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Basics of Nur
Basics of Nursing Chapter 3-9
| Question | Answer |
|---|---|
| Legal Safeguards - Risk Management | Programs are based on a systematic reporting system of incidence or unusual occurrences |
| Incident Reports | -A tool used as a means of identifying & improving client care-Required by federal law-Written as soon as possible after the occurrence by the person who witnesses the incident-Should be legible, factural & objective-Follow specific guidelines |
| Physicians Orders | Obligated to carry out a physician's orders EXEPT when the nurse believes the order is inappropriate-May be legally responsible for any harm suffered-Must clarify an unclear or inappropriate order with the physician-No verbal order except in Emerg. |
| Telephone Orders | -Date & time the entry-Repeat the order to the physician & record the order given-Sign the order beginning with t.o. (telephone order) write physician's name, & sign the order (Full name)-Physician needs to countersign the order within a time frame |
| Documentation | Legally required by accrediting agencies |
| Narrative | -Use black pen only-Date & time entries-Provide objective, factual, accurate, & specific documentation-Document in order-Document care, meds, treatments, & procedures as soon as possible-Document client response-Document consent or refusal |
| SPN | Student Practical Nurse |
| Computerized Documentation | Use only the user ID code, name, or passwordNever lend access ID to another |
| Client/Family Teachings | Responsibility of the RN & the LPN reinforces teaching once the instruction & education has been started by the RN.Provide complete instructions in a language the client can understand.Document client & family teaching, what was taught. |
| Will | Documentation should include who was present, any significant comments by the client, & the nurse's observations of the client's conduct during the process |
| Advance Directives | Written document recognized by state law that provides directions concerning the provision of care when a person is unable to make his/her own treatment choices.A physician must be notified of it's presence |
| Living Will | Prepared by a compentent adult that provides direction regarding medical care in the event of a person's incapacitation. |
| Durable Power of Attorney | Authorization that enables any competent individual to name someone to exercise decision-making authority under specific circumstances on the individual's behalf. |
| Right of Informed Refusal | A competent adult has the right to refuse treatment, even life-sustaining treatment |
| Do Not Resuscitate (DNR) Orders | Specific agency guidelines must be followed regarding when & under what circumstances a verbal DNR order is acceptable. Both DNR & cardiopulmonary resuscitation (CPR) orders must be clearly defined so that other treatment can continue. |
| Organ Transplant | The option to accept an organ transplant can be refused |
| Organ Donation | Any person 18 or older may become an organ donor by written consent.A family member or legal guardian may authorize donation of the decedent’s organs in the absence of appropriate documentation |
| Autopsy | Medical examination of the body after death for the purpose of determining the cause of death |
| Assisted Suicide | Taking an active role in assisting a client to die is a criminal offense in many states |
| Reporting Responsibilities - Requirements | Nurses are required to report certain communicable diseases or criminal activities such as abuse, gunshot or stab wounds, assaults, homicides, and suicides to the appropriate authorities |
| Reporting ResponsibilitiesThe Impaired Nurse | If a nurse suspects that a coworker is abusing chemicals, the nurse must report the individual to nursing administration in a confidential manner with the goal of treatment being the priority issue |
| Occupational Safety and Health Administration (OSHA) | employer provide a safe workplace for employees according to regulationsEmployees can confidentially report working conditions that violate regulationsAn employee who does not report unsafe working conditions can be retaliated against by the employer |
| Sexual Harassment | Includes unwelcome conduct of a sexual nature |
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