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NCM 103 (LEC)
EXAM WEEK
| Term | Definition |
|---|---|
| Nursing Process | Scientific approach in which critical thinking is used to solve problems and this approach was introduced into nursing practice and education. |
| Major communication techniques used by healthcare providers: | Reporting and Documentation |
| Documentation | Serves as permanent record of client information and care. |
| Reporting | Takes place when two or more people share information about client care, either face to face or by telephone. |
| Purposes of client's record chart: | Communication Legal Documentation Research Statistics Education Audit and Quality Assurance Planning Client Care Reimbursement |
| Communication | The record serves as the vehicle by which different health professionals who interact with a client communicate with each other. This prevents fragmentation, repetition, and delays in client care. |
| Legal Documentation | Usually admissible in court as evidence. In some jurisdictions, however, the record is considered inadmissible as evidence when the client objects, because information the client gives to the primary care provider is confidential. |
| Research | The information contained in a record can be a valuable source of data for research. The treatment plans for a number of clients with the same health problems can yield information helpful in treating other clients. |
| Education | Students in health disciplines often use client records as educational tools. A record can frequently provide a comprehensive view of the client, the illness, effective treatment strategies, and factors that affect the outcome of the illness. |
| Audit and Quality Assurance | An audit is a review of client records for quality assurance purposes. Accrediting agencies such as The Joint Commission may review client records to determine if a particular health agency is meeting its stated standards. |
| Planning Patient Care | Each health professional uses data from the client’s record to plan care for that client. Nurses use baseline and ongoing data to evaluate the effectiveness of the nursing care plan. |
| Reimbursement | Documentation also helps a facility receive reimbursement from the federal government. For a facility to obtain payment through Medicare, the client’s clinical record must contain the correct diagnosis-related group (DRG) codes. |
| Statistics (Healthcare analysis) | Information from records may assist healthcare planners to identify agency needs, such as overutilized and underutilized hospital services. |
| Types of Nursing Record: | Admission Nursing Assessment NCM (Nursing Care Plan) Kardex Medication sheet with date and time of administration Daily treatment and procedures Graphic Record Fluid Balance Record Nurses Progress Notes |
| Admission Nursing Assessment | Also referred to as an initial database, nursing history, or nursing assessment, is completed when the client is admitted to the nursing unit. |
| Nursing Care Plans | The Joint Commission requires that the clinical record include evidence of client assessments, nursing diagnoses and client needs, nursing interventions, client outcomes, and evidence of a current nursing care plan. |
| 2 types of Nursing Care Plans: | Traditional Care Plan and Standardized Care Plan |
| Traditional Care Plan | Written for each client. The form varies from agency to agency according to the needs of the client and the department. Most forms have three columns: nursing diagnoses, expected outcomes, and a nursing interventions. |
| Standardized Care Plan | Were developed to save documentation time. These plans may be based on an institution’s standards of practice, thereby helping to provide a high quality of nursing care. |
| Kardex | Widely used, concise method of organizing and recording data about a client, making information quickly accessible to all health professionals. |
| Graphic Record | Indicates body temperature, pulse, respiratory rate, blood pressure, weight, and, in some agencies, other significant clinical data such as admission or postoperative day, bowel movements, appetite, and activity. |
| Fluid Balance Record | All routes of fluid intake and all routes of fluid loss or output are measured and recorded on this form. |
| Medication sheet with date and time of administration | Include designated areas for the date of the medication order, the expiration date, the medication name and dose, the frequency of administration and route, and the nurse’s signature. |
| Nurse Progress Notes | Nurses provide information about the progress a client is making toward achieving desired outcomes. |
| Factual Record | Descriptive, objective information about what a nurses sees, hears, feels, and smells. |
| Objective Description | Result of direct observation and measurement. |
| Methods of Documentation: | Problem Oriented Medical Record (POMR) PIE Charting Focus Charting Electronic Health Record |
| Source- Oriented Charting | Traditional client record. Each healthcare provider or department makes notations in a separate section or sections of the client’s chart. |
| Traditional part of source-oriented charting: | Narrative charting consists of written notes that include routine care, normal findings, and client problems. |
| Problem Oriented Medical Record (POMR) | Established by Lawrence Weed in the 1960s, the data are arranged according to the problems the client has rather than the source of the information. |
| The POMR has four basic components: | Database Problem list Plan of care Progress notes |
| Database | Consists of all information known about the client when the client first enters the healthcare agency. |
| Problem List | Is derived from the database. It is usually kept at the front of the chart and serves as an index to the numbered entries in the progress notes. |
| Plan of Care | The initial list of orders or plan of care is made with reference to the active problems. Care plans are generated by the individual who lists the problems. |
| Progress Notes | Chart entry made by all health professionals involved in a client’s care. Numbered to correspond to the problems on the problem list and may be lettered for the type of data. |
| PIE Charting | Acronym for problems, interventions, and evaluation of nursing care. This system consists of a client care assessment flow sheet and progress notes |
| Flow Sheet | Uses specific assessment criteria in a particular format, such as human needs or functional health patterns. |
| Focus Charting | Intended to make the client and client concerns and strengths the focus of care. Three columns for recording are usually used: date and time, focus, and progress notes. |
| DAR (Data, Action, Response) | Data reflects the assessment phase of the nursing process and consists of observations of client status and behaviors. Action reflects planning and implementation and includes immediate and future nursing actions. Response evaluation phase. |
| Electronic Health Record | Use computers to store the client’s database, add new data, create and revise care plans, and document client progress. |
| Types of Reporting | Summary/Hand-off reports Walking Rounds Reports Incident Report Telephone Order/Report |
| FDAR | Focus Data Action Response |
| Asepsis | Absence of germs. |
| Aseptic Technique | Standard healthcare practice that helps prevent the transfer of germs to or from an open wound and other susceptible areas on a patient's body. |
| Surgical Asepsis (Aseptic Technique) | Eliminate germs. Surgical handwashing |
| Medical Asepsis (Clean Technique) | Reducing the number of microorganisms in general. Medical Handwashing |
| Healthcare-associate infection (HAIs) | Infection that a person acquires as a result of treatment from a healthcare professional. |
| Types of Aseptic Technique: | Barriers Patient and Equipment Preparation Environmental Controls Contact Guidelines |
| Barriers | Prevent the transfer of germs between healthcare professionals, patients, and the environment. |
| Patient and Equipment Preparation | Prepare both the patient and the equipment before a medical procedure takes place. |
| Environmental Controls | It is essential to maintain an aseptic environmental before and during the procedures. |
| Contact Guidelines | Once a healthcare professional has washed their hands and donned their sterile barriers, they must follow sterile-to-sterile contact guidelines, These guidelines prohibit any contact between sterile and nonsterile items. |
| Aseptic Field | The designated procedural area. |
| Method of Transmission: | Direct Transmission Indirect Transmission Airborne Transmission |
| Direct Transmission | Person to person through touching, sexual intercourse, and droplet. |
| Indirect Transmission | Vehicle and Vector |
| Airborne Transmission | Droplet Nuclei or Dust. |
| Infectious Agent | Pathogen that causes diseases. |
| Reservoir | Environment where pathogen lives. |
| Portal of Exit | The way infectious agent leaves the reservoir. |
| Mode of Transmission | The way infectious agent can be passed on. |
| Portal of Entry | The way an infectious agent enter a new host. |
| Susceptible Host | A person that can be infected. |
| Blood Tests | Used diagnostic tests about the hematologic system. |
| Venipuncture | Puncture of a vein for collection of a blood specimen. |
| Phlebotomist | Person who performs venipuncture |
| Complete Blood Count | Basic Screening test and one of the most frequently ordered blood. |
| Serum Electrolyte | Screening of electrolytes and acid-base imbalances. |
| Blood Chemistry | Determining enzymes such as Cardiac Markers, Thyroid hormones, Cholesterol, Triglycerides, SGPT and SGOT, FBS. |
| Hemoglobin A1C (HbA1C test) | Measures blood glucose for the past 3 to 4 months. |
| Capillary Blood Glucose | A capillary blood specimen is taken to measure the current blood glucose level when frequent test are required or when a venipuncture cannot be performed. |
| Stool Exam | Determine the presence of bacteria or viruses, blood, ova or parasites. |
| Urine Analysis | Urinalysis |
| Medication | A substance prescribed for cure, treatment or relief of symptoms. |
| Prescription | Written direction for the preparation and drug administration. |
| Routes of Administration: | Oral Sublingual Parenteral Topical Inhalation Intravaginal/Rectal |
| 10 rights of medication | Right Client Right Medication Right Dose Right Route Right Client Education Right Assessment Right to refuse Right to documentation Right evaluation |
| Transformational Leadership | Focused on change and innovation through team development, motivates and empowers staff to function at a high level of performance and serves as a role model for the nurses on the unit. |
| TEEAMS | Time Empowerment Enthusiasm Appreciation Management Support |
| Nursing Care Delivery Methods: | Traditional models: Team Nursing Primary Nursing Today's Model: Patient-centered care Total Patient Care Case Management |
| Team Nursing | Rn is the leader who leads a team of other RNs, practical nurses, and nursing assistive personnel (NAP) who provide direct patient care. |
| Primary Nursing | Model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members. |
| Patient-Centered Care | Mutual partnerships among the patient, family, and health are team are formed to plan, implement, and evaluate the nursing and health care delivered. |
| Total Patient Care | RN is responsible for all aspects of care for one or more patients during a shift of care. |
| Case Management | Care-management approach designed to coordinate and link health care services across all levels of care for patient and their families while streamlining costs and maintaining quality. |
| Decentralized management | Decisions making occurs at the level of the staff. |
| Delegation | Skill that you need to observe and practice to improve your own management skills. |
| the 5 rights of Delegation: | Right Task Right Circumstances Right Person Right Direction/Communication Right Supervision/Evaluation |
| Right Task | Repetitive, require little supervision, are relatively noninvasive have results that are predictable and have potential minimal risk. |
| Right Circumstances | Consider the appropriate patient setting, available resources, and other relevant factors. |
| Right Person | Delegating the tasks to the right person to be performed on the right person. |
| Right Direction/Communication | Give a clear. concise description of a task. |
| Right Supervision/Evaluation | Provide appropriate monitoring, evaluation, intervention as needed and feedback. |
Created by:
coffeemanga
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