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Semester One - Nursing 111 > Week Three > Flashcards

Week Three Flashcards

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1
Q

Purposes of the client medical record

A

communication, planning client care, auditing health agencies, research, education, reimbursement, legal documentation, health care analysis (evidence based practice)

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2
Q

Admission sheet

A

client’s demographic, billing, allergies, MD info

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3
Q

Nursing care plan must be initiated how many hours within admission?

A

24 hours

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4
Q

Client discharge plan

A

upon admission, includes discharge plans and referral data

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5
Q

1000 mcg (mg)

A

1

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6
Q

60mg (gr)

A

1 gr

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7
Q

1gm (mg)

A

1000mg

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8
Q

5cc (tsp)

A

1 tsp

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9
Q

1kg (lb)

A

2.2 lb

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10
Q

1 ml (cc)

A

1cc

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11
Q

1oz (ml)

A

30 mL

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12
Q

1 qt

A

1 liter or 1000 mL

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13
Q

DSSP

A

two tsps

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14
Q

MCC documentation error policy

A

1 line strike through initials, date, and error

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15
Q

Kardex

A

system of cards or computer generated forms designed to state concisely the care for each client. name, age, room #, medical diagnoses, admission date, MD/PCP’s name

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16
Q

Source-Oriented Record

A

each department has their own section of the chart to record under (nursing, PT, RT)

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17
Q

Problem-Oriented Medical Record

A

data in the record is arranged according to identified client problems. Progress notes are then recorded under each of the identified problems by all disciplines involved in care

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18
Q

Four basic components of POMR

A

database, problem list, plan of care, progress notes

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19
Q

SOAP

A

subjective data, objective data, assessment, plan

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20
Q

narrative charting

A

chronological order, example of source-oriented record

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21
Q

PIE charting

A

problems identified, interventions performed, evaluation of care/interventions

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22
Q

Charting by exception

A

significant findings or exceptions to norms are recorded.

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23
Q

Three key elements of charting by exception

A

flowsheets, standards of nursing care, bedside access to chart forms

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24
Q

Who updates kardexes?

A

all nurses assigned to providing care to that client

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25
Q

Acceptance

A

receiving the client’s honest feelings/actions without judgement

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26
Q

Commitment

A

a pledge or contract to fulfill an obligation or agreement

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27
Q

Communication

A

any means of exchanging information or feelings between two or more people

28
Q

Concreteness

A

being specific and clear when communicating

29
Q

Confrontation

A

RN points out discrepancies between thoughts, feelings, and actions that inhibit the client’s self-understanding or exploration of specific areas

30
Q

Empathy

A

the ability the discriminate what the other person’s world is like and to communicate to the other this understanding in a way that shows that the helper understand the client’s feelings and the behavior and experience underlying these feelings

31
Q

Genuineness

A

statement that is helpful is solidifying the rapport between the RN and the client

32
Q

Respect

A

attitude that considers the client’s point of view

33
Q

self-disclosure

A

same as boundaries which are limits in which a person may act or refrain from acting within a designated time or place

34
Q

therapeutic communication

A

promotes understanding and can help establish a constructive relationship between the RN and the client

35
Q

therapeutic relationship

A

also known as a helping relationship that is made up of four phases (pre interaction, introductory, working, termination)

36
Q

trust

A

reliance on someone without doubt or question

37
Q

Communication Process

A

Message —> Receiver —> Decode —> Encode —> Message (Response) —> Decode —> Encode –> Sender

38
Q

Public Space

A

12-15 feet

39
Q

Intimate Space

A

touching to 1.5 feet

40
Q

PErsonal Space

A

1.5-4 feet

41
Q

Social Space

A

4-12 feet

42
Q

Three major barriers to communication

A

failure to listen, improper decoding of client’s message, placing one’s needs over the other’s

43
Q

Attentive Listening

A

listening actively, using all the senses as opposed to listening passively with just the ear

44
Q

Use of Silence

A

accepting pauses or silences that may extend for several seconds or minutes without any verbal response

45
Q

Providing General Leads

A

using statements or questions that encourage verbalization, a topic choice, and facilitate continued verbalization

46
Q

Using Open-ended questions

A

asking broad questions that lead or invite the client to explore thoughts or feelings

47
Q

Using Touch

A

Proving appropriate forms of touch to reinforce caring feeling. Must be sensitive to the differences and practices of clients and self

48
Q

Paraphrasing

A

repeating client’s basic message in similar words

49
Q

Seeking Clarification

A

a method of making a client’s broad overall meaning of the message more understandable. used when paraphrasing is difficult or when the communication is rambling or garbled

50
Q

Consensual validation

A

similar to clarifying - verifies the meaning of specific words rather than the overall meaning

51
Q

Offering self

A

suggesting one’s presence, interest, or wish to understand client without making any demands or attaching conditions that the client must comply with the receive attention

52
Q

Giving Information

A

providing simple, factual info the client may or may not request

53
Q

Focusing

A

helping the client expand on and develop a topic of importance

54
Q

Reflection

A

directing thoughts, feelings, questions content back at client for further exploration

55
Q

Summarizing

A

stating the main points of a discussion to clarify the relevant points discussed

56
Q

Agreeing/Disagreeing

A

akin to judgmental responses, agreeing and disagreeing imply tha tthe client is either right or wrong and that the nurse is in a position to judge this. these responses deter clients from thinking through their position and may cause a client to become defensive

57
Q

Being defensive

A

protection from admitting weaknesses “you have no right to complain”

58
Q

Challenging

A

giving a response that makes clients prove their statement or point of view. these responses indicate that the nurse is failing to consider the client’s feelings, making the client feel it is necessary to defend a position

59
Q

Changing Subject

A

directing the communication into areas of self-interest rather than considering client’s concerns is often a self-protective response to a topic that causes anxiety. these responses imply that what the nurse considers important will be discussed and that the clients should not discuss certain topics

60
Q

Giving common advice

A

telling client what to do “if I were you, I’d go to a nursing home”

61
Q

Passing judgment

A

giving opinions and approving or disapproving responses, moralizing or implying one’s own values. these responses imply that the client must think as the nurse thinks, fostering client dependence

62
Q

Probing

A

asking for information chiefly out of curiosity rather than with the intent to assist the client. these responses are considered probing and violate the client’s privacy. asking why is often probing and places the client in a defensive position

63
Q

Rejecting

A

refusing to discuss certain topics

64
Q

stereotyping

A

offering generalized and oversimplified beliefs about groups of people that are based on experiences too limited to be valid. these responses categorize clients and negate their uniqueness as individuals

65
Q

Unwarranted reassurance

A

“don’t worry” “I’m sure everything will be okay”

Semester One - Nursing 111 (15 decks)

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