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Terms and Knowledge Flashcards

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0
Q

Which of these do you DO in a change-of-shift report

  1. Review all biographical information already available in written form
  2. Review all routine care procedures or tasks
  3. Describe objective measurements or observations about patient’s condition and response to health problem, emphasize recent changes
  4. Share significant information about family members as it relates to patient’s problems
  5. Force oncoming staff to guess what to do first
  6. Describe detailed content only if staff members ask for clarification
A
  1. Describe objective measurements or observations about patient’s condition and response to health problem emphasize recent changes
  2. Share significant information about family members as it relates to patient’s problems
  3. Describe detailed content only if staff members ask for clarification
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1
Q

Which of these do you DO during a change-of-shift report:

  1. Identify patient’s nursing diagnoses/health care problems and related causes
  2. Describe results as “good” or “poor”
  3. Make assumptions about relationships among family members
  4. Evaluate results of nursing or medical care measures
  5. Describe instructions given in teaching plan and patient’s response
  6. Relay significant changes to staff in the way therapies are to be given
A
  1. Identify patient’s nursing diagnoses/health care problems and related causes
  2. Evaluate results of nursing or medical care measures
  3. Describe instructions given in teaching plan and patient’s response
  4. Relay significant changes to staff in the way therapies are to be given
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2
Q

Evidence-based knowledge

A

knowledge based on research or clinical expertise

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3
Q

Critical Thinking Skills

A 
Interpretation
Analysis
Inference
Evaluation
Self-regulation
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4
Q

Concepts for a Critical Thinker

A 
Truth seeking
Open-mindedness
Analyticity
Systematicity
Self-confidence
Inquisitiveness
Maturity
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5
Q

Levels of Critical Thinking

A

Level 1- Basic
Level 2- Complex
Level 3- Commitment

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6
Q

At this critical thinking level:
Answers to complex problems are either right or wrong
A learner trusts that experts have the right answer for every problem
Thinking is concrete and based on a set of rules or principles

A

Basic

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7
Q

At this critical thinking level:
Thinkers begin to separate themselves from experts
Thinkers analyze and examine choices more independently
Each solution has benefits and risks that are weighed

A

Complex

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8
Q

At this critical thinking level:
A person anticipates when to make choices without assistance
A person accepts accountability for decisions made
Action chose based on available alternatives

A

Commitment

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9
Q

Steps to the Scientific Method

A 
Identify Problem
Collect Data
Formulate Question/Hypothesis
Test Question/Hypothesis
Evaluate Results
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10
Q

Obtaining information and using it plus what you already know to find a solution when a problem arises. Also involves evaluating the solution to ensure it is effective

A

Problem solving

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11
Q

A product of critical thinking that focuses on problem resolution.

A

Decision Making

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12
Q

Critical Thinking Competencies

A 
Scientific method
Problem solving
Decision making
Diagnostic reasoning and inference
Critical decision making
Nursing process as a competency
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13
Q

Critical thinking competencies Specific to Nursing

A

Diagnostic reasoning and inference
Clinical decision making (Nursing diagnosis)
Nursing process as a competency

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14
Q

The analytical process for determining a patient’s health problems; begins once you receive information about a patent in a clinical situation.

A

Diagnostic reasoning

Nursing diagnosis

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15
Q

A problem-solving activity that focuses on defining a problem and selecting an appropriate action. A nurse identifies a patient’s problem and selects a nursing intervention.

A

Clinical decision making

Nursing intervention

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16
Q

The process of drawing conclusions from related pieces of evidence and previous experience with evidence.

A

Inference

Assessment

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17
Q

Attitudes for Critical Thinking

A 
Confidence
Independence
Fairness
Responsibility
Risk taking
Discipline
Perseverance
Creativity
Curiosity
Integrity
Humility
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18
Q

Intellectual Standards of Critical Thinking

A 
Clear
Precise
Specific
Accurate
Relevant
Plausible
Consistent
Logical
Deep
Broad
Complete
Significant
Adequate 
Fair
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19
Q

Learn how to introduce yourself to a patient
Speak with conviction when you begin a treatment or procedure
Do not lead a patient to think you are unable to perform safe care
Always be well prepared before performing activity
Encourage a patient to ask questions

A

Confidence

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20
Q

Read nursing literature, especially when there are different views
Talk with other nurses
Share ideas about nursing interventions

A

Thinking Independently

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21
Q

Listen to both sides of a discussion

Assume care of patients with openness and desire to meet needs

A

Fairness

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22
Q

Ask for help if you are uncertain
Refer to a policy or procedure manual
Report problems immediately
Follow standards of practice

A

Responsibility and Authority

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23
Q

Question wrong health care orders

Recommend alternative approaches to care

A

Risk Taking

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24
Q

Be thorough in whatever you do
Use known scientific and practice-based criteria
Manage time effectively

A

Discipline

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25
Q

Be cautious of an easy answer
Clarify information, or talk to patient directly
Look for patterns and find a solution

A

Perseverance

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26
Q

Look for different approaches

A

Creativity

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27
Q

Always ask why

Explore and learn more about the patient

A

Curiosity

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28
Q

Recognize when your opinions conflict with the patient’s
Review your position
Decide how to reach an outcome to satisfy everyone
Do not compromise nursing standards or honesty

A

Integrity

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29
Q

Recognize when you need more information
Ask for orientation of new areas
Ask other nurses for assistance

A

Humility

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30
Q

Developing critical thinking skills

A 
Reflective Journaling (used to recall situations)
Meeting with Colleagues (draw from others experiences)
Concept Mapping (or care planning)
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31
Q

Judgement that includes critical and reflective thinking and action and application of scientific and practical knowledge

A

Clinical decision making

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32
Q

The thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.

A

Culture

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33
Q

A shared identity related to social and cultural heritage such as values, language, geographical space, and racial characteristics

A

Ethnicity

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34
Q

An insider/native perspective of any intercultural encounter

A

Emic worldview

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35
Q

An outsider perspective in any intercultural incounter

A

Etic worldview

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36
Q

Socialization into one’s primary culture as a child

A

Enculturation

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37
Q

When members of an ethnocultural community are absorbed into another community and lose their unique characteristics such as language, customs, and ethnicity.

A

Assimilation

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38
Q

A comparative study of cultures to understand similarities and differences across human groups.

A

Transcultural nursing

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39
Q

Care that fits the person’s life patterns, values, and set of meanings.

A

Culturally congruent care

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40
Q

Process of acquiring specific knowledge, skills, and attitudes to ensure delivery of culturally congruent care.

A

Cultural competence

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41
Q

Five steps towards cultural competence

A 
Cultural awareness
Cultural knowledge
Cultural skills
Cultural encounters
Cultural desire
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42
Q

An in-depth self-examination of one’s own background, recognizing biases, prejudices and assumptions about other people.

A

Cultural awareness

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43
Q

Obtaining sufficient comparative knowledge of diverse groups, including their indigenous values, health beliefs, care practices, worldview, and bicultural ecology

A

Cultural knowledge

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44
Q

Being able to assess social, cultural, and biophysical factors influencing treatment and care of patients

A

Cultural Skills

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45
Q

Engaging in cross-cultural interactions that provide learning of other cultures and opportunities for effective intercultural communication development.

A

Cultural Encounters

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46
Q

The motivation and commitment to caring that moves an individual to learn from others, accept the role as learner, be open and accepting of cultural differences, and build on cultural similarities.

A

Cultural desire

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47
Q

A tendency to hold one’s own way of life as superior to others

A

Ethnocentrism

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48
Q

Using one’s own values and lifestyles as their absolute guide in dealing with patients and interpreting their behaviors.

A

Cultural Imposition

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49
Q

Components of cultural Assessment

A 
Family Structure
Bicultural Effects on Health
Ethnic Heritage/Ethnohistory
Social Organization
Religious and Spiritual beliefs
Foods with Cultural Significance
Communication Patterns
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50
Q

Three Nursing Interventions that achieve culturally congruent care

A

Cultural care preservation or Maintenance
Cultural care accommodation or negotiation
Cultural care repatterning or restructuring

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51
Q

Retain and/or preserve relevant care values so patients maintain their well-being, recover from illness, or face handicaps and/ordeath

A

Cultural care preservation or maintainence

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52
Q

Adapt or negotiate with others for a beneficial or satisfying health outcome

A

Cultural care accommodation or negotiation

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53
Q

Reorder, change, or greatly modify patients’ lifestyles for a new, different, and beneficial health care pattern

A

Cultural care repatterning or restructuring

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54
Q

Nurses are ______ and ______ obligated to keep all patient information ______.

A

legally, ethically, confidential

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55
Q

HIPAA

A

Health Insurance Portability and Accountability Act

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56
Q

_____ requires that disclosure or requests regarding _____ _________ are limited to the ________ necessary.

A

HIPAA, health information, minimum

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57
Q

Purposes of records

A 
Communication
Legal Documentation
Reimbursement
Research
Education
Auditing and Monitoring
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58
Q

Home care Documentation:

  • _____ has specific guidelines for establishing eligibility for home care.
  • These guidelines sever as the basis for ______ by home care nurses.
  • _______ is the quality control and justification for ______ from insurance (Medicare, Medicaid, or private)
  • Nurses need to document _____ their services for payment
A

Medicare
Documentation
Documentation/Reimbursement
All

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59
Q

Long-Term Health care documentation:

  • Patients are referred to as _______
  • _____ ______ are instrumental in determining standards and policies for documentation
  • The _____ of 1987includes Medicare and Medicaid legislation for long-term care documentation
  • The department of health in states governs the _______ of written nursing records
  • Includes the _____ _____ ______
A 
Residents
Governmental Agencies
OBRA
Frequency
Minimum Data Set (MDS)
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60
Q

_______ communication is essential within the health care team

A

Interdisciplinary

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61
Q

Records or charts are _____ ______ legal documents. They are available to al members of a health team.

A

Confidential permanent

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62
Q

Team members communicating in a group

A

Conference

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63
Q

A professional caregiver giving formal advice to another caregiver

A

Consultation

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64
Q

______ documentation is one of the best defenses for legal claims associated with nursing

A

Acurate

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65
Q

When do you chart?

A

Immediately after providing care

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66
Q

Care not documented is….

A

Care not provided

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67
Q

DRGs are…

A

Diagnosis-related groups are the basis for establishing reimbursement for patient care.

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68
Q

Hospitals are reimbursed a ___________ _____ _____ by Medicare for each DRG

A

Predetermined dollar amount

Accurate documentation= reimbursement

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69
Q

Charting mistakes that result in malpractice:

A
  • Failing to record pertinent health or drug information
  • Failing to record nursing actions
  • Failing to record that medications have been given
  • Failing to record drug reactions or changes in patient’s condition
  • Writing illegible or incomplete records
  • Failing to document discontinued medications
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70
Q

Guidelines for quality documentation and reporting:

A 
Factual
Accurate
Complete
Current
Organized
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71
Q

Objective data

A

observations of a patient’s behaviors. (avoid words like appears, seems, or apparently)

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72
Q

Subjective data

A

What a patient tells you. (use quotes, use patient’s exact words, back up with objective data)

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73
Q

Methods of Recording:

A 
Paper records
Electronic Health Records (EHR)
Narrative
Problem-oriented Medical Record (POMR)
Source Records
Charting by Exception (CBE)
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74
Q

Paper Records

A
  • Episode-oriented

- Key information may be lost from one episode of care to another (hospital to clinic– jeopardizes patient safety)

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75
Q

EHR

A
  • Electronic Health Record
  • A digital version of a patient’s medical record
  • Integrates all of a patient’s information into one record
  • Improves continuity of care
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76
Q

Narrative

A
  • The traditional method for recording care
  • Story-like format to document information specific to patient conditions and nursing care.
  • Repetitious and time consuming
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77
Q

POMR

A

-Problem-Oriented Medical Record
-Method of documentation that emphasizes patients’ problems
Includes these major sections:
-Database
-Problem List
-Care plan
-Progress Notes

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78
Q

SOAPIE progress notes

A 
S-Subjective data
O-Objective data
A-Assessment
P- Plan
I- Intervention
E- Evaluation
R- Revision
(Originated from medical records)
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79
Q

PIE progress notes

A

P- Problem
I- Intervention
E- Evaluation
(has a nursing origin)

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80
Q

DAR progress notes

A

D-Data
A- Action (nursing intervention)
R- Response
(addresses patient concerns, FOCUS CHARTING)

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81
Q

Has a separate section for each discipline to record data.

A

Source Record (eg- nursing, medicine, social work, respiratory therapy)

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82
Q

Focusing on documenting deviations from established norms.

A

CBE- Charting by exception

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83
Q
  • Allows you to quickly and easily enter assessment data about a patient (vital signs, routine repetitive care (ADLs), weight, safety and restraint checks)
  • Help team members quickly see patient trends over time and decrease time spent on writing narrative notes
A

Flow sheets (graphic records)

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84
Q

Guides the nurse through a complete assessment to identity relevant nursing diagnoses or problems

A

Admission nursing history form

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85
Q

A portable flip-over file or notebook with patient information

A

Kardex

  • Activity and treatment
  • Care plan
  • Code status
  • Allergies
  • Emergency contact
  • ADLs
  • Safety Precautions
  • Scheduled tests/procedures
  • Nursing orders
  • Current health care provider orders
  • Medical diagnosis
  • Health care provider
  • Demographic data
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86
Q

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

A

Standardized carep lans

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87
Q

Determine hours of care and staff required for a given group of patients. Not part of a patient’s medical record.

A

Activity record

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88
Q

The application of computer and information science for managing health-related data

A

Health Informatics

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89
Q

A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice

A

Nursing Informatics

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90
Q

Types of Reporting

A

Hand-off Report
Telephone Reports
Verbal or Telephone Orders
Incident or occurrence reports

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91
Q

SBAR

A

-Standardizes telephone communication of significant evens or changes in the patient’s condition and is a communication strategy designed to improve patient safety

Situation
Background
Assessment
Recommendation

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92
Q

Important part of the quality improvement program of a unit

A

Incident Reports (or occurrence reports)

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93
Q

Guidelines for Telephone/Verbal Orders

A
  • Clearly determine patient’s name, room number, and diagnosis
  • Repeat any prescribed orders back to the physician or health care provider
  • Use clarification questions to avoid misunderstandings
  • Write TO or VO, including date and time, name of patient, the complete order; sign the name of the physician or health care provider and nurse
  • Follow agency policies (some institution require TO/VO to be reviewed by two nurses)
  • The health care provider must co-sign the order within a time frame required by the institution (avg. 24hrs)
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94
Q

A process by which a health care provider directly enters orders for patient care into the hospital information system

A

CPOE- Computerized provider order entry

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95
Q

Legal Guidelines for recording:

A
  • Do not erase, apply correction fluid, or scratch out errors
  • Do not document retaliatory or critical comments
  • Do not enter personal opinions
  • Correct all errors promptly
  • Record all facts
  • Do not leave blank spaces
  • Record legibly and in black ink
  • Record clarification
  • Chart only for yourself
  • Avoid generalized, empty phrases (had a good day, status unchanged)
  • Begin entry with date, time and end with signature and title
  • Keep password to yourself
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96
Q

Maintaining confidentiality of records and reports

A

Do not include patient identifiers on student written material
Never print material from EHR
HIPAA policies for disclosure and requests

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97
Q

__________ reports happen any time one health care provider transfers care of a patient to another health care provider.

A

Hand-off or Change-of-shift

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98
Q

Which of these do you DO at a change-of-shift report

  1. Use critical comments about patient’s behavior
  2. Describe basic steps of a procedure
  3. Review ongoing discharge plan
  4. Verbalize priorities to which oncoming staff must attend
  5. Provide essential background information about patient
  6. Engage in idle gossip
A
  1. Review ongoing discharge plan
  2. Verbalize priorities to which oncoming staff must attend
  3. Provide essential background information about patient
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99
Q

Like learning, ______ is a lifelong learning process for nurses

A

communication

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100
Q

Human tendencies that interfere with accurately perceiving and interpreting messages from others.

A

Perceptual biases

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101
Q

Levels of Communications

A 
Intrapersonal
Interpersonal
Transpersonal
Small-group
Public
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102
Q

Communication that occurs within an individual

A

Intrapersonal Communication

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103
Q

A one-to-one interaction between two people

A

Interpersonal Communication

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104
Q

Interaction that occurs within a person’s spiritual domain

A

Transpersonal Communication

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105
Q

n interaction that occurs when a small number of persons meet.

A

Small-group communication

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106
Q

An interaction with an audience.

A

Public communication

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107
Q

Something that motivates one person to communicate with another.

A

Referent

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108
Q

The person who encodes and delivers a message

The person who receives and decodes the message

A

Sender

Receivers

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109
Q

Content of the communication

A

Message

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110
Q

Means of conveying and receiving messages through visual, auditory, and tactile senses.

A

Channels

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111
Q

The message the receiver returns.

A

Feedback

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112
Q

Factors within both the sender and receiver that influence communication

A

Interpersonal variables

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113
Q

Setting for sender-receiver interaction

A

Environment

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114
Q

Using spoken or written words

A

Verbal communication

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115
Q

Forms of communication:

A
  • Verbal
  • Nonverbal
  • Symbolic
  • Metacommunication
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116
Q

Vocabulary, Pacing, Intonation, Clarity and Brevity, Timing and Relevance

A

Verbal communication

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117
Q

Includes the five senses and everything that does not involve the spoken or written word.

A

Nonverbal communication

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118
Q

Personal appearance, Posture and gait, Facial expression, Eye contact, Gestures, Sounds, Territoriality and personal space

A

Nonverbal Communication

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119
Q

The verbal and nonverbal symbolism used by others to convey meaning

A

Symbolic communication

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120
Q

A broad term that refers to all factors that influence communication

A

Metacommunication

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121
Q

Professional Nursing relationships:

A

Nurse-patient helping
Nurse-family
Nurse-health
Nurse-community

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122
Q

Elements of professional communication:

A 
Courtesy
Use of names
Trustworthiness
Autonomy and Responsibility
Assertiveness
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123
Q

Being self-directed and independent in accomplishing goals and advocating for others

A

Autonomy

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124
Q

Allows you to express feelings and ideas without judging or hurting others.

A

Assertiveness

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125
Q

Communication: Factors related to Assessment

A
  • Physical and emotional factors
  • Developmental factors
  • Sociocultural factors
  • Gender
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126
Q

Communication: Factors affecting Diagnosis

A
  • Many clients experience difficulty with communication
  • Lacking skills in attending, listening, responding, or self-expression
  • Inability to articulate/inappropriate verbalization
  • Difficulty forming words
  • Difficulty with comprehension
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127
Q

Communication: Factors influencing Planning

A
  • Goals and outcomes must be specific and measurable
  • Setting priorities
  • Continuity of care: Collaboration with other health care providers
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128
Q

Communication and Implementation:

A

Therapeutic communication
Nontherapeutic communication
Adapting communication techniques

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129
Q

Therapeutic Communication Techniques

A 
Active listening
Sharing observations
Sharing empathy
Sharing hope
Sharing humor
Sharing feelings
Using touch
Using silence
Providing information
Clarifying
Focusing
Paraphrasing
Asking relevant questions
Summarizing
Self-disclosure
Confrontation
130
Q

Specific responses that encourage the expression of feelings and ideas and convey acceptance and respect.

A

Therapeutic Communication Techniques

131
Q

Being attentive to what a patient is saying both verbally and nonverbally

A

Active Listening

132
Q

SOLER

A

How to Actively Listen

  • S- sit facing the patient
  • O- Observe an open posture
  • L- Lean toward the patient
  • E- Establish and maintain intermittent eye contact
  • R- Relax
133
Q

The ability to understand and accept another person’s reality, accurately perceive feelings, and communicate this understanding to the other.

A

Empathy

134
Q

Nontherapeutic Communication Techniques

A 
Asking Personal questions
Giving personal opinions
Changing the subject
Automatic responses
False reassurance
Sympathy
Asking for explanations
Approval or disapproval
Defensive responses
Passive or aggressive responses
Arguing
135
Q

Techniques that hinder or damage professional relationships. Cause recipients to activate defenses to avoid being hurt or negatively affected.

A

Nontherapeutic Communication Techniques

136
Q

concern, sorrow, or pity felt for a patient.

A

Sympathy

137
Q

Changing the way you communicate based on the patient.

A

Adapting Communication Techniques

138
Q

Communication and Evaluation

A
  • Determine whether the plan of care has been successfully met (nurse and patient)
  • Evaluate effectiveness of nursing interventions
  • Modify plan of care as needed
139
Q

Law created by elected legislative bodies such as state legislatures and US Congress

A

Statutory law

140
Q

_____ _____ _____ describe and define the legal boundaries of nursing practice within each state.

A

Nursing Practice Acts

141
Q

Laws that reflect decisions made by administrative bodies such as State Boards of Nursing when they pass rules and regulations

A

Regulatory law (or administrative law)

142
Q

This law results from judicial decisions made in courts when individual legal cases are decided

A

Common law

143
Q

Protect the rights of individuals within our society and provide for fair and equitable treatment when civil wrongs or violations occur.

A

Civil laws

144
Q

Protect society as a whole and provide punishment for crimes, which are defined by municipal, state, and federal legislation

A

Criminal laws

145
Q

A crime of serious nature that has a penalty of imprisonment for longer than 1 year or even death.

A

Felony

146
Q

A less serious crime that has a penalty of a fine or imprisonment for less than 1 year.

A

misdemeanor

147
Q

Legal requirements for nursing practice that describe minimum acceptable nursing care.

A

Standards of care

148
Q

The _______ develops standards for nursing practice, policy statements, and similar resolutions.

A

ANA- American Nurses Association

149
Q

Standards of care are set by _____ and ______ laws that govern where nurses work

A

state and federal

150
Q

The rules and regulations enacted by a ______ _____ __ _____ define the practice of nursing more specifically

A

State Board of Nursing

151
Q

The _____ _______ requires accredited hospitals to have written nursing policies and procedures

A

Joint Commision

152
Q

Proof of Negligence

A
  • The nurse owed a duty to the patient
  • The nurse did not carry out the duty or breached it
  • The patient was injured (Medical bills, lost wages, pain and suffering, perinatal damages, wrongful death damages)
  • The patient’s injury was caused by the nurse’s failure to carry out the duty
153
Q

Federal Statutory Issues in Nursing Practice:

A 
Americans with Disabilities Act
Emergency Medical Treatment and Active Labor Act
Mental Health Parity Act
Uniform Anatomical Gift Act
Living Wills, Durable Power of Attorney
Advance Directives
Health Insurance Portability and Accountability Act
Restraints
154
Q

A broad civil rights statute that protects the rights of people with physical or mental disabilities.

A

American with Disabilities Act (ADA 1990)

155
Q

Provides that, when a patient comes to the emergency department or the hospital, an appropriate medical screening occurs within the capacity of the hospital.

A

Emergency Medical Treatment and Active Labor Act (EMTALA)

156
Q

Forbids health plans from pacing lifetime or annual limits on mental health coverage that are less generous than those placed on medical or surgical benefits.

A

The Mental Health Parity Act (1996)

157
Q

Written documents that direct treatment in accordance with a patient’s wishes in the event of a terminal illness or condition

A

Living Wills

158
Q

A legal document that designates a person or persons of one’s choosing to make health care decisions when the patient is no longer able to make decisions on his or her own behalf.

A

DPAHC (Durable power of attorney for health care)

159
Q

Advance Directives

A

Living Wills
Health care proxies
Durable power of attorneys for health care

160
Q

Requires health car institutions to provide written information to patients concerning their rights under state law to make decisions, including the right to refuse treatment and formulate advance directives.

A

The Patient Self-Determination Act (PSDA, 1991)

161
Q

Prohibits the purchase or sale of organs

A

The National Organ Transplant Act (1984)

162
Q

The ______ has a contract with the federal government and sets policies and guidelines for the procurment of organs

A

UNOS- United Network for Organ Sharing

163
Q

The right of patients to keep personal information from being disclosed

A

Privacy

164
Q

Protects private patient information once it has been disclosed in health care settings.

A

Confidentiality

165
Q

Gives residents in certified nursing homes the right to be free of unnecessary and inappropriate restraints.

A

The Federal Nursing Home Reform Act (1987)

166
Q

_______ and _____ have set standards for reducing the use of restraints in health care settings and for using them only with extreme caution.

A

Centers for Medicare and Medicaid Services and The Joint Commision

167
Q

Restraints can only be used under these three circumstances:

A
  1. To ensure the physical safety of the resident or other residents
  2. When less restrictive interventions are not successful
  3. Only on the written order of a health care provider
168
Q

A _________ licenses all registered nurses in the state ni which they practice.

A

State Board of Nursing

169
Q

All states have _______ laws enacted to encourage health care professionals to assist in emergencies. Also offers immunity from liability as long as you acted without gross negligence.

A

Good Samaritan

Failure-to-act laws in Louisiana, Minnesota, and Vermont

170
Q

The ______ and _______ provide guidelines on a national level for safe and healthy communities and work environments

A

CDC (centers for disease control and prevention) and OSHA (occupational health and safety act)

171
Q

Irreversible cessation of circulatory and respiratory function

A

Cardiopulmonary standard of death

172
Q

Irreversible cessation of all functions of the entire brain, including the brainstem

A

whole-brain standard of death

173
Q

States that health care providers can use either the cardiopulmonary or the whole-brain definition to determine death.

A

Uniform Determination of Death Act (1980)

174
Q

First statute that permitted physician or health care provider-assisted suicide.

A

The Oregon Death with Dignity Act (1994)

175
Q

The _____ has held that nurses’ participation in assisted suicide violate the code of ethics for nurses while the ______ supports the International Council of Nurses’ mandate to ensure an individual’s peaceful end of life.

A

ANA (American Nurses Association)

AACN (American Association of Colleges of Nursing)

176
Q

A civil wrong made against a person or property

A

Tort

177
Q

Willful acts that violate another’s rights such as assault, battery, and false imprisonment

A

Intentional torts

178
Q

Any action that places a person in apprehension of a harmful or offensive contact without consent. No contact is necessary (threatening)

A

Assault

179
Q

Intentional touching without consent. Contact can be harmful and cause injury or merely offensive to the person’s dignity

A

Battery

180
Q

Unjustified restraint of a person without legal warrant.

A

False Imprisonment

181
Q

Acts in which intent is lacking but volitional action and direct causation occur.

A

Quasi-intentional tort

182
Q

A violation of a patient’s right to be free from unwanted intrusion into his or her private affairs

A

Invasion of Privacy

183
Q

Publication of false statements that result in damage to a person’s reputation

A

Defamation of character

184
Q

Occurs when one speaks falsely about another.

A

Slander

185
Q

Written defamation of character

A

Libel

charting false entries in a medical record

186
Q

Conduct that falls below a standard of care.

A

Negligence

187
Q

Professional negligence resulting form falls below a standard of care.

A

Malpractice

188
Q

Common Negligent Acts

A

Failure to assess and/or monitor- in a timely fashion, with the proper equipment and to document
Failure to make a nursing diagnosis
Failure to notify health care provider of problems
Failure to follow orders
Failure to follow the six rights of medication administration
Failure to convey discharge instructions
Failure to ensure patient safety
Failure to follow policies and procedures
Failure to properly delegate and supervise

189
Q

A person’s agreement to allow something to happen such as surgery or an invasive diagnostic procedure, based on full disclosure of risks, benefits, alternatives, and consequences of refusal

A

Informed Consent

190
Q

Statutory guidelines for legal consent: Adults

A
  • Competent individual 18 years of age or older
  • Parent for his or her unemancipated minor
  • Any guardian for his or her ward
  • Any adult for the treatment of his or her minor brother or sister (if an emergency and parent not present)
  • Any grandparent for a minor grandchild (if an emergency and parents are not present)
191
Q

Statutory Guidelines for legal consent: Minors

A
  • For his or her child and any child in his or her legal custody
  • For himself or herself if: lawfully married or a parent, pregnant, venereal disease, drug or substance abuse
  • Unemancipated minors may not consent to abortions without: consent of one parent, self-consent granted by court order, consent specifically given by a court
192
Q

US Supreme Court ruled that there is a fundamental right to privacy, which includes a woman’s right to have an abortion

A

Roe v. Wade

193
Q

Some states require viability tests if the fetus is more than 28 weeks gestational age.

A

Webster v Reproductive Health Services

194
Q

Nursing students are _____ if their actions cause harm to patients.

A

Liable

along with instructor, hospital, university

195
Q

______ problems occur if there are not enough nurses to provide ____ care or if nurses work ____ overtime

A

Legal, competent, excessive

196
Q

based on census load and patient acuities

A

Floating

197
Q

Abandonment and Assignment Issues

A

Short Staffing
Floating
Health Care Providers’ Orders

198
Q

An organization’s system for ensuring appropriate nursing care by identifying potential hazards and eliminating them before harm occurs.

A

Risk management

199
Q

Steps involved in Risk Management

A

Identify Possible Risks
Analyze Risks
Act to Reduce Risks
Evaluate Steps Taken

200
Q

Tool used in risk management

A

Occurrence report/Incident report

201
Q

Serves as a database for further investigation

Alerts risk management to potential claim situation

A

Occurrence report

202
Q

The study of conduct and character. Determining what is good or valuable for individuals, for groups of individuals, and for society at large

A

Ethics

203
Q

Freedom from external control

A

Autonomy

204
Q

taking positive actions to help others

A

Beneficence

205
Q

Harm or hurt

A

Maleficence

206
Q

Avoidance of harm or hurt

A

Nonmaleficence

207
Q

Fairness

A

Justice

208
Q

The agreement to keep promises

A

Fidelity

209
Q

A set of guiding principles that all members of a profession accept. It is a collective statement about the group’s expectations and standards of behavior

A

Code of Ethics

210
Q

The support of a particular cause

A

Advocacy

211
Q

A willingness to respect one’s professional obligations and follow through on promises

A

Responsibility

212
Q

The ability to answer to one’s actions

A

Accountability

213
Q

Personal beliefs about the worth of a given idea, attitude, custom, or object that set standards that influence behavior

A

Values

214
Q

Basic principles of Codes of Ethics

A

Advocacy
Responsibility
Accountability
Confidentiality

215
Q

Defines actions as right or wrong

A

Deontology

216
Q

Proposes that the value of something is determined by its usefulness

A

Utilitarianism

consequentialism or teleology

217
Q

Focuses on the inequality between people

A

Feminist Ethics

218
Q

Emphasizes the importance of understanding relationships, especially as they are revealed in personal narratives

A

Ethics of Care

219
Q

_______ _____ almost always occur in the presence of _____ values.

A

Ethical dilemmas, Conflicting

220
Q

To resolve ethical dilemmas, one need to distinguish among ______, ______, and _______

A

Values, facts, and opinions

221
Q

Processing an ethical dilemma (7 steps)

A
  1. Ask if this is an ethical dilemma
  2. Gather all relevant information
  3. Clarify values
  4. Verbalize the problem
  5. Identify possible courses of action
  6. Negotiate a plan
  7. Evaluate the plan
222
Q

_______ _________ are usually multidisciplinary and serve several purposes: education, policy, recommendation, and care consultation. They process ethical dilemmas and may be requested by nurses, physicians, health care providers, patients, and family members.

A

Ethics Committees

223
Q

Issues in Health care Ethics

A

Quality of life
Genetic screening
Care at the end of life
Access to care

224
Q

Central to discussions about end-of-life care, cancer therapy, physician assisted suicide, and DNR

A

Quality of life

225
Q

Can alert a patient to a condition that may not yet be evident but that is certain to develop in the future (What are the risks and benefits to individuals and society of earning about the presence of a disease that has not yet caused symptoms or for which a cure is not yet available?)

A

Genetic Screening

226
Q

Interventions unlikely to produce benefit for the patient, futile

A

Care at the end of life

227
Q

Number of insure in the US grew from 39million to 46.3million– more than 15% of the total population
Many uninsured are women and children
Although two thirds of the uninsured are poor, nearly 80% come from working families

A

Access to Care

228
Q

Describes the anguish experienced when a person feels unable to act according to closely held core values. Is a shared experience, efforts to alleviate are most successful when also shared

A

Moral Distress

229
Q

Includes the willingness to speak up

A

Moral Distress

230
Q

Biomedical ethics is based on four principles

A

Autonomy
Normaleficence
Beneficence
Justice

231
Q

DECIDE model

A 
D efine problems
E thical review
C onsider options
I nvestigate ethical outcomes (advocate)
D ecide on a plan (clarify/advocate)
E valuate results (clarify/advocate)
232
Q

Problems in Ethical Dilemma resolution

A
  • Breakdown in Communication
  • Nurse concerns are not elicited
  • Nurses aren’t included in decision making
233
Q

Mandatory Reporting: Child abuse or Neglect

A

CFS and Law enforcement

234
Q

Mandatory Reporting: Spousal abuse

A

CFS

*Do not report to law enforcement- HIPAA violation

235
Q

Mandatory Reporting: Elder/Disability abuse:

A

CFS

236
Q

SANE nurse

A

Certified nurse for sexual abuse examination (usually in the ER)

237
Q

Healthcare professionals making decisions about diagnosis, therapy, and prognosis for the patient. Based upon the health care professional’s belief about what s in the best interest of the patient, he/she choses to reveal or withhold patient information in these three important arenas.

A

Paternalism

238
Q

Medication Legislation and Standards:

A

Pure Food and Drug Act
Food and Drug Administration
MedWatch Program
State and local regulations
Health care institutions and medication laws
Medication regulations and Nursing Practice Acts

239
Q

Law that requires all medications to be free of impure products

A

Pure Food and Drug Act

240
Q

Ensures that all medications on the market undergo vigorous testing before they are sold to the public

A

Food and Drug Administration (FDA)

241
Q

Voluntary program that encourages nurses and other health care professionals to report when a medication, product, or medical event causes serious harm to a patient by completing a form

A

MedWatch program

242
Q

These laws must conform to federal legislation, but have additional controls, including control of substances not regulated by the federal government (alcohol, tobacco)

A

State and Local Regulation of Medication

243
Q

Agencies that establish individual policies to meet federal, state, and local regulations.

A

Health Care Institutions and Medications Laws

244
Q

Have the most influence over nursing practice by defining the scope of nurses’ professional functions and responsibilities.

A

Nurse Practice Acts (NPAs)

245
Q

Name of medication that provides an exact description of its composition and molecular structure.

A

Chemical (ex. N-acetyl-para-aminophenol)

246
Q

Common names of a medication

A

Trade Name (ex. Tylenol)

247
Q

The official name listed in official publications such as the USP

A

Generic Name (ex. Acetaminophen)

248
Q

Indicates the effect of a medication on a body system, symptoms the medication relieves, and medication’s desired effect.

A

Classification

249
Q

the _____ of medication determines its route of administration

A

form (tablet, capsule, elixir, suppository)

250
Q 
The study of how medications:
Enter the Body
Are absorbed and distributed into cells ,tissues, or organs
Reach their site of action
Alter physiological functions
Are metabolized
Exit the body
A

Pharmacokinetics

251
Q

Passage of medication molecules into the blood from the site of medication administration.

A

Absorption

252
Q

Factors influencing absorption

A 
Route of administration
Ability of medicine to dissolve
Blood flow to site of administration
Body surface area
Lipid solubility
253
Q

Medication distributed within the body to tissues and organs and ultimately to its specific site of action.

A

Distribution

254
Q

Factors affecting distribution:

A 
Physical and chemical properties of the medication
Physiology of the person taking it
Circulation
Membrane permeability
Protein binding
255
Q

Medications ______ into a less active or inactive form that is easier to excrete

A

Metabolized

256
Q

_______ occurs under the influence of _____ that _____, break down, and remove biologically active chemicals

A

Biotransformation, enzymes, detoxify

257
Q

Biotransformation occurs in:

A 
The liver (mostly)
lungs
kidneys
blood
intestines
258
Q

Medication exits the body

A

Excretion

259
Q

medication excreted by:

A

Kidneys
liver
bowel
lungs- gaseous and volatile compounds
exocrine glands- lipid-soluble medications
(the chemical makeup of a medication determines the organ of excretion)

260
Q

Types of medication action

A 
Therapeutic Effects
Side Effects
Adverse Effects
Toxic Effects
Idiosyncratic Reactions
Allergic Reactions
261
Q

Expected or predicted physiological response that a medication causes

A

Therapeutic effect

262
Q

Predictable and often unavoidable secondary effects produced at a usual therapeutic does

A

Side Effect

263
Q

Unintended, undesirable, and often unpredictable sever responses to medication

A

Adverse Effects

264
Q

Develop after prolonged intake of a medication or when a medication accumulates in the blood because of impaired metabolism or excretion

A

Toxic Effect

265
Q

Unpredictable effect in which a patient overreacts or under-reacts to a medication or has a reaction different (or opposite) from normal.

A

Idiosyncratic Reactions

266
Q

The medication acts as an antigen, triggering the release of antibodies into the body.

A

Medication Allergy

267
Q

Severe reaction which is life threatening and characterized by sudden constriction of bronchiolar muscles, edema of the pharynx and larynx and server wheezing and shortness of breath

A

Anaphylactic Reactions

268
Q

When one medication modifies the action of another

A

Medication Interaction

269
Q

When two medcations’ combined effect is greater than the effect of the medications when given separately

A

Synergistic Effect

270
Q

The plasma level of a medication below which the effect of the medication does not occur

A

Minimum effective concentration (MEC)

271
Q

The level at which toxic effects occur

A

Toxic concentration

272
Q

The range in which you want to keep a medicaiton

A

therapeutic range

273
Q

Time it takes for a medication to produce a response

A

Onset

274
Q

Time at which a medication reaches its highest effective concentration

A

Peak

275
Q

Minimum blood serum concentration before next scheduled dose

A

Trough

276
Q

Time medication takes to produce greatest result

A

Duration

277
Q

Point at which blood serum concentration is reached and maintained

A

Plateau

278
Q

Time for serum medication concentration to be halved

A

Biological half-life

279
Q

All medication have a ________ which is the time it take for ______ processes to lower the amount of unchanged medication by ______. This number never changes no matter how ______ _______ is given.

A

biological half-life, excretion, half, much medication.

280
Q

Routes of administration

A 
topical
oral
inhalation
parenteral
intraocular
281
Q

Sublingual Route

A

Under tongue

Not swallowed

282
Q

Buccal route

A

Between back teeth and cheek
Alternate cheeks
Should not be swallowed

283
Q

Parenteral Routes:

A

Intradermal (Injection into the dermis/ just under epidermis)
Subcutaneous (Injection into tissues just below dermis)
Intramuscular (Injection into the muscle)
Intravenous (Injection into a vein)
Epidural (via catheter)
Intrathecal (via catheter in subarachnoid space in brain)
Intraosseous (infusion of medication into bone marrow)
Intraperitoneal (into the peritoneal cavity)
Intrapleural (Syringe, needle or chest tube into pleural space)
Intraarterial (directly into arteries)
Intracardiac (injection into cardiac tissue)
Intraarticular (injection into a joint)

284
Q

Topical Administration:

A 
transdermal disk or patch
Intraocular
Skin
Nasal
Eye
Ear 
Vaginal
Rectal
285
Q

Instillation

A

Fluid retained

286
Q

Irrigation

A

Fluid not retained

287
Q

Prescriber

A

Physician
Nurse practitioner
Physicians Assistant

288
Q

AMDS

A

Automatic Medication Dispensing System

289
Q

Verbal Order guideines

A
  • Nurse writes down complete order
  • Enters it into computer
  • Reads it back
  • Receives confirmation from prescriber to confirm accuracy
  • Indicates time and name of prescriber who gave order
  • Signs order and follows agency policy to indicate it was read back
  • Prescriber countersigns the order at a later time, usually within 24 hours of giving it
  • Nursing students cannot take them.
  • Do not use abbreviations when documenting order or other information about medications
290
Q

Each medication order needs to include:

A 
Patients name
Order date
Medication Name
Dosage
Route
Time of administration
Drug indication
Prescribers signature
291
Q

Types of orders

A 
Standing/Routine
PRN orders
Single (one-time) orders
STAT orders
Now orders
Prescriptions
292
Q

Prepares and distributes prescribed medications

A

pharmacist

293
Q

A nurse must asses a patient’s _____ to self-administer a medication, determine whether the patient should ____, administer medication ________, and closely ________ effects.

A

ability, receive, correctly, monitor

*Do not delegate this

294
Q

Medication errors

A 
Inaccurate prescribing
Administering the wrong medication
Giving the medication using the wrong route
Giving the medication at the wrong time
Administering extra doses 
Failing to administer
295
Q

The nurse is responsible for preparing a written ______ _____ for medication errors

A

Occurrence report

296
Q

Process for Medication Reconciliation

A 
Verify
Clarify
Reconcile
Tranmit
*Nurses play essential role
297
Q

Critical Thinking and Medication Administration

A

Knowledge
Experience (psychomotor skills)
Attitudes (discipline, responsible, accountable)
Standards (6 rights)

298
Q

Six rights for medication administration

A 
Drug
Dose
Patient
Route 
Time
Documentation
299
Q

MAR

A

Medication Administration Record

300
Q

Maintaining a patients’ rights:

A
  • Be informed of the name, purpose, action and potential undesired effect of a medication
  • To refuse a medication regardless of the consequences
  • To have qualified nurses or physicians assess a medication history, including allergies and use of herbals
  • To be properly advised of the experimental nature of medication therapy and given written consent for its use
  • To receive labeled medications safely without discomfort in accordance with the six rights
  • To receive appropriate supportive therapy in relation to medication therapy
  • To not receive unnecessary medication
  • To be informed if medications are a part of a research study
301
Q

Assessment for Medication administration:

A 
Medical History
Allergies
Medications 
Diet History
Patients adherence to therapy
Patients perceptual or coordination problems 
Current Condition
Attitude about medication use
Understanding of and adherence to therapy
Learning needs
302
Q

Nursing diagnosis with Medical Administration

A 
Anxiety
Ineffective health maintenance
Readiness for enhanced immunization status
Deficit knowledge (medications)
Noncompliance (medications)
Disturbed visual sensory perception
Impaired swallowing
Effective therapeutic regimen management
303
Q

Planning:

A

Organize care to ensure safety of medication administration
Setting Goals and Outcomes
Setting Priorities (Provide most important information first)
Teamwork and Collaboration (on discharge ensure that patients know where and how to obtain medications)

304
Q

Implementation: Teaching family and patient about medication administration

A 
Medication benefits
How to take the medication correctly
Symptoms and side effects
Safe use and storage of medications
Establish a medication routine
Refer them to community resources for transportation if needed
305
Q

Implementation: Acute care and medication administration

A

Receiving, transcribing, and communicating medication orders
Accurate dose calculations and measurement
Correct administration
Recording medication administration

306
Q

Specific Considerations for Medication Adminsitration

A

Infants and children (dose and psychological prep)
Elderly
Polypharmacy

307
Q

When a patient takes two or more medications to treat the same illness, takes two or more medications from the same chemical class, uses two or more medications with the same or similar actions to treat several disorders simultaneously or mixes nutritional supplements or herbal products with medications.

A

Polypharmacy

308
Q

Increased risk for Polypharmacy

A

Taking OTC medications frequently
Lack of knowledge about medications
Incorrect beliefs about medications
Visiting several health care providers to treat different illnesses

309
Q

Medication administration Evaluation

A 
Reactions
Physiological measures
Behavioral responses
Rating scales
Patient statements
310
Q

How many times do you check the MAR/drug dose?

A

3
Before you prep the meds
After you prep the meds
At the bedside

311
Q

How do you discontinue a medication on the MAR?

A

Initial, circle, write “Discontinued, “DATE”” then highlight in yellow

312
Q

Best way to verify tube placement

A

X-ray

313
Q

Advantages of Topical administration

A 
Provides local effect
Painless
Limited side effects
(Skin^)
Prolonged systemic effects with limited side effects
(Transdermal^)
314
Q

Disadvantages of topical administration

A

Client with skin abrasions are at risk for rapid medication absorption and systemic effects
Medication slowly absorbed through skin
(Skin^)
Leaves oily or pasty substance on skin and sometimes soils clothing
(Transdermal^)

315
Q

These medication are absorbed directly through the skin or mucous membranes and applied directly to body surfaces or body cavities

A

Topical

316
Q

Advantages of Parenteral Route

A

No GI upset
Emergencies
Effective route for drug delivery when compromised mental or physical state
Can deliver precise dose to targeted area of the body (Joint, spinal canal)

317
Q

Disadvantages of Parental route

A 
Patient anxiety
Hematoma
Allergic reactions
Higher risk of reactions
Introduction of microorganisms
Injury to tissue, nerves, veins, vessels
Can strike bone
Can traumatize a vein 
More invasive
Expensive
318
Q

What is the least painful/safest IM injection site?

A

ventrogluteal

319
Q

Average: Gage, needle size, dose for an IM

A

23G (20-25)
Deltoid- 1” or 1/2”, 0.5mL (up to 2mL)
Vastus Lateralus- 1” or 1/2”, 2mL (1-5mL)
Ventrogluteal: 1 1/2”, 2mL (1-5mL)

320
Q

Average gage, needle size, and dose for SC

A

25G (25-27 or 28-31In)
5/8” or 1/2”In
1-3mL or 25, 50, 100u

321
Q

Average gage, needle size, dose ID

A

27G (25-27)
1/2”
0.1mL (0.001-1.0mL)

322
Q

Skills for client teaching

A
  1. Assess client’s knowledge of subject and readiness to learn
  2. Review goals of session with client
  3. Assemble materials and prepare environment
  4. Implement teaching plan, using appropriate content
  5. Obtain evaluative feedback
  6. Summarizes content taught
  7. Evaluates effectiveness of session and documents
323
Q

Nurses role in Medication Administration

A

Assess that medication ordered is correct
Assess patient’s ability to self-administer medications
Determine whether a patient should receive a medication at a given time
Administer medications correctly
Closely monitor effects of medications
Educate patient and family about proper medication administration
*Do not delegate these tasks

Nursing Exam 2 (2 decks)

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