Unit 2 Test Flashcards
Why is it important to understand normal growth and development?
It helps prevent predict and detect deviations from patients own expected patterns and help us identify abnormal
Physical changes that occur from the prenatal period too older adulthood; it demonstrates advancement and deterioration ; Includes measurable changes in the physical body
Growth
Refers to the biological cognitive and socioeconomic changes that begin at conception and continue throughout a lifetime ; Behavioral changes in functional abilities and skills
Development
Theory in which individuals need to accomplish a particular task before successfully mastering that stage and moving onto the next one ; Each stage has opposing conflicts ; Established tasks can be challenged again in the future
Erikson’s eight stages of development
Trust versus mistrust, autonomy versus shame and doubt, initiative versus guilt, industry versus inferiority, identity versus role confusion, intimacy versus isolation, generativity versus stagnation, integrity versus despair
Eight stages of development
Stage in which you develop the ability to trust others it requires a constant caregiver results in faith/optimism ; Ages birth to one year
Trust vs mistrust
Stage in which they gain self-control and independent; ages one through three
Autonomy versus shame and doubt
Stage in which children are highly imaginative it results in direction and purpose if successfully pass; Ages three through six years
Initiative versus guilt
Age in which children love to be engaged in tasks and activities ; ages six through 11 years
Industry versus inferiority
Identity development begins if successfully passed results in devotion and fidelity ; Occurs during puberty
Identity versus role confusion
Stage in which people search for friendships And or marriage or partners ;if it fails isolation occurs; Occurs In young adulthood
Intimacy versus isolation
Parenthood ,teaching ,community involvement Occur during this stage ;inability results in stagnation ; Middle age
Generativity versus stagnation
Engaged in retrospective appraisal ;search for the meaning of life; lose independence ; physical and social loss; Occurs during old age
Integrity versus despair
Statutory law; regulatory law; common-law
Sources of law
Created by legislative bodies ; defines legal boundaries and practice ; Example -nurse practice act
Statutory law
Protect the rights of individuals within society; Occurs when harm to an individual happens or property damage Occurs ; usually awarded by monetary funds
Civil law
Protect society as a whole provide punishment for crime defined by municipal state or federal legislation; Includes felonies and misdemeanors
Criminal law
Reflect decisions made by administrative body such as the State Board of nursing when they pass rules and regulations
Regulatory law
Judicial decisions made in courts when individual legal cases are decided including informed consent cases
Common-law
Legal requirement for nursing practice that describes the minimum acceptable nursing care
Standard of care
Develop standards for nursing practice policy statement and similar resolutions
American nurses Association
Defines the scope of nursing practice ;distinguishes between nursing and medical practice ;establishes education/licensure requirements for nurses; protect public and is different in each state
The nurse practice act
Defines practice of nursing more specifically. For that state
State Board of nursing
Requires accredited hospitals to have written nursing policies and procedures is a voluntary action
The joint commission
Have their own policies and procedures
Healthcare agencies
A civil wrong made against a person or property
Tort
Willful acts that violate another person’s right such as assault , battery or false imprisonment, or insurance fraud
Intentional tort
Intent is lacking but Direct causation occurs and involves injury; Example would be invasion of privacy or defamation of character
Quasi-intentional Tort
Negligence or malpractice
Unintentional tort
Assault, battery or false imprisonment
Intentional torts
Any action that place the person in apprehension of a harmful or offensive contact without consent ;contact is not necessary
Assault
Any unintentional touching without consent ; Giving an injection without consent
Battery
Unjustified restraint of a person without legal warrant ; Restraining a conscious patient
False imprisonment
Invasion of privacy or defamation of character
Quasi-intentional tort
Protects from unwanted intrusion into his or her private affairs ; Hippa
Invasion of privacy
Publication of false statements that damages reputation
Defamation of character
Person is aware what is written or said is false but proceeds anyway
Malice
Speaking false about someone
Slander
Written defamation of character
Libel
Conduct that fall below the standards of care ; a breach of duty
Negligence
Professional negligence ;four steps ; 1)nurse had a duty to patient 2) didn’t carry out that duty 3) patient was injured 4) nurses failure caused the injury
Malpractice
Informed consent ; contracts and collective-bargaining; documentation; incident report; professional liability insurance
Legal safeguards for nurses
Agreement to allow something to happen; written confirmation after exclamation has been given an individual understands; violations could result in battery
Informed consent
Evidence of care
Documentation
Database for further investigation in an attempt to determine deviations from standard of care
Incident report
Contracts between a nurse and an insurance company
Professional liability insurance
Living will and durable power of attorney
Advanced directives
Protects people with disabilities which includes mental or physical impairments
ADA ;Americans With Disabilities Act
Basis for privacy and confidentiality
HIPPA health insurance portability and accountability act
The right to be free of unnecessary and inappropriate restraint
Restraints
Encourages health professionals to assist in emergencies outside of work ;limits their liability and offers legal immunity for nurses to help at the scene of an accident with in their Scope of practice
Good Samaritan act
Encourages identification and discipline of practitioners to engage and unprofessional conduct
National practitioner data Bank
That’s legal standards for healthy workplace
OSHA
Child elder abuse impaired nurses communicable diseases
Reporting obligations
Narcotics
Controlled substances
Study of conduct and character ;what is right and wrong based on moral reasoning and reflects value
Ethics
Formal statement that States a profession’s guidelines for ethical behavior; Set standards for the professional to achieve
Code of ethics
Refers to freedom from external control ; protects patient’s independence ;Example would be a self-determination act
Autonomy
Taking positive actions to help others; Example would be getting a different Form of a medication
Beneficence
Avoidance of harm or hurt; Oath taken at graduation
Non-maleficence
Fairness
Justice
Obligation to tell the truth
Veracity
Agreement to keep promises
Fidelity
Support of a particular cause
Advocacy
Willingness to respect one’s professional obligations and follow through on promises
Responsibility
Ability to answer for one’s own actions
Accountability
Protect someone’s information; keep it private ;example HIPPA
Confidentiality
Personally about the worth of a given idea attitude customer object that set standards that influence behavior
Values
Begins in childhood ;shaped by experience ;Government ,school ,religion ,social institutions all play a role
Value formation
Distinguish among value fact and opinion
Values clarification
Ask the question is this an ethical dilemma; gather information relevant to the case; clarify values; verbalize the problem; identify possible courses of action; negotiate a plan; evaluate the plan overtime
Seven steps of processing an ethical dilemma
Multidisciplinary; serves several purposes including education policy recommendation and case consultation
Ethics committee
Initiate dialogue concerning the client wishes. Do more listening than talking. Assess clients understanding of illness and available treatment options. Allow time to explore values and communicate. Facilitate communicating of clients desires to family and other healthcare providers.
Strategies for providing ethical care
The first of the recording of information relevant to data collection planning implementation and client response to care given
Documentation
Communication, legal documentation, financial billing, education, research, auditing/monitoring,
Purposes of patient records
One way that the healthcare team communicate through Charting. Tracks patient Progress education discharge planning
Communication
Best defense is for legal claims associated with nursing care
Legal documentation
DRGs are basis for establishing reimbursement For patient care. Document supplies used in treatment done and help support reimbursement
Financial billing
Helps anticipate the type of care the patient will need
Education
Gather data for the frequency of clinical disorders complications etc.
Research
Quality improvement
Auditing/monitoring
Be factual, be accurate, be complete, keep current, Be organized
Guidelines for quality documentation and reporting
Say what you mean and be descriptive. Do not use words appears or apparently. Quantify measurements accurately. Avoid catch all phrases such as patient comfortable, Record only what you see in here.
Factual Documentation
If using paper documentation write neatly and legibly. use proper spelling and grammar. be precise. use military time do not Prepay sentence with patient as the record is only the one patient. Do not use blank space on paper chart. Amend mistakes correctly
Accurate documentation
Do not omit significant information
Complete documentation
Chart promptly.
Current charting
Narrative charting should flow and tell a story. Documentation should follow a logical pattern
Organize documentation
Do not document someone else’s notes. Do not document care provided by another staff member. Do not criticize other healthcare professionals in the chart. Document noncompliant behavior to defend yourself
Miscellaneous guidelines for charting
Narrative charting, problem oriented charting, focus charting, charting by exception, critical pathways
Methods of charting
Traditional method. Story like format to document findings. Specific to patient condition/nursing care
Narrative charting
SOAP - Subjective, objective, assessment, plan
PIE -Problem, intervention, evaluation
Problem oriented charting
DAR- Data, action, response
Focus charting
Documenting deviations from established norm ;reduces documentation time/highlights changes; Flow records specific to disease; usually kept at bedside; does not always paint the picture
Charting by exception
Interdisciplinary care plan that includes problems intervention and expected outcomes within an established timeframe; DRGs
Critical pathways
Detailed form; Guides nurse through holistic care; provide the claimant embarrassment
Admission database
Allow you to quickly/easily enter assessment data i.e. vital , meals, ADLs; notes for abnormal
Flow sheet
Have activity and treatment section; a nursing care plan Demographics, meds ,diagnosis and rate of fluids included
Kardex
On paper/PC; list medicine/time/history; must be verified for accuracy. Read everything
MAR medication administration Record
Specialty that integrates nursing science computer science and information science to manage and communicate data information and knowledge and nursing practice
Nursing informatics
Support the way we function ;support/enhance nursing practice
Two goals of nursing informatics
Increase of time spent with patients, better access to information, enhanced quality of documentation, reduced errors of omission, lower hospital costs, increased nurse job satisfaction, compliance with requirements of accrediting agencies, development of a common clinical database
Advantages of nursing informatics system
Secure reliable in real time, episode of/longitudinal, primary information resources, evidence-based practice, CQI UR risk management and performance management, reimbursement, research, clinical trials
Attributes of an Electronic health record
Ranking patient based on need used for staffing
Acuity
Sharing essential information about the patient or changes in their condition; The bedside rounding
Change of shift Report
Use of SBARidentify self and validate the message
Telephone report
Repeat order back to healthcare provider; follow agency policies ;verified by the physician within 24 hours
Telephone/verbal orders
Must document who you spoke to
Transfer reports