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FUN 9,10,11
Plan of Care/Admit, Xfer, Disch/Documentation
Question | Answer |
---|---|
Describe interdisciplinary approach to health care | Following treatment prevents fragmentation of patient care |
Define nursing process | Systematic method by which nurses plan & provide care for patients |
What are the Steps of nursing process in order? | Assess, Diagnosis, Plan & Identify Outcomes, Implement, Evaluate |
Describe assess | Gather information about the patients condition |
Describe diagnosis | Identify the patients problems |
Describe Plan & Identify Outcomes | Identify appropriate nursing actions |
Describe Implement | Perform the nursing actions identified in planning |
Describe Evaluate | Determines if goals met & outcomes are achieved |
What does a complete assessment involve? | A review and physical examination of all body systems |
How does the collection of data assist in forming the nursing care plan? | Related diagnostic procedures are analyzed in development of a plan of care |
What is nursing diagnosis? | Clinical judgment about the client's response to actual or potential health conditions or needs |
What role does the LPN play in the development of a nursing diagnosis? | RN collaborates with the LPN when determining the nursing diagnosis |
Define actual nursing diagnosis | Clinical judgment about human experience/responses to heath conditions/life processes that exist in an individual, family, or community |
Define risk nursing diagnosis | Describes human responses to health conditions/life processes that may develop in a vulnerable individual/family/community |
Define syndrome nursing diagnosis | Clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions |
Define health promotion diagnosis | (Wellness nursing diagnosis) Clinical judgment about a person's family, or community's motivation and desire to increase well being & actualize human health potential as expressed the readiness to enhance specific health |
What is medical diagnosis? | The identification of a disease or condition with evaluation of physical signs, symptoms, patient interview, laboratory test, diagnostic procedures, review of med records, and patient history |
What is the difference between medical & nursing diagnosis? | Diagnostic studies and laboratory studies are used to help w/identification of medical diagnoses, however a nursing diagnosis addresses human response to health problems and life processes |
What is an outcome statement? | Indicates the degree of wellness desired, expected, or possible for the patient to achieve and contains a patient goal statement |
Who should the nurse include when developing nursing interventions for the patient? | Patient |
Explain basic principle of Maslow's model of health and illness | A person has to meet the need at the base of pyramid before moving up to the next level |
What is the bottom tier of Maslow's hierarchy pyramid? | Physiologic - nutrition, elimination, oxygen, sexuality, ABC's |
What is the 2nd tier of Maslow's hierarchy pyramid? | Safety & Security - stability, protection, security, freedom from fear, & anxiety |
What is the 3rd tier of Maslow's hierarchy pyramid? | Love & Belongingness - Affection, acceptance by peers & community |
What is the 4th tier of Maslow's hierarchy pyramid? | Esteem - self respect, self confidence, feelings of self worth |
What is the 5th tier of Maslow's hierarchy pyramid? | Self-Actualization - full use of individual talents |
Define evidence-based practice (EBP) | Scholarly and systematic problem-solving paradigm that results in the deliver of high quality health care |
What steps must a nurse take to complete the evaluation? | Review, Reassess, Compare |
What is some information that should be included in the end-of-shift report? | V/S, types of IV fluid (rate of infusion), I/O of feces, urine & gastric juices, PRN meds w/time administered, Any abnormal signs/symptoms or abnormal LOC or mental status |
What is a reaction for Loss of Identity? | Patient feels reduced to a number or just a name on ID bracelet |
What can nurse do to help with Loss of identity? | Explain ID is necessary for positive means of ID, for meds & procedures. Also, learn patients name quickly |
What is a reaction for Separation anxiety? | Patient being withdrawn or very talkative (older adult exhibits disorientation, small child cry's) |
What can a nurse do to help with separation anxiety? | Encourage family & friends to visit, be liberal w/visiting hours, allow pets to visit, give small child toys and let parents remain with them |
How should the nurse address the patient? | By surname unless patient request otherwise |
How does the nurse prepare for new admission? | Prepare room, care items in place, bed at correct height & pulled down |
How can the nurse ensure a good first impression for patient arriving on the unit? | Courteously greet the patient by surname, introduce yourself, project interest & concern |
List information that should be included when orientating patient to their room | Orient to unit, lounge, nurses station, room, phone, bed, call light, television, and explain routines such and visiting hours and meal times |
What should be done with patients valuables? | Follow facility's policy / log on personal belongings sheet and place in safe |
Describe techniques the LPN can use to decrease anxiety while performing a young child's assessment | Encourage parents to stay with child, encourage children to use equipment on dolls to help reduce anxiety, answer any questions the children may have (but on their level) |
What is the difference between an intra-agency transfer & interagency transfer? | Intra-agency transfer is moving pt from one unit to another in the same facility, interagency transfer is moving the pt from one facility to another |
Why is documentation so important during the transfer of a patient? | To maintain continuity of care |
When does discharge planning begin? | At time of admission or shortly after |
What instruction does the Joint Commission require to be provided to patient discharge? | Safe effective use of medications & equipment, Instruction on nutrition & modified diets, Rehab techniques to support adaptation, access to avail. community resources, when & how to obtain further treatment, pt & families respon. in pt ongoing health care |
What is included in discharge summary? | Pt's learning needs, how will they have been met, pt's teaching completed, short-term & long-term goals of care, referrals made, and coordinated care plan to be implemented after discharge |
What does a dietitian do? | Provides proper nutrient food source requirements in patients diet |
What does a social worker do? | Provides counseling for major life crisis, assist in finding community resources, assist in finding financial resources |
What does a physical therapist do? | Assist in examination & treatment of disabled, assist is rehab of patient |
What does a occupational therapist do? | Teaches patient to adapt to physical or cognitive challenges by learning new vocational skills or activities of daily living |
What does a home health nurse do? | Provides follow-up discharge visits to patients home for delivery of nursing services |
What is discharge against medical advice (AMA)? | When a patient leaves health care facility without a health care providers order for discharge |
What should the nurse do if a patient decides to leave AMA? | Notify health care provider immediately, if provider isn't available, ask patient to sign AMA form after discussing discharge with patient |
What do you do if they refuse to sign the AMA form? | Let them go, document incident thoroughly & notify health care provider |
What are 5 basic purposes for accurate and complete patient records? | Documented communication, permanent record for accountability, legal record of care, teaching, research and data collection |
What is peer review? | Appraises the manner in which an individual nurse conducts practice, education, or research |
What is quality assurance/assessment/improvement? | An audit in health care that evaluates services provided and the results achieved compared with accepted standards |
Managed care facilities are reimbursed according to DRG's or other illness categories. What do these private insurance co. & govt agencies base their reimbursement on? | Prospective payment system that classifies patients by age, diagnosis, surgical procedure, or other information with hundreds of different categories to predict the use of hospital resources |
What are the advantages of using an EHR? | Increase efficiency, consistency, accuracy, and decrease cost |
What is SBAR? | Situation, Background, Assessment, and Recommendation - method of communication among health care workers and part of document |
What should all documentation include? | Correct patients name, ID#, DOB, Date / time appropriate. Use only approved abbreviations & medical terms, be timely & specific, write legibly |
When should the nurse chart the care given to a patient? | After care is given - Implementation - as soon & as often as possible, use direct quotes as appropriate, be objective, describe each item as you see it |
How should a late entry be written? | "Late entry" then proceed with your notes |
Inappropriate documentation may lead to malpractice, list examples of inappropriate documentation | Not charting correct time that events occurred or that the event occurred at all, failing to record verbal orders, charting nursing care in advance, documenting incorrect data |
What should the nurse include with using narrative charting? | Subjective, objective, or both - about the basic patient need or problem, whether anyone has been contacted or consulted, care & treatments provided (implementation), and the patients response to treatment (evaluation) |
What is the SOAPIER acronym? | Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision |
What does charting by exception mean? | Nurse charts complete physical assessments, observations, v/s, IV site & rate, and other pertinent data at beginning of each shift |
What two formats may the nurse use when charting by exception? | PIE - Problem, Intervention, Evaluation / SOAPE - Subjective, Objective, Assessment, Plan, Evaluation |
What should the nurse include when filling out an incident report? | Nurse should only give objective & observed information |
Who owns the health record? | Institution or health care provider |
Can the patient access their medical record? | Not immediate access, they have to request a copy (not original) and patient may have to pay for copies |
What does HIPAA mean? | Health Insurance Portability Accountability Act |
What does HIPAA do for the patient? | Affords certain protections to persons covered y health plans, including continuity of coverage when changing jobs, standards for electronic health care transactions, and primary safeguards for privacy of individually identifiable patient information |
List 3 guidelines for safe computer documentation | Log on with secure password (NEVER SHARE YOUR PASSWORD), Be sure to log off system before you walk away, Keep monitor out of view of others |