communication and address issues more directly. They are also more likely to talk about issues.
Women tend to disclose more personal information and use more active listening, answering with responses that encourage the other person to continue the conversation.

59
Q

nursing diagnosis/analysis: communication

A

Intrapersonal analysis of assessment findings
Validation of health care needs and priorities during discussion with the patient
Focus on the cause of the communication problem
Remember that impairment of communication can be physiological, mechanical, anatomical, psychological, cultural, or developmental.
The primary nursing diagnostic label used to describe a patient with limited or no ability to communicate verbally is impaired verbal communication.
This is the state in which an individual experiences a decreased, delayed, or absent ability to receive, process, transmit, and use symbols for a variety of reasons.
The defining characteristics for this diagnosis include the inability to articulate words, inappropriate verbalization, difficulty forming words, and difficulty comprehending, which you cluster together to form the diagnosis.
Although a patient’s primary problem is impaired verbal communication, the associated difficulty in self-expression or altered communication patterns may contribute to other nursing diagnoses:
Impaired verbal communication
Anxiety
impaired Social isolation
ineffective coping
compromised family coping
powerlessness

60
Q

planning: communication

A

Health care team planning sessions
Collaboration with patient and family to determine implementation methods
Written documentation of expected outcomes
Patient will be able to clearly convey messages with healthcare team- speech therapist or an interpreter.

61
Q

implementation: communication

A

Delegation and verbal discussion with healthcare team members
Verbal, visual, and tactile teaching activities
Therapeutic communication techniques are specific responses that encourage the expression of feelings and ideas and convey acceptance and respect.
Active listening means being attentive to what a patient is saying both verbally and nonverbally.
Use “SOLER”:
Sit facing the patient; observe an open posture, lean toward the patient, establish and maintain intermittent eye contact; relax

62
Q

therapeutic communication

A

Promote personal growth and attainment of health-related goals
Occurs within a healing relationship between a nurse and a patient
Therapeutic interactions are often intense, difficult and uncomfortable
Comfort is key to creating a therapeutic environment
Assess verbal and nonverbal client communication needs
Respect the client’s personal values and beliefs
Allow time to communicate with the client
Use therapeutic communication techniques to provide client support
Encourage the client to verbalize feelings (e.g., fear, discomfort)
Evaluate the effectiveness of communications with the client

63
Q

therapeutic communication techniques

A 
Active listening
Sharing Observations
Sharing Empathy
Sharing Hope
Sharing Humor
Sharing Feelings
Using touch
Self-Disclosure
Using silence
Providing information
Clarifying
Focusing
Paraphrasing
Asking Questions
Summarizing
Validation
Confrontation
64
Q

non therapeutic communication

A

Personal questions-not related to the situation and are to satisfy personal curiosity
Personal opinion differs from giving professional advice
Changing subject-shows lack of empathy and can stall further communication
Automatic responses-stereotyping, being only task oriented
False reassurance-”don’t worry everything will be alright”
Sympathy-concern or pity, not use of empathy
Defensive-implies the other person has no right to their opinion
Aggressive-provoke confrontation at the other’s expense
Arguing-challenging or arguing can often imply that the other person is lying

65
Q

adapting communication techniques

A

Patients who cannot speak clearly
Cognitive impairment
Hearing impairment
Visual impairment
Unresponsive
Patients who do not speak English (or your language)
Patients with impaired verbal communication require special consideration and alterations in communication techniques to facilitate sending, receiving, and interpreting messages.

66
Q

pediatric nursing considerations: communication

A

Show respect to all members, build trust by being honest, genuine and authentic in your relationships, never make promises you can’t keep
Never breach privacy
Active listening is maintaining eye contact, direct attention
Be aware of your verbal and nonverbal communication
Show empathy
Provide conflict management by using creativity, clarification of feelings, safety
Use of humor
solicit information
offer solutions
support child and family
educate

67
Q

I CUS because I am concerned

A

CUS protocol
C=“ I am concerned about……..”
U= “I am uncomfortable with…….”
S= “I think we have a safety issue that needs to be addressed…….”

68
Q

SBAR

A

SBAR-Standardized way of communicating for a specific situation
Can be used by nurses, doctors, ancillary staff, all health care team members
The Situation, Background, Assessment and Recommendation (SBAR) technique has become the Joint Commission’s stated industry best practice for standardized communication in healthcare

S=Situation
B=Background
A=Assessment
R=Recommendation

69
Q

evaluation: communication

A

You and your patient determine the success of the plan of care by evaluating patient communication outcomes together. You determine which strategies or interventions were effective and which patient changes (behaviors or perceptions) resulted because of the interventions.
Evaluation of the communication process helps nurses gain confidence and competence in interpersonal skills. Becoming an effective communicator greatly increases your professional satisfaction and success.
There is no skill more basic, no tool more powerful.

70
Q

confidentiality

A

Only discuss information with those that need to know
HIPAA-legislation to protect patient privacy for health information, governs all areas of patient information and management of that information
This includes not reading other charts for which you are not providing care and never using information for personal use-includes looking up your own or family and friends personal information
Only members of the health care team who are directly involved in a patient’s care have legitimate access to the medical record.
Patients have the right to request copies of their medical records and read the information.
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was the first federal legislation providing protection for patient records; it governs all areas of patient information and management of that information. Requires that disclosure or requests regarding health information be limited to the specific information required for a particular purpose.
Sometimes nurses use health care records for data gathering, research, or continuing education. As long as a nurse uses a record as specified and permission is granted, this is permitted.
You can review your patients’ medical records only for information needed to provide safe and effective patient care.
Not only is it unethical to view medical records of other patients, but breaches of confidentiality lead to disciplinary action by employers and dismissal from work or nursing school(It is ok to view records as long as it is being used for educational purposes)

71
Q

what is in a patient record

A 
pt info and demographic data
informed consent for treatment and procedures 
admission data
nursing diagnosis and plan of care
record of nursing care treatment and evaluation 
medical history 
medical diagnosis 
therapeutic orders
medical and discipline progress notes
physical assessment findings 
diagnostic study results 
patient education 
summary of operative procedures
discharge plan and summary
72
Q

why do we need medical records?

A 
Communication
Legal documentation
Financial billing
Education
Research
Auditing-Monitoring: used a part of quality improvement programs used for ongoing reviews of patient care, used to determine if standards are being met and can be used to make changes in policy and practice
73
Q

5 characteristic of quality documentation

A
  1. Factual-use of descriptive, objective information, avoid terms like appears, seems or apparently(like stating an opinion instead of facts)
    Use of subjective data should include exactly what the patient says
  2. Accurate-use of exact measurements gives clearer picture than non descriptive statements, makes documentation clear and easy to understand, use of approved medical terminology and spelling
  3. Complete-must be complete containing all essential information
  4. Current-delays in documentation can lead to unsafe patient care
  5. Organized-communicate information in a logical order, be clear, concise and to the point
74
Q

handling and disposing of information

A

Destroy (e.g., shred) anything that is printed when the information is no longer needed.
You need to de-identify all patient data when you write it onto forms or include it in papers written for nursing courses.
Historically, the primary sources for inadvertent, unauthorized disclosure of PHI occurred when information was printed from a patient record and/or faxed to other health care providers. Destroy all printed material after faxing.
The following are some steps to take to enhance fax security:
Confirm that fax numbers are correct before sending to be sure that you direct information properly.
Use a cover sheet to eliminate the need for the recipient to read the information to determine who gets it.
Authenticate at both ends before data transmission to verify that source and destination are correct.
Use programmed speed-dial keys to eliminate the chance of a dialing error and misdirected information.
Use the encryption feature on the fax machine. Encoding transmissions makes it impossible to read confidential information without the encryption key.
Place fax machines in a secure area and limit machine access to designated individuals.
Log fax transmissions. This feature is often available electronically on the machine.

75
Q

legal perspective on documentation

A

Nothing documented = nothing done
Poorly documented = poorly done
Incorrectly documented = fraudulent

76
Q

charting DO’S

A

time and date: all entries

chart: as you make observations and provide care
describe: patients behavior; use direct pt quotes when appropriate
record: exactly what happens to the pt and interventions given; be factual and complete

77
Q

charting DON’TS

A

Don’t begin charting until you verify the name and identifying number on the patient’s medical record
Don’t chart procedures or interventions in advance.
Don’t clutter notes with repetitive or frequently changing data already charted in other places.
Don’t make an entry for someone else, or change an entry because someone tells you to.
Don’t show bias toward patients.
Don’t try to cover up a mistake or incident by inaccuracy or omission.
Don’t use meaningless words and phrases such as “good day” or “no complaints”.

78
Q

methods of recording

A

Several documentation systems for recording patient data- either paper or electronic health record(EHR)
Narrative-use of a story like format to document information specific to patient conditions and nursing care-can be time consuming
Problem oriented medical record-method of documentation that emphasizes patients problems, data is organized by problem or diagnosis
Source records -separate section for each discipline to record data(dr, nurse, cm, etc), doesn’t show how care is related or coordinated to meet the patients needs
Charting by exception- focuses on documenting from established norms, reduces documentation time, all standards are met unless otherwise documented
Case management plan/critical pathways-interdisciplinary approach to documenting patient care, critical pathways are interdisciplinary approach to care plans that include patient problems, key interventions, and expected outcomes
Kardex-contains most basic information at hand for the nurse without having to constantly refer and search through chart
Flow sheet -allow information to be entered quickly and easily, can be paper or computerized-ex restraint log
Care plan -preprinted established guidelines used to care for patients with similar health problems
Discharge -safe, timely discharge with desired outcomes, begins at admission with identifying needs and plans

Fundamentals (4 decks)

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