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NURS 115 > Outline Unit 1 > Flashcards

Outline Unit 1 Flashcards

1
Q

initiation of independent nursing interventions without medical records

A

autonomy

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2
Q

reasonably independent and self-governing in decision making

A

reach through experience, advanced education

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3
Q

professionally and legally responsible for the type and quality of nursing care provided

A

accountability

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4
Q

code of ethics and legal aspects of nursing

A

ANA - American Nurses Association

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5
Q

NPA - Nurse Practice Act

A

regulates the scope of nursing practice for the state and protects public health, safety, and welfare

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6
Q

NPA differs from

A

state to state

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7
Q

concepts for a critical thinker

A 
truth seeking
open-mindedness
analytic approach
systematic approach
self-confidence
inquisitiveness
maturity
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8
Q

critical thinker reflecting on your own judgments

A

maturity

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9
Q

being eager to acquire knowledge and learn explanations

A

inquisitiveness

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10
Q

trust own reasoning processes

A

self-confidence

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11
Q

organized and focused critical thinker

A

systematic approach

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12
Q

alert to potentially problematic situations

A

analytic approach

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13
Q

tolerant to diff views and clearly know the views of PT

A

Open-mindedness

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14
Q

be courageous, honest, and objective about asking questions

A

truth seeking

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15
Q

make more conscious effort to apply critical thinking BC initially you are more task oriented and trying to learn how to organize nursing care activities

A

Level 1 basic critical thinking

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16
Q

develop new thought or idea based on your experience and knowledge over time

A

Level 2 Complex critical thinking

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17
Q

anticipate the need to make choices without assistance from others - accept accountability for decisions you make

A

Level 3 commitment critical thinking

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18
Q

scientific method to critical thinking

A
  1. identify the problem
  2. collecting of data
  3. forming a question or hypothesis
  4. testing the questing or hypothesis
  5. evaluating results of the test or study
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19
Q

drawing conclusions from related pieces of evidence and previous experience with the evidence

A

diagnostic reasoning and inference

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20
Q

requires careful reasoning so you choose the options for the best PT outcomes on the basis of PT condition and priority of the problem

A

Clinical decision making

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21
Q

components of critical thinking

A
  1. knowledge base
  2. experience
  3. competence
  4. attitude
  5. standards
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22
Q

visual representation of PT problems and interventions that illustrates and interrelationship

A

concept mapping

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23
Q

reasoning process used to reflect on and analyze thoughts, actions, and knowledge

A

developing critical thinking skills

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24
Q

decision making

A

responsibility, autonomy, authority, accountability

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25
Q

duties and activities an individual is employed to perform

A

responsibility

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26
Q

independent decisions about PT care

A

autonomy

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27
Q

legitimate power to give commands and make final decisions specific to give position

A

authority

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28
Q

answerable for the actions

A

accountability

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29
Q

leadership skills for nursing students

A

clinical care coordination, team communication, delegation, knowledge building

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30
Q

requires knowing which skills are transferable

A

delegation

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31
Q

improves PT care, improves efficacy, increased productivity

A

delegation

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32
Q

5 rights of delegation

A

Task, circumstance, person, direction/communication, supervision

33
Q

always care for PT as if they can hear everything you say; tell them what you’re doing before you do it

A

nonverbal communication

34
Q

nonverbal communication

A
  1. personal appearance
  2. posture & gait
  3. facial expression
  4. eye contact
  5. gestures
  6. territoriality and personal space
35
Q

all factors that influence communication

A

metacommunication

36
Q

factors influencing communication

A
  1. psychophysiological
  2. relational
  3. situational
  4. environmental
  5. cultural
37
Q

ability to understand and accept another persons perspective

A

empathy

38
Q

attentive to what PT says verbally and nonverbally

A

listening

39
Q

therapeutic communication technigues to listening

A 
S-Sit facing PT
O- Open posture
L- Lean toward the PT
E- Eye contact
R-Relax
40
Q

observe and comment on PT appearance, sounds, acts

A

sharing observations

41
Q

helps communication without extensive questioning

A

sharing observations

42
Q

time to collect thoughts

A

using silence

43
Q

helps PT make decisions, less anxiety, feel safe & secure

A

providing info

44
Q

validates whether the person interpreted correctly

A

clarifying

45
Q

direct convo on specific topic when it becomes unclear

A

focusing

46
Q

restating senders message in receivers own worlds to make sure info understand accurately

A

paraphrasing

47
Q

review main ideas from discussion

A

summarizing

48
Q

personal statements intentionally revealed to other person

A

self-disclosure

49
Q

“sense of possibility”

A

instilling hope

50
Q

standards are set by federal & state regulations, state statuses, standards of care, & accreditation agencies

A

documentation

51
Q

require each PT have an assessment:

A

physical, psychosocial, environmental, self-care, PT edu, knowledge level, discharge planning

52
Q

guidelines for documentation

A

factual, accurate, complete, organized, current

53
Q

descriptive, objective info - what you see, hear, feel, and smell

A

factual - guidelines of documentation

54
Q

precise measurements make documentation more…

A

accurate

55
Q

episode oriented, info can be lost from one episode to another

A

paper record

56
Q

Electronic health record

A
  1. a digital version of PT medical records
  2. integrates PT info in one record
  3. improves continuity of care
57
Q

Progress notes

A

narrative, SOAP, SOAPIE, PIE, focus charting

58
Q

charting by exception

A

focuses on documentation deviations from norms

59
Q

incorporate a multidisciplinary approach to care; focuses to providing quality care in a cost-effective manner

A

case management plan and critical pathways

60
Q

Methods of Documentation

A

paper records, electronic health record, progress notes, charting by exception, case management plan and critical pathways

61
Q

SOAP

A

Subjective, Objective, Assessment, Plan

62
Q

SOAPIE

A

Subjective, Objective, Assessment, Plan, Intervention, Evaluation

63
Q

guides the nurse through a complete assessment to identify relevant nursing diagnoses

A

Admission nursing history form

64
Q

help team members quickly see PT trends over time and decrease time spend on writing narrative notes

A

flow sheets in graphic records

65
Q

computerized systems provide certain basic information in the form of a PT care summary

A

Patient care summary or Kardex

66
Q

“flip-over” file a notebook with PT info

A

Kardex

67
Q

Preprinted, established guidelines used to care for PT who have similar health problems

A

Standardized care plans

68
Q

begin at admission and before admission on same-day surgery

A

discharge summary forms

69
Q

system determines the hour of care for nursing unit and the number of staff required to care for given group of PT

A

acuity records

70
Q

purpose of records

A

communication, reimbursement, research, legal documentation, education, quality process and performance improvement

71
Q

standards for PT education

A
  1. all state NPA recognize PT edu is a professional responsibility of every nurse
  2. PT edu is considered basic nursing competency
  3. edu takes place, evaluate if learning occurred and document all steps of the process
  4. help individuals, families, or communities achieve optimal levels of health, safety and independence
72
Q

cognitive learning

A

what the PT knows and understands

73
Q

affective learning

A

PT feelings, attitudes, opinions and values

74
Q

Psychomotor learning

A

PT acquires skills that require the integration of knowledge and physical skills

75
Q

Domains of learning

A

cognitive, affective, psychomotor

76
Q

basic learning principles

A

motivation and ability to learn

77
Q

motivation to learn

A

address the PT desire or willingness to learn

78
Q

ability to learn

A

depends of physical and cognitive abilities, developmental level, physical wellness, thought process

79
Q

ACCESS model

A 
Assessment
Communication
Cultural negotiation/compromise
Establishment of respect
Sensitivity
Safety

NURS 115 (3 decks)

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