Weeks 1 and 2- Nurse's Role, Documentation, Health Hx, Social/cultural Flashcards
CAGE test
screening questionnaire to identify excessive drinking:
- C Cut down - Have you ever thought you should cut down your drinking?
- A Annoyed - Have you ever been annoyed by criticism of your drinking?
- G Guilty - Have you ever felt guilty about your drinking?
- E Eye-opener - Do you drink in the morning (i.e. an eye-opener?)
PES
problem- etiology - symptoms/defining characteristics
Diagnosis (P) r/t Etiology (E) aeb Characteristics (S)
disease condition based on specific evaluation of signs and symptoms
medical diagnosis
nursing diagnosis
judgment about the PT in response to an actual or potential health problem
an actual or potential physiological complication that nurses monitor to detect the onset of changes in patient’s status
collaborative diagnosis
3 types of nursing diagnoses
actual
risk (potential)
wellness (health promotion)
Healthy People 2020
framework for health promotion efforts. Objectives address most significant preventable threats to health with goals to reduce threats
functional assessment
focuses on the functional patterns that all humans share: health perception and health management, activity and exercise, nutrition and metabolism, elimination, sleep and rest, cognition and perception, self-perception and self-concept, roles and relationships, cop- ing and stress tolerance, sexuality and reproduction, and values and beliefs
role of the professional nurse
to promote health, prevent illness, treat human responses, and advocate for patients.
SOAP
subjective-objective-assessment-plan
PIE
problem-intervention-evaluation
DAR
data-action-response
CBE
charting by exception
What is SBAR for?
it is a mental model for organizing verbal communication
**It does NOT replace written documentation!!
Computerized provider order entry (CPOE)
allows providers to enter all orders directly into the computer, electronically communicating orders to the laboratory, pharmacy, and nursing unit
purpose of auditing charting
To determine if staff members are providing and documenting standards of care
Agencies usually perform audits to look at systems, not individuals, and to determine whether staff members are meeting the standard of care
what are the 4 phases of an interview
preinteraction (always review the record chronologically)
beginning (introduce yourself)
working (assessing, asking questions, head to toe, etc)
closing (summarize!)
aphasia
name given to a collection of language disorders caused by damage to the brain
what does it mean to be culturally sensitive
Possessing basic knowledge of and constructive attitudes toward diverse cultural populations
what does it mean to be culturally appropriate
Applying underlying background knowledge necessary to provide the best possible health care
what does it mean to be culturally competent
Understanding and attending to the total context of the individual’s situation, including immigration status, stress factors, other social factors, and cultural similarities
Race
genetic in origin and includes physical characteristics:
Skin color, bone structure, eye color, and hair color
What are the CLAS standards
There are 14 standards, made to ensure equitable and effective treatment
Organized around 3 themes:
1) Culturally Competent Care (Standards 1–3),
2) Language Access Services (Standards 4 –7), and
3) Organizational Supports for Cultural Competence (Standards 8–14).
Purnell model of cultural care
Addresses subjective (attitudes, beliefs, values, behaviors) culture and does not address objective (material) culture. This is NYU’s model for culturally competent care
The nurse assessing an older adult focuses the health history on
sensory deficits, illness history, and lifestyle factors
CAM therapies used ______of conventional treatments to restore health are often termed _______, whereas CAM therapies used _____conventional medicine are often labeled _______.
INSTEAD, alternative
WITH, complementary
Culture can be defined as
a shared, learned, and symbolic system of values, beliefs, and attitudes that shapes and influences the way people see and behave in the world
The purpose of comparing culture care needs of the specific individual to the general themes of people from similar cultural background is to:
provide a picture of the individual’s culture-based health care needs
With transcultural assessment, the nurse must
determine which questions to ask (the list is too extensive to ask everything!)
