Test 2 Flashcards
The art of recording client assessments and care in written or electronic form
Documentation
The purpose of the written record that states members of the multidiscipinary team uses the health record to communicate about the patient’s status and care
Communication between providers
Purpose of the written record that is served as a shanpshot of what is going on with the client so that you are able to research unfamiliar diagnoses, orders, and treatments before direct care begins
Educational Tool
The purpose of the written record that discusses how the health record will be scrutinized by legal experts if a dispute about a client’s care arises.
Legal documentation of care
The purpose of the written record used to formulate strategies to improve care, decrease length of stay, control costs, and pinpoint knowledge and practice gaps that can be addressed through continuing professional education
Quality improvement
The function of the written record to be used to gather data for clinical research
Research
The function of the written record for insurance companies to gather data for clinical research, budget managers & staff billing.
Reimbursement
Standard terminologies are constructed by
NANDA (NIC & NOC)
A documentation system where the disciplines document in separate sections of the chart
Source-oriented system
Advantage of source oriented system
each discipline is easily found
Disadvantages of this system include
- data may be fragmented & scattered
- difficult to track the treatments and client outcomes associated with a particular problem
source oriented system
Documentation system that is organized around client problems
Problem oriented system
Four components of the problem-oriented system
database, problem list, plan of care, progress notes
Advantages of this system include:
- common problem list
- easy to monitor progress
- may encourage greater collaboration
problem oriented system:
Disadvantages of this system include:
- have to read through entire chart to find information
- lengthy
- different people chart differently
problem oriented system
This type of charting may be used with source- or problem-oriented systems
Narrative charting
Advantages of Narrative charting:
story in chronological format
tracks the client’s changing status
Disadvantages to this type of charting include:
-timely
-have to read whole note to fine outcomes
inconsistent
-difficult to track problems day to day or see trends
narrative charting
P in PIE charting
problem
I in PIE charting
Interventions
E in PIE charting
Evaluation
This is a step in ___ charting that uses data from the original assessment to identify appropriate nursing diagnoses
PIE, P
This is a step in ___ charting that documents the nursing actions taken for each nursing diagnosis
PIE, Interventions
This is a step in ____ charting that documents the patient’s response to interventions and treatments
Evaluation
The primary disadvantage of PIE charting
no planning portion of the nursing process
PIE charting is used only in ______ charting
problem oriented
S in SOAP charting
Subjective Data
O in SOAP charting
Objective
A in SOAP charting
Assessment
P in SOAP charting
Plan
I in SOAP modified charting
Intervention
E in SOAP modified charting
Evaluation
R in SOAP modified charting
Revision
Charting that highlights the client’s concerns, problems or strengths in 3 colomns
Focus Charting
Column 1 of Focus charting
Time and date
Column 2 of focus charting
focus or problem being addressed
column 3 of focus charting
charting in a DAR format
DAR
Data, Action, Response
Subjective and objective information that supports the focus.
Data
Aspect of focus charting that reflects the assessment phase of the nursing process
Data
Describes interventions performed
Action
Aspect of focus charting that reflects the planning and implementation phases of the nursing process
Action
Advantages of focus charting
-holistic
Disadvantages of this type of charting include:
- lacks a common problem list
- leads to inconsistency in labeling the focus of notes
- difficult to track progress
focus charting
This type of charting only charts significant findings or exceptions to norm
Charting by Exception
Advantages in charting by exception:
- streamlines charting
- saves time
Disadvantage to charting by exception
omissions
Documentation that includes only exceptions to the norm or significant information about the patient.
FACT Documentation
F in FACT documentation
flow sheets individualize specific services
A in FACT documentation
assessment with baseline data
C in FACT documentation
Concise progress notes
T in FACT documentation
Timely entries
A patient being able to administer their own SQ insulin would be what letter in focus charting?
R-Response
The nursing admission assessment determines:
a baseline to data to monitor change
Allows you to monitor change and view patterns
flow sheets and graphic records
Comprehensive list of all ordered medications
MAR
Document medications according to times they are given, examples of orders would be:
scheduled, unscheduled, continuous, prn, stat
contains:
- demographics
- diagnosis
- allergies
- dietary/activity orders
- safety precautions
- IV therapy orders
- ordered treatments
- medication summary
- special instructions
Kardex or Client Care Summary
Are the kardex & electronic care summary part of the patient’s permanent record?
no
A combined charting and care plan form
integrated plans of care
Maps out on a daily basis, from admission to discharge
Integrated plans of care
IPOCs help administrators predict:
- length of stay
- cost of care
- staffing needs
Advantages of using these include:
eliminate duplicate charting, increases team effort, enhances the nurse’s teaching about what patient can expect
Integrated plans of care
A formal record of unusual occurrence or accident
occurrence reports
In the occurrence report, identify:
client, date, time, location
Method to inform other caregivers about the client’s condition, vital info & plan of care
Reporting
Handoff report may be:
verbal, walking rounds, audio-recorded
the process of adapting to one’s body and environment over time, enabled by increasing complexity of function and skill progression
Development
A child who recognizes right from wrong, an older adult who recognizes nearness of death, are both examples of:
Development
physical changes that occur over time
growth
Development = ___ + _____
Growth + behavioral
genetic endowment
nature
Usual patterns of growth and development occur in these 3 patterns
predictable
cephalocaudal
proximodistal
when an infant is born, their head is largest and progressively other body parts grow to proportion is an example of :
cephalocaudal growth
An infant’s tendency to use their arms before their legs is an example of:
cephalocaudal development
in utero, the baby’s central body is formed before the limbs is an example of:
proximodistal growth
when an infant first opens it eyes, then lifts head, then pushes up and rolls over is an example of:
proximodistal development
T/F each body system grows at its own rate
true
body system functions become increasingly ____ over time
differentiated
midway between an individual need and societal demand. Assumes an active learner interacting with an active social environment
developmental task
Advantage to Havighurts’s developmental task theory:
it is easy to evaluate a client’s completion of the tasks
Disadvantage to Havighurts’s developmental task theory:
nonspecific time frame limits the ability to assess whether an individual is developing within an expected range
Theory involving the id, ego, superego and unconscious mind
Freud’s psychoanalytic theory
instinctual urges, present from birth on, dominant in children and older adults who cannot control their urges
id
begins to develop around 4-6 months, represents reality, balances urges and what is possible to obtain
ego
conscience, develops at age 5-6 as a result of the internalization of primary caregiver responses to environmental events
superego
composed of thoughts and memories not readily recalled
unconscious
thought patterns or behaviors that the ego makes use of in the face of threat to biological or psychological integrity
defense mechanisms
Principle of development described with: Later they are integrated into more complex skills. Many complex skills represent a combination of simple skills.
simple skills develop separately and independently
Principle of development described with: In the years leading up to puberty, the cardiovascular, respiratory, and nervous systems grow and develop dramatically, yet the reproductive system changes very little. Puberty is a series of changes that leads to full development of the reproductive system.
Each body system grows at its own rate
Principle of development described with: Have you ever seen a newborn respond to a loud noise? The newborn’s startle response involves the whole body. With maturity, the response becomes more focused, for example, covering the ears. An adult is often able to state the location of the sound and distinguish the origin of the sound.
Body systems functions become increasingly differentiated over time
Robert Havighurst theorized that learning is a lifelong process. He believed that a person moves through six life stages, each associated with a number of tasks that must be learned.
Developmental task theory
Freud believed human development is maintained by instinctual drives, such as libido (sexual instinct), aggression, and survival (Sadock & Sadock, 2010). Different drives predominate, depending on the age of the individual. Each factor or force, has a unique function.
Psychoanalytic theory
Piaget: Cognitive development requires three core competencies; adaptation, assimilation, and accommodation.
Cognitive development theory
Cognitive development occurs from birth through adolescence in a sequence of four stages:
sensorimotor, preoperational thought, concrete operations, and formal operations.
The rate at which a child moves through the four stages of Piaget’s theory is determined by
the inherited intellect and the influence of the environment.
individuals must negotiate eight stages as they progress through the life span. Most people successfully move from stage to stage; however, a person can regress during times of stress to earlier stages or be forced to face tasks of later stages because of unforeseen life events. Failure to successfully move through a stage leads to maladjustment.
Psychosocial development theory
by studying the development of 84 boys over a period of 20 years. In this theory, moral reasoning appears to be somewhat age related, and moral development is based on one’s ability to think at progressively higher levels.
Moral development theory (Kohlberg)
developed a theory of faith development, which includes a pre-stage (stage 0) and six stages of faith
James Fowler’s Spiritual developmental theory
The time between conception and birth is called the
gestational period
A key developmental task of infants:
trust
This is a time of rapid language development and increasing curiosity.
toddler
The most important psychosocial developmental task for______ is to initiate more independence, control, and autonomy.
toddler
The ____ develops a conscience, recognizes right from wrong, becomes socially aware of others and develops the ability to consider other people’s viewpoints.
preschooler
They become more independent, places more importance on relationships outside the immediate family, and becomes more confident. They are able to see another person’s point of view and develops an understanding of relationships.
school-age children
experiences progressive physical, cognitive, and psychological change. shift their emotional attachment away from their parents and create close bonds among their peers.
adolescents
: Time of transition to independence and responsibility.
young adulthood
usually the healthiest stage of a person’s life
young adulthood
One of the principal changes that occurs is menopause
middle adulthood
middle adulthood is from age __ to ___
40-64
characterized by a decrease in testosterone production, a lower sperm count, and a need for more time to achieve an erection
andropause
are a time when people realize the difference between their early aspirations and their actual achievements
middle adulthood
The fastest growing age group
older adults (65
A syndrome, or a set of characteristics, that describes a heightened state of vulnerability for developing adverse health outcomes.
frailty
A multisystem reduction in the person’s physiological capacity.
frailty
The point at which the human organism is believed to have its least capacity for survival, and will fail in response to a minor internal or external insult. For example, a frail older adult might die merely as a result of falling ill to an upper respiratory infection (such as a cold).
frailty
Physical and psychological adaptations to retirement are paramount in this age group. Lack of supplemental insurace, self perception of aging, changes in physical activty, and being in a deconditioned state are common barriers to health in this age group
young old (65-74)
the ability to adjust to and interact with one’s environment
adaptation
the integration of new experiences with one’s own system of knowledge
assimilation
the change in one’s system of knowledge that results from processing new information
accommodation
Developmental challenge includes an increasingly solitary, sedentary lifestyle.
Middle old (75-84)
sensory impairments, oral health, inadequate nutritional intake, and functional limitations are the developmental challenges of this age group
oldest-old (85+)
Sensory deficits of oldest-old individuals to expect are:
hearing, vision, edentulism, nutrition & functional limitations
the seven leading causes of death among older adults
heart disease, cancer, chronic low respiratory diseases, stroke, alzheimer’s, diabetes, influenza/pneumonia
Age related physical changes of the _____ system include Decreased: muscle strength, body mass, bone mass, joint mobility, increased fat deposit
musculoskeletal
Age related physical changes of the _____ system include cardiac output, increased peripheral resistance, systolic blood pressure
cardovascular
Age related physical changes of the _____ system include Decreased elasticity of chest wall, intercostals muscle strength, cough reflex, increased anteroposterior diameter of chest, rigidity of lung tissue
respiratory
Age related physical changes of the _____ system include Decreased saliva production, GI motility, gastric acid production
Integumentary: Decreased skin elasticity, nail growth, increased dryness of skin, thinning of skin layers, nail thickening, hair thinning
GI
Age related physical changes of the _____ system include Decreased glomerular filtration rate, blood flow to kidneys, bladder capacity, vaginal lubrication, hardness of erection
geritourinary
Age related physical changes of the _____ system include Decreased nerve cells, neurotransmitters, REM sleep, blood flow to CNS
neurological
Age related physical changes of the _____ system include Decreased insulin release, thyroid function, estrogen, and testosterone
endocrine
Age related physical changes of the _____ system include Decreased visual acuity (presbyopia, or impaired near vision) and depth perception, tear production, pupil size, accommodation, acuity of smell and taste, hearing of high-frequency sound, sense of balance changes in pain sensation, increased glare sensitivity, thickening of lens of the eye, changes in pain sensation
sensory
Age related physical changes of the _____ system include Decreased short-term memory, increased reaction time, information processing time
cognitive
Age related physical changes of the _____ system include Increased cautiousness, retirement, widowhood, grandparenthood
personality
T/F there is a loss of intelligence as a person ages
False
T/F . Loss of short-term memory is more common than loss of long-term memory
True
an irreversible, progressive decline in mental abilities that affects about 1 in 5 of adults older than age 70. involves both memory impairments and a disturbance in at least one other area of cognition
Dementia
loss of ability to carry out purposeful movement
Apraxia
impaired ability to recognize or identify objects
agnosia
loss of ability to communicate
aphasia
Psychological or emotional abuse or coercive tactics after prior physical violence between persons who are spouses or nonmarital partners or former spouses or nonmarital partners
Intimate partner violence
Alcohol or substance abuse
Early onset of sexual activity or risk behaviors
Signs of mental illness or poor performance at school
are all risk factors for:
intimate partner violence
failure to provide for a child’s basic physical, educational, medical, and emotional needs
neglect
punching, beating, kicking, biting, burning, shaking, or otherwise harming a child; even if parent or caretaker did not intend harm, such acts are considered abuse when done purposefully
physical abuse
fondling child’s genitals, incest, penetration, rape, sodomy, indecent exposure, and exploitation through prostitution or production of pornographic materials
sexual abuse
any pattern of behavior that harms child’s emotional development or sense of self-worth; includes frequent belittling, rejection, threats, and withholding of love and support
emotional abuse
failure to provide basic social stimulation
psychological neglect
intentional misuse of elderly person’s financial and material resources
financial abuse
failure to use elderly person’s assets to provide needed services
financial neglect
Common health indicators include:
injury/bleeding complications, circulatory homeostasis disruption, fluctuations in BP, infections, cardiac complications, STIs
Elder abuse
T/F Suspected self-neglect is also a mandatory reportable activity to adult protective services
True
If you suspect abuse of an elder, it is important to notice these parts of the physical examination
head to toe visual exam, baseline lab tests
highest rates of IPV is found in
multiracial women
Barriers to report:
societal stressors, legal regulations, lack of access, cultural values or gender roles
T/F If a patient with dementia doesn’t understand you rephrase your sentence to make it easier to understand
false
living and caring for yourself independently in your home
aging in place
self-talk
intrapersonal communication
The _____ of communication describes the actual subject matter, words, gestures, and substance of the message. It is the message that everyone may hear or see.
content
5 parts of communication:
message, sender, channel, receiver, feedback
factors influencing verbal communication
educational background, culture, language, age, and past experiences.
The characteristics of therapeutic communication:
client centered, goal directed, strengthens/establishes therapeutic relationship, obtains healthcare info, express concern
Phase of the therapeutic relationship used for gathering information prior to meeting the client
Preinteraction phase
Phase of the therapeutic relationship where the nurse meets the client, introduction, establishes rapport & trust
orientation phase
Orientation ends when:
the relationship has been defined
Phase of the therapeutic relationship where the nurse communicates caring, the patient expresses thoughts and feelings.
Working phase
The goal of the working phase of the therapeutic relationship is to:
assist the patient to clarify feelings and concerns
Phase of the therapeutic relationship that concludes the relationship
Termination phase
This is the desire to understand and be sensitive to the feelings, beliefs, and situation of another person.
Empathy
_____ requires you to be willing to adapt your style, tone, vocabulary, and behavior to create the best approach for each client situation
Empathy
valuing the client and being flexible to meet the client’s needs
respect
This is the ability to respond honestly. If you are unable to answer a client’s question, do not offer guesses.
genuineness
means using your own words to summarize the message you received from the client.
restating
s helps ensure that you have accurately interpreted the information
clarifying
asking the client whether you are making a correct interpretation.
validating
Name the five steps of assertive communication
Get person's attention express concern state the problem propose an action reach a decision
Barriers to ______ include:
too many questions, close ended questions, asking why, changing the subject abruptly, failing to listen or explore issues, expressing approval/disapproval, offering advice, giving false reassurance, stereotyping, using patronizing language
therapeutic communication
The interview contract consists of
spoken and unspoken rules for behavior
The receiver in conversation attaches meaning to the message based on:
past experience, culture, self-concept & current physical & emotional state
internal factors of communicatoin
liking others, empathy, ability to listen
recognizing a feeling and putting it into words
empathy
when the frame of reference shifts from the patient’s perspective to yours
confrontation
focusing on a discrepancy or inconsistency in the patient’s narrative
confrontation
giving honest feedback about what you see or feel
confrontation
health literacy involves the use of:
quantitative measurement and memory aspects
Tools for determining health literacy
TOFHLA, REALM, NVS
The health history sequence:
biography source of history reason for seeking care present health/history of illness past health family history system review ADLs
Does biographical data include any health information?
no
Recording the source of history involves:
determining who provided the information, & reliability of informant, note presence of interpreter
objective abnormality that can be detected on physical examination or in laboratory reports
sign
When assessing pain, find out the:
P = Provocative or palliative Q = Quality or quantity R = Region or radiation S = Severity scale: 1 to 10 T = Timing or onset U = Understand patient’s perception of problem
How does person describe health and illness
How does person see problems he or she is now experiencing
Health perception
CAGE test determines:
risk for alcohol addiction
Adolescent psychosocial interview mneumonic
HEEADSSS
HEEADSSS stands for:
Home Education and employment Eating Activities Drugs Sexuality Suicide and depression Safety
The assessment interview questions for older adults focuses more on:
ways ADLs are affected by the normal aging process
T/F Patients require a complete head to toe physical examination during every 24 hour stay
False
The initial assessment I should involve
noting anything needed continuous monitoring
determine necessary frequency of determining status
The initial assessment II is necessary in:
med-surg & cardiac step down units
auscultating rhythm at apex, checking apical pulse against radial, assess heart sounds, cap. refill
Cardiovascular system I assessment
pretibial edema, posterior tibial & dosalis pedis pulse, verify IV infusion factors
Cardiovascular system II assessment
If patient is on bed rest, HOB should be
greater than 15 degrees as patient at risk for skin breakdown
Infantalizing communication commonly used towards the older generation
Elderspeak
healthiest stage of life
young adulthood
stage of life where maturation of body systems completes
young adulthood
phase when one is able to think rationally, predict outcomes, and hypothesize about the future
formal operations
phase where one is able to accept contradictions and fine points in thinking
post-formal operations
common health problems include STIs, pregnancies, traumatic injury, suicide attempts, substance abuse, domestic violence, obesity, diabetes, HTN
young adulthood
Assessment of self-esteem and self-concept is part of the functional assessment. Areas covered under self-esteem and self-concept include:
education, financial status, and value-belief system.
PQRSTU is a mnemonic that helps the clinician to remember to address characteristics specific to:
symptoms
Managing and processing information necessary to make decisions
Informatics
Managing and processing information applying to nursing practice, education, and research
Nursing informatics
unprocessed numbers, symbols, words; no context
Data
groupings of processed data
information
meaningful information created by grouping and compiling information
knowledge
appropriate use of knowledge
wisdom
BP systolic measurement requiring immediate assistance
> 160 or
O2 sat requiring immediate assistance
O2 sat requiring immediate assistance
Urine output requiring immediate assistance
> 30 or
SBAR is used for
effective verbal communication
SBAR stands for:
situation, background, assessment, recommendation
Portion of SBAR that provides specific information relative to patient issue
situation
portion of SBAR that provides context & assessment data relative to patient issue
background
portion of SBAR that is the nurse’s interpretation of data relative to the patient issue
assessment
portion of SBAR that is the expectation of physician’s orders relative to the patient issue
Recommendation
A new bruise is usually red & develops a purplish or purple-bluish appearance how long after blunt-force trauma?
12-36 hours
Bruise coloring changes from ___ to ___ to ___ to ____ before fading away
purple blue; bluish-green; greenish-brown; brownish-yellow
used at healthcare facilities all over the country to improve verbal communication and reduce medical errors
SBAR
age-based discrimination
ageism
A pap test is no longer recommended by the American cancer society after what age?
70
colon cancer screenings are necessary between the age of ___
50-75
the bone density scan is recommended for all women age ___ and older
65
activities needed to maintain one’s immediate environment (shopping, using the phone, housekeeping, managing money, preparing food and managing one’s medications)
instrumental activities of daily living
bathing, dressing, toileting, transferring, continence and feeding
activities of daily living
use of the health record that determines whether the medical treatments and interventions were necessary and appropriate
utilization review
use of the health record that determines whether the medical treatments and interventions were necessary and appropriate
utilization review
_____ system organizes information according to the patient’s problems and requires keeping a daily record and progress notes
PIE
Using the ___ system eliminates the need for a separate care plan and provides a nursing-focused rather than medical-focused record
PIE
Aspect of focus charting that reflects the evaluation phase of the nursing process
Response
the process of selecting the words, gestures, tone of voice, signs and symbols used to transmit the message
encoding
the literal/dictionary meaning of a word
denotation
the implied or emotional meaning of a word
connotation
intonation is the:
tone of voice
intonation is determined by the
pitch, cadence & volume
groupings of data processed into a meaningful, structured form
information
the appropriate use of knowledge in managing or solving human problems
Wisdom
occurs when the wrong action occurs
error of comission
occurs when the correct action does not occur
error of omission
Database that covers nursing, alllied health, biomedical, and consumer health journals.
CINAHL
Database that provides regularly updated collections of evidence based medicine databases, includice systematic reviews, effectiveness and trials. Reliable evidence about the effects of healthcare
Cochrane Library
Database that provides integrated acess to medical, health, and wellness information from reference sources, magazine and journal articles, pamphlets,a nd internet resources.
Health and Wellness Resource Center
Database that is the world’s largest medical library in all areas of biomedicine and healthacre
MEDLINE
Database that covers worldwide literature in psychology/psychiatry/sociology/anthropology/education/linguistics and pharmacology.
PsycINFO 1887
Studied cognitive development based on the assumption that human nature is rational.
Piaget
