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ATI Final Review 1
ATI Final Review for Chapters 2, 3 and 4
| Question | Answer |
|---|---|
| Affordable Care Act | A law enacted in 2010 to improve health care quality while lowering costs and expanding the Medicaid program. |
| The Joint Commission | a nonprofit organization that accredits health care organizations in multiple types of health care settings, ranging from inpatient hospitals to pharmacies. |
| Sentinel Event | An adverse event that should never occur. Ex; A client is given blood that has been incorrectly typed in the laboratory, An infant death, A client has the wrong arm or leg amputated during surgery. |
| National Committee for Quality Assurance | an independent, nonprofit organization that accredits health care plans, providers, facilities, and case management companies. |
| American Nurses Credentialing Center | An organization that supports nurses to improve client care through education, certifications, and professional designations. |
| Magnet Recognition Program | A program that recognizes acute care facilities that demonstrate excellence in nursing based upon meeting standards in five categories. |
| The Components of Magnet | Structural empowerment Exemplary professional practice New knowledge, innovations, or improvements Transformational leadership Empirical outcomes |
| Pathway to Excellence Program | A program for long-term or outpatient facilities to recognize excellence in nursing. |
| Hospital Consumer Assessment of Healthcare Providers and Systems | A system that acute care facilities use to measure the client's satisfaction |
| Press Ganey | A survey tool designed to evaluate the client's perception of their experience within the outpatient setting of the health care system. |
| Medicare | Government health care coverage for a client who is age 65 or older, under age 65 with disabilities, or any age with End Stage Renal Disease (ESRD). |
| Medicare Benefits pt.1 | Part A: Hospitalization, skilled nursing facilities, some hospice care, some home health care Part B: Doctor’s services, physical therapy, occupational therapy, some home health care |
| Medicaid | Government health care coverage for a client who must meet eligibility requirements based on the client's income in relation to the poverty level. |
| Children’s Health Insurance Program | Government health care coverage that provides for children who may not meet Medicaid's requirements but need health coverage. |
| Private Insurance | Insurance coverage that is not provided by a government agency. |
| Health Maintenance Organizations(HMOs) | A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. |
| Fee For Service | Reimbursement payments made to service providers based on the volume of services delivered. |
| Centers for Medicare and Medicaid Services (CMS) | A government agency that oversees the health care delivery of Medicare, Medicaid, and CHIP programs. |
| Diagnosis Related Groups (DRGs) | A fixed payment system for reimbursement for health care services based upon client diagnosis and procedures performed. |
| Inpatient Prospective Payment System (IPPS) | A method of standardized insurance reimbursement based on the client’s diagnosis and procedures performed within the acute care setting. |
| Hospital-Acquired Condition Reduction Program | A program instituted by the Centers for Medicare & Medicaid (CMS) to increase the quality of care in health care facilities. This program denies reimbursement for services associated with specific health care-acquired infections. |
| Hospital-Acquired Infections | An infection a client develops during an admission to an acute care facility. |
| Resource Utilization Groups (RUGs) | A fixed payment system for reimbursement of health care services provided in the long-term care setting based upon client diagnosis and services required. |
| Minimum Data Set (MDS) | A clinical assessment of a client's physical and cognitive status required to be conducted on nursing home residents who receive Medicare and Medicaid benefits. |
| Social Determinants of Health (SDOH) | Factors that impact health other than health care services, including location, environment, genetics, income, relationships, and gender. |
| Key Factors of Social Determinants of Health | Neighborhood and Built Environment Health and Health Care Economic Stability Education Social and Community Context |
| Primary Care | The primary care provider (who may be a physician, nurse practitioner, or physician’s assistant) can screen the client and treat him or her for routine illness, promote wellness, and prevent disease. |
| Community Care | The community care setting also focuses on preventive services, caring for clients before admission to a facility. |
| Acute Care | An acute care illness is one that requires treatment in an emergency department or an overnight stay in an acute care setting. It is usually a brief or short admission to treat and stabilize the episode. |
| Long-Term Care | A long-term care (LTC) facility cares for clients who do not need specific nursing skills such as dressing changes or tube feedings, but rather a place to live. |
| Skilled Nursing Facility | A skilled nursing facility, sometimes referred to as a nursing home or LTC, may provide short-term rehabilitation care such as occupational and physical therapy as well as oversight for activities of daily living. |
| Long Term Care Hospital | A long-term care hospital (LTCH) specializes in clients who require hospitalization for long-term illnesses such as severe burns, trauma, or ventilation needs. |
| Assisted Living | Assisted living care provides services for clients who are mostly independent in their living but choose to live in a community setting for assistance with some part of their daily life. |
| Hospice Care | Hospice care is provided to a client when the provider has determined the individual has less than six months to live. The goal of care is not to treat or cure the illness, but rather to provide comfort and support services. |
| Palliative Care | Palliative care services, sometimes called supportive care, provide services that help clients feel as comfortable as possible during their illness, with the goal of promoting pain relief and overall comfort during their illness. |
| Respite Care | Respite care provides care for the client to allow the caregiver a break from these responsibilities for a short time for vacations, to travel, or to simply stay at home without caring for the client. |
| Home Care | The delivery of continued health care services within the client's home. Services can include nurse visits as well as occupational therapy, physical therapy, and social work. |
| Advanced Practice Registered Nurse | A registered nurse who has completed advanced education in a specialty and passed the associated certification examination. |
| Case Manager | A Case Manager collaborates with health care team members and the client to ensure the treatment plan meets the client’s needs and provides quality, cost-effective care. |
| Dentist | A Care Provider a doctoral degree from a school of dentistry and must pass licensure examinations. These practitioners diagnose and treat issues within the oral cavity, including those involving the teeth, gums, and jaw. |
| Dietitian | A Care Provider with a bachelor’s degree and must pass a certification or licensure examination also advising clients about healthy food choices for nutrition and weight management, they recommend therapeutic diets to treat specific medical conditions. |
| Licensed Practical Nurse | A Care provider who has completed a state-approved program and passed a national licensure exam. LPN programs vary by state, but are generally 12 months long and include both classroom learning and supervised clinical practice. |
| Naturopathic Physician | They are health practitioners who specialize in treating clients by prescribing more natural methods. They recommend changes in lifestyle, herbs, dietary supplements and manipulative therapy instead of more traditional approaches to medicine. |
| Occupational Therapist | OT's a master’s or doctoral degree, and has passed a licensure examination. OT's provide care in many settings, assisting clients to either recover or develop new skills to maintain daily living and return to work. |
| Emergency Medical Technician | EMT's completed an educational program that is one to two years in length and then (typically) passed a certification exam. A paramedic has a higher level of education and skills and typically holds an associate degree. |
| Pharmacist | Doctor of Pharmacy (PharmD) degree and must pass two licensure examinations to practice. They prepare and dispense medications prescribed by providers, double-check for interactions with other medicines, and educate clients on how to take medicine. |
| Physical Therapist | PT's have a master’s degree and has passed a licensure examination. Physical therapists provide services to clients to assist in their recovery from injury or illness. |
| Physician | Physicians diagnose and treat illness, prescribe medications and therapies as needed, and interpret diagnostic testing. They can educate clients on disease and diet and make referrals to specialists as required. |
| Specialist Physician | A subtype of physician that have completed additional education, focused in a specific field of medicine. |
| Physician Assistant | PA's have a master’s degree and have passed a licensure examination. They work under the direction and supervision of a physician, but can treat, diagnose, and prescribe medications, laboratory and other diagnostic tests, and treatments for clients. |
| Respiratory Therapist | Respiratory therapists have an associate or bachelor’s degree from a program accredited in respiratory care and must pass a licensure examination to practice in most states. They treat clients who have chronic or acute diseases of the lung. |
| Registered Nurse | RN's complete a nursing program that is approved by the State Board of Nursing (BON) and pass the national licensure examination. They can obtain certifications demonstrating they are an expert in a specific area. |
| Social Worker | SW's have a bachelor’s or master’s degree, depending on their field of work and they must pass a licensure examination. In general, social workers collaborate with the interprofessional health care team to help find solutions to client challenges. |
| Assistive Personnel | Assistive personnel (AP) are usually nurses’ aides who assist the health care team. They can become certified nursing assistants by completing a brief state-approved course of study and then passing a certification examination. |
| Accreditation Commission for Education in Nursing | ACEN accredits clinical doctoral, master’s, baccalaureate, associate, diploma, and practical nursing programs. |
| Commission on Collegiate Nursing Education | CCNE is an autonomous commission protects the health and well-being of recipients of nursing care by maintaining high standards for baccalaureate, master’s, and doctoral programs. |
| Nursing Practice Act | a Nurse Practice Act, the law that governs the scope and standards of nursing practice. |
| American Nurses Association | ANA is a professional organization concerned with advancing the nursing profession by protecting the interests of nurses, promoting a safe and ethical work environment, and advocating on health care issues that affect the public. Only for RN's. |
| National Association of Licensed Practical Nurses | NALPN promotes competencies through education, certification, and lifelong learning. |
| National Association for Practical Nurse Education and Service | NAPNES promotes and defends the practice, nursing education, and regulation of practical nurses. NAPNES, together with PN educators and the licensing boards, has created Standards of Practice and Educational Competencies for PN education programs. |
| Advocacy | Speaking up for clients' needs when the clients are unable to speak for themselves and supporting clients to make choices for their own health. |
| Nurse Staffing | The process of determining the correct number and skill mix of nurses for the number and acuity of patients needing care. Affects the ability of nurses to deliver safe care. |
| Nurse-to-Patient Ratio | The number of clients each nurse is assigned. The ratio is based on the service area and client acuity. |
| Policy and Procedure Manuals | Policies and Procedures that provide the standard of care that meets regulatory and accreditation requirements and promote safety. |
| Determinants of Health | Factors that impact health other than health care services, including location, environment, genetics, income, relationships, and gender. |
| Health in All Policies | An approach to public policy making that systematically accounts for the health implications of all decisions. |
| The Patient Protection and Affordable Care Act (ACA) | “Obamacare” A multipronged approach to provide affordable health coverage to each person in the United States. Having health insurance that provides preventive care helps keep people healthy, children in school, and adults at work |
| ACA Benefits pt.1 | Ambulatory (outpatient) patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavior health treatment |
| ACA Benefits pt.2 | Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care |
| Underinsured | Those with insurance who pay more than 10% of annual income, or 5% if below the poverty level, on health care costs out-of-pocket. |
| Uninsured | People without health insurance coverage. Correlated with poor access to care and lack of preventative care. |
| Health Insurance Portability and Accountability Act | Protects individual health insurance coverage through portability—that is, the ability to transfer and continue coverage if a person loses employer-sponsored health insurance due to job loss or a job change. |
| The Health Information Technology for Economic and Clinical Health (HITECH) | Act was signed into law to promote the use of information technology in health care settings in a meaningful way. An example of how this benefits clients is the ability to access portions of their health records from home. |
| Emergency Medical Treatment and Active Labor Act (EMTALA) | passed to prevent “patient dumping”—the practice of one health care organization moving a client based on the client’s inability to pay or lack of insurance coverage. |
| Patient Self-Determination Act | requires all health care organizations to inform clients of their rights to make decisions regarding their care and to indicate whether the client has made an advance directive. |
| Living Will | Legal document that allows individuals to decide what lifesaving measures they desire towards the end of life. |
| Durable Power of Attorney for Health Care | Legal document that allows an individual to choose a designated person, a proxy, to make health care decisions on their behalf. |
| The Controlled Substances Act | federally regulates substances that have the potential for abuse by placing them in one of five schedules. |
| Schedule I | No accepted medical use High potential for abuse ​​​​​​​Not prescribed |
| Schedule II | High potential for abuse and severe physical or psychological dependence |
| Schedule III | Potential for abuse, but less than substances in Schedules I and II ​​​​​​​Abuse may lead to moderate or low physical or high psychological dependence |
| Schedule IV​​​​​​​ | Lower potential for abuse |
| Schedule V | Low potential for abuse; consists of preparations with limited quantities of certain narcotics |
| Diversion | When a health care professional replaces a controlled substance with another and takes the substance for personal use. |
| Mental Health Parity and Addiction Equity Act | ensures that individuals with mental illness receive coverage equal to those with medical illness or need for surgical intervention. |
| Mental Health Disorder | Mental health disorders are characterized by alterations in thinking, judgment, mood, or behavior and are among the most common causes of disability. |
| Newborns’ and Mothers’ Health Protection Act | requires group health plans to pay for a 48-hour hospital stay or 96-hour stay in the case of cesarean birth, beginning at the time of delivery. |
| Mortality | The number of deaths due to a specific illness or injury. |
| Americans with Disabilities Act | prohibits discrimination against individuals living with a physical or mental impairment that substantially hinders life activities. Examples include vision or hearing impairments, physical challenges, and stigmatized disease processes. |
| Uniform Anatomical Gift Act | prohibits another person from revoking the consent of an organ donor after death. |
| Omnibus Reconciliation Act | provides for regulation and oversight of long-term care facilities in an effort to protect residents. |
| Chemical Restraints | The use of antipsychotic medications to control uncooperative behavior rather than for a specific medical condition. |
| Health Disparities | Preventable differences in incidence and prevalence of disease, injury, or violence among populations, based on race, ethnicity, gender, gender identity, LGBT, age, or socioeconomic status. |
| Health Inequity | Unjust, avoidable, uneven distribution of resources that impact health, stemming from systemic racism and discrimination of marginalized groups based on race, ethnicity, gender, gender identity, LGBT, and low socioeconomic status. |
| Health Equity | Valuing all individuals equally and removing obstacles to optimal health and health care across different populations. |
| Social Justice | Change in health policy aimed at analysis and critique of social structures, laws, and customs that harm groups through exclusion. Every individual has the right to quality health care. |
| Deductibles | A fixed amount of money a client must pay before health insurance begins to cover, calculated annually. |
| Copays | An abbreviation of copayment, a copay is a fixed amount a consumer pays for health care typically at the time services are received. |
| Medicare Benefits pt.2 | Part C: Parts A and B and is funded through private insurance and aka Advantage Plan. Part D: Rx Drug Coverage |
| Accountable Care Organizations | Accountable care organizations (ACOs) consist of networks of providers of health care services that join together to share the costs and coordination of services for a population |
| Agency for Healthcare Research and Quality | The Agency for Healthcare Research and Quality helps the health care industry maintain and improve safety, quality, accessibility, and affordability through its provision of evidence. |
| Culture of Safety | Systems approach to change that leads to safer procedures taking blame away from individuals who make errors based on systems issues. |
| Administration on Aging | The Administration on Aging (AoA) is the federal agency responsible for protecting the concerns and interests of older adults and the people who provide their care. |
| Centers for Disease Control and Prevention (CDC) | CDC serves as an official authority on disease processes, injury and violence, and overall health and safety of the public. It performs research and development to help prevent and treat all diseases and disorders. |
| Administration for Children and Families | advises on issues such as child care, child welfare, child support enforcement, and family assistance. Children are considered vulnerable because they are dependent on their families for food security, shelter, and health and wellness. |
| Food and Drug Administration | responsibility for protecting consumers’ health by ensuring the safety and quality of many products. It regulates prescription and nonprescription (over-the-counter [OTC]) medications, vaccines, blood and blood products, food and food products. |
| Indian Health Service | Indian Health Service is to raise the health of American Indians and Alaska Natives to the highest level. IHS provides health services and advocates for culturally appropriate care. American Indians and Alaska Natives are most uninsured @ 22%. |
| National Institutes of Health | NIH serves as a credible repository of health information supported by research, also known as evidence |
| Substance Abuse and Mental Health Services Administration | provides leadership through programs, policies, information, data, and personnel to reduce the impact of mental illness and substance abuse. It offers resources for treatment to those affected by mental illness and substance abuse. |
| Department of Defense | U.S. Department of Defense (DOD) provides health care to all of the country’s military personnel. The military health system administers health care to approximately 9.5 million service members, families, and retirees. |
| Department of Labor | U.S. Department of Labor provides oversight to protect consumers’ interests with regard to health insurance benefits and nurses’ interests and safety. It requires equal-opportunity hiring practices and enforces fair wages, safety and health. |
| Occupational Safety and Health Administration | sets and enforces safe and healthful working conditions for nurses and workers in the private sector and for some state employees. |
| U.S. Department of Agriculture | U.S. Department of Agriculture works to support farmers, ranchers, foresters, and producers, and to ensure a safe and secure food supply. |
| U.S. Department of Justice | Department of Justice has authority to enforce laws and seek justice for those guilty of unlawful behavior. In the case of health policy, it enforces laws surrounding Medicare and Medicaid to fight health care fraud. |
| Epidemiology | The incidence and prevalence of illness and injury. |
| Incidence | The number of individuals newly afflicted with an illness or injury, expressed as a percent of a larger population. |
| Prevalence | The number of individuals who have an illness or injury at a given point in time, expressed as a percent of a larger population. |
| Morbidity | The number of individuals affected by a specific illness or injury. |
| Prevention | The action of stopping something from happening |
| Primary Prevention | focuses on decreasing the risk for development of medical conditions by changing behaviors or minimizing exposures. Ex: Vaccines |
| Secondary Prevention | consists of early screening to detect a disease process before it progresses to cause symptoms or complications in the client. Ex: Pap Smears & Colonoscopies |
| Tertiary Care | controlling the chronic effects of a health issue that has already occurred and on restoring the individual to optimal functioning. Ex: Cardiac rehabilitation |
| Self Care | An inclusive group of activities nurses can utilize to promote one's mental health and overall well-being. |
| Quaternary Prevention | protecting clients from the excessive use of medical interventions that can cause more harm than good. |
| Health Promotion | The process of enabling people to increase control over and improve their health. |
| Wellness | A positive state of health. |
| Disease Prevention | Specific, population-based and individual-based interventions for primary and secondary (early detection) prevention, aiming to minimize the burden of diseases and associated risk factors. |
| Health Education | Learning experiences that are designed to improve the health of an individual or community through increased knowledge or by influencing attitudes. |
| Healthy People Initiative | improving the overall health of Americans. The DHHS sets new decade-long goals and objectives every 10 years based on the trends, issues, and data gathered on an ongoing basis. |
| Healthy People Initiative Principals pt.1 | Provide a framework that focuses on foundational principles, the development of overarching goals, constructing a plan of action, and providing history and context that will promote healthy habits of Americans for the next decade. |
| Healthy People Initiative Principals pt.2 | Provide public access to a collection of data on American health trends and issues for the past 10 years. |
| Healthy People Initiative Principals pt.3 | Provide tools for health professionals to use with clients and in communities. Offer interactive access so that members of the public can use this information. |
| Health Outcomes | The result of health promotion and disease prevention measures. Individuals are empowered to make healthier decisions to reduce the likelihood of developing disease and disability through health promotion and disease prevention programs. |
| Ways to Improve Health Outcomes pt.1 | Knowledge and health literacy: Increase one’s understanding and knowledge of health, wellness, and disease. Mental well-being and self-awareness: Implement measures to improve one’s life satisfaction and an awareness of one’s own health status. |
| Ways to Improve Health Outcomes pt.2 | Physical activity: Participate in a moderate level of exercise several times a week at regular intervals. Healthy eating: Consume an appropriate caloric intake of nutritious foods. |
| Ways to Improve Health Outcomes pt.3 | Risk avoidance: Receive vaccinations, practice safe sex, avoid tobacco use, and limit alcohol intake. Good hygiene: Practice handwashing, dental hygiene, and washing foods prior to consumption. |
| Ways to Improve Health Outcomes pt.4 | Rational and responsible use of products and services, including prescription and nonprescription medications, preventive health services, vitamins and supplements, and health and wellness services. |
| Factors that Affect Health Status | Access to Urgent Care Access to Preventative Care Clean Environment Safety & Security Family Wellness Mental Health Clean Food, Fitness & Obesity Avoidance Healthy Teeth & Gums Sexual & Reproductive Health Society Influences Substance & Tobacco |
| Modifiable Health Risks | Behaviors and actions that can affect a client’s risk for developing a disease. Ex: Tobacco Use |
| Nonmodifiable Risk Factors | Risk factors that cannot be changed. Ex: Genetics & Age |
| Environmental Factors | Elements in the environment that can affect health and well-being include air and water quality; exposure to toxic pollutants, hazards, and waste; and the safety of homes, work environments, and schools. |
| Health Literacy | Health literacy is the ability to process and comprehend basic health information that is necessary for the client to make appropriate health care decisions. |
| Culture | The learned, shared, and transmitted values, beliefs, norms, and lifeways of a particular group that guides their thinking, decisions, and actions in patterned ways. |
| Communication | The process of sending and receiving information. Dynamic interactions between people and their environment using a process that involves celebration (thinking), cognition, hearing, speech production, and motor coordination. |
| Sender | Person expressing the message. |
| Receiver | Person listening to the message |
| Message | What is being communicated between the sender and receiver. |
| Feedback | Response to a message, either positive or negative. |
| ABX Communication Model | Also known as the Newcomb's model of communication, made up of a sender, receiver and message. |
| How does the ABX Communication Model work? | Person A and Person B conversate about X also known as the topic. |
| SMCR Model | A communication model comprised of a Sender-Message-Channel-Receiver. |
| Channel | The method or medium used to deliver a message. Ex: Speaking, Letters or Texts. |
| 5 Levels of Communication | Verbal Physical Emotional Auditory Energetic |
| Therapeutic Communication | Techniques used to improve communication, such as active listening. |
| Auditory Communication | What message the receiver hears. |
| Emotional Communication | A form of communication that expresses feelings and emotions. |
| Energetic Communication | The speaker's presence or vibration that is expressed when communicating. |
| Empathy | Ability to understand the feelings of another. |
| Modes of Communication | verbal, nonverbal, electronic, and written |
| Verbal Communication | aka Spoken word. |
| Nonverbal Communication | Body language, behavior that is not spoken. |
| Electronic Communication | This mode includes email, texting, video conferencing, and social media. |
| Written Communication | Electronic communication and can be in the form of a letter, handwritten or typed, or an email or computer-based post. |
| Aggressive Communication | Hostile or forceful style of communication. Most commonly uses "You" statements. |
| Assertive Communication | Communication style that displays confidence or self-assurance. Honest communication, commonly uses "I" statements. |
| Passive Communication | Communication style that does not act or openly express discomfort. Conflict avoidant communication. |
| Passive-Aggressive Communication | Communication style that finds indirect ways to protest or express unhappiness with a situation. Communication that acts out of anger indirectly. |
| Dementia | A cognitive disorder that can impair communication ability due to language and memory changes. |
| Down Syndrome | A developmental disorder that can cause physical, cognitive and communication deficits. Trisomy 21 |
| Examples of Physiological Barriers to Communication | hearing or vision loss |
| Autism Spectrum Disorder | A developmental disorder that can cause barriers in social interaction and communication. |
| Developmental and Cognitive Barriers to Communication | ASD, Dementia and Down Syndrome |
| Situational or Environmental Barriers to Communication | excessive noise, extreme temperatures, poor or too bright lighting, fatigue, anxiety, and fear. |
| Cultural and Demographic Barriers to Communication | Language and Sexual Orientation |
| Nontherapeutic Communication | Techniques that hinder communication, such as stating the person is wrong. |
| Phases of Developing Relationships | orientation, identification, exploitation, and resolution/termination |
| Orientation Phase | the initial phase in which the client reaches out to the nurse or other health care provider for help. |
| Identification Phase | occurs when the two establish a mutually respectful relationship. |
| Exploitation Phase | the active phase of the relationship where the nurse educates the client to change the situation or behavior. |
| Resolution or Termination Phase | the client has had the issue resolved and the relationship between the nurse and client is terminated until the next event. |
| Open-Ended Questions | Questions that require more than a yes or no answer. |
| Therapeutic Communication Techniques | Examples include using silence, engaging in active listening, asking open-ended questions, accepting, giving recognition, restating, summarizing, and reflecting. |
| Active Listening | the nurse considers both the client’s verbal and nonverbal messages to understand the true meaning of the exchange. |
| Restating | A therapeutic communication technique where the receiver summarizes or paraphrase the message back to the sender to ensure understanding. |
| Reflection | A therapeutic communication technique where one person mirrors back the message of the speaker to encourage further sharing. |
| Accepting | which is acknowledging that the nurse has heard and understood the client; giving recognition of changes without compliments, which can be seen as bias; and offering to spend time with the client by simply sitting with them. |
| Motivational Interviewing | Communication strategy that empowers the receiver to make positive changes. |
| OARS | Mnemonic for motivational interviewing techniques: Open-ended questions, Affirmations, Reflective listening, Summarizing. |
| Affirmations | Positive comments that help build the receiver's confidence. |
| Potential Communication Barriers | Language differences, cultural diversities, speech or hearing impairments, developmental or cognitive disorders, medication effects, effects of recreational drugs, emotional distress, and environmental factors. |
| Types of Charting | Source-oriented medical records Problem-oriented medical records Subjective, objective, assessment, and plan charting (SOAP notes) Problem–intervention–evaluation charting (PIE model) Focus charting Charting by exception (CBE) |
| PIE Chart | Type of documentation that omits the plan of care and utilizes flow sheets and progress notes. |
| Source-Oriented Medical Records | Traditional form of documentation, divided into specific sections within the medical record. |
| Problem Oriented Medical Records | Used to create a comprehensive and organized approach among all members of the interdisciplinary team. |
| Subjective Objective Assessment Plan System (SOAPs) | The SOAP note helps guide healthcare workers use their clinical reasoning to assess, diagnose, and treat a patient based on the information provided by them. |
| Focus Charting | Centers on specific health care problems and the change in condition, client events and concerns. Three items must be documented which are data, action and response (DAR). |
| Charting by Exception | Documenting only unexpected or unusual findings. |
| Electronic Documentation Advantages pt.1 | Real-time access to client records by all members of the interdisciplinary team Built-in clinical alerts that contribute to the reduction and prevention of medical errors and duplicate tests |
| Electronic Documentation Advantages pt.2 | Increased coordination of care Elimination of illegible records Client portals that allow the client to interact with providers |
| FACT Charting Guideline | Acronym used to help nurses with proper documentation practices. FACT stands for factual, accurate, complete, and timely. |
| Verbal Prescriptions | Prescriptions received from a provider directly, transcribed by licensed personnel, and later cosigned by the provider. |
| Telephone Prescriptions | A prescription received over the telephone from a provider when the provider is not physically present. |
| HIPPA Privacy Rule | Part of HIPAA. Established in 2003, it created regulations that govern EHR records to protect the privacy of healthcare consumers. |
| Computerized Provider Order Entry | Allow providers to enter and transmit prescription electronically. |
| Code of Ethics (CoE) | Developed by the ANA, this document outlines rules for nurses about client privacy, nursing conduct, and nursing behaviors to protect clients and the profession. |
| ANA CoE Provisions 1-3 | The nurse should provide compassionate care and respect for the client. The nurse should recognize that each client is unique, has worth, and deserves to be treated with dignity. The nurse should be an advocate for each client’s rights and needs. |
| ANA CoE Provisions 4-6 | The nurse should promote and protect the health and safety of each client. The nurse should demonstrate authority, accountability, and responsibility for promoting best practices. The nurse should promote health and provide the best care. |
| ANA CoE Provisions 7-9 | The nurse should maintain competence, practice the accepted values of the nursing profession, and promote a healthy and safe practice environment. The nurse should adhere to the ethical principles of the nursing profession. |
| ANA CoE Provisions 10-11 | The nurse should participate in the development of standards of practice and policies governing nursing and health care. |
| ANA CoE Provisions 12 & 13 | The nurse should promote the profession of nursing through research and inquiry. The nurse should collaborate with other members of the interprofessional team to protect the rights of all individuals and decrease health disparities. |
| Autonomy | Independence or freedom, ability to make one's own decisions. |
| Beneficence | Doing good and acting in the best interest of a client by providing care that benefits them. |
| Nonmaleficence | Doing no harm, or the least amount of harm to the client, while trying to achieve the best possible outcome. |
| Veracity | Telling the truth. |
| Fidelity | Keeping promises or commitments. |
| Justice | The ethical principle of justice refers to the nurse’s obligation to provide treatment, care, and resource allocation that is impartial, fair, and equitable to all clients regardless of age, sex, race, or economic status. |
| Altruism | To do something, or take action, for the sake of benefiting someone else. |
| Human Dignity | Implies that each individual, regardless of things such as race, religion, sex, gender, etc., has value and shall be respected simply because human beings are all equal. |
| Integrity | The quality of being honest and having strong moral principles. |
| Autonomy | the right to self-determination. |
| Social Justice | Change in health policy aimed at analysis and critique of social structures, laws, and customs that harm groups through exclusion. Every person has the right to quality health care. |
| Ethical Dilemma | Situation where a critical choice must be made, but the solution may not be ethically acceptable. |
| Ethical Decision Making | Process of evaluating and choosing options in an ethically consistent manner using ethical principles. |
| Standards of Practice | Explanatory statements that describe a competent level of care for all nurses, using the critical thinking model known as the nursing process |
| Standards of Professional Performance | Defines competent behavior of all registered nurses where professional care is provided. |
| Professionalism | Embodies the actions, behaviors, and attitudes of an individual that are reflective of the core values, ethical principles, and regulatory guidelines of the profession. |
| Unprofessionalism | Refers to conduct that does not adhere to the standards of practice or the Code of Ethics. |
| Novice Nurse Definition | This is the beginner stage when the person has no experience. Ex: Student nurses, as well as experienced nurses who transition to new areas of practice. |
| Advanced Beginner Nurse Definition | The nurse demonstrates skills based on their previous exposure during the novice stage but continues to need guidelines with prompting and support from a mentor. |
| Competent Nurses Definition | The individual can plan, make decisions, and perform their job responsibly and efficiently. |
| Proficient Nurse Definition | The nurse has a more rounded understanding of their role, views the situation from beginning to end, and modifies their behavior and performance based on unpredictable clinical situations. |
| Expert Nurse Definition | The expert is a master with a deep understanding and will multitask effortlessly and fluently without a second thought. |
| Accountability | A legal obligation with a moral and ethical commitment to do the right thing every time and in every situation. |
| Responsibility | An obligation to perform work, duties, or tasks using sound professional judgment. |
| Transformational Leader | establish a common mission and vision and, in turn, encourage employees to heighten their level of performance. These leaders relay trustworthiness, voice an attractive and hopeful future, provide meaning, and challenge the best within people. |
| Laissez-faire Leader | are hands-off leaders that oversee and encourage their team to work independently, providing little direct control over decision making gives up the power and responsibility to others, facilitating independent decision making, goal setting, and solutions |
| Bureaucratic Leader | abide by the specific policy and procedures or rules established within a top-down decision-making organization "By the Book" |
| Situational Leader | flexible and transition or move from style to style depending on the circumstances at hand. This leader assesses the situation and decides which strategy is best to use based on the task. |
| Transactional Leader | Leaders who give for good actions and behavior and take for the opposite. |
| Caregiver | The process of caring for another individual involves respect for the dimensions of the client—their needs, values, beliefs, emotions, opinions, and preferences. |
| Critical Thinker | the logical process of interpretation and examination of a problem; reasoning and application of a solution; and evaluation of the outcomes. |
| Change Agent | nurse to identify or recognize a problem, determine a need, recommend a plan, and participate in interprofessional care and evaluation. |
| Educator | able to teach and support clients to better comprehend, address, and assume responsibility for their own health status. |
| Counselor | Nurse takes into consideration and encompasses the intellectual, emotional, mental, and psychological aspects of the client. |
| Leader | use of interpersonal skills to influence the attitudes, behaviors, feelings, and beliefs of those around them. Nurses take a holistic approach with their clients by creating, guiding, involving, and aligning everyone involved |
| Mentor | experienced nurse that shares their knowledge and time to support, guide, encourage, and motivate another nurse to take control of their own learning, develop their skills, and maximize their potential. |
| Researcher | involves the use of past and present evidence-based research to improve nursing practice. research assesses and questions current practice; investigates improved or innovative interventions or treatments; and helps transform practice, care, and outcome |
| Care Coordinator | organizing client care, including the involvement of the client, family, interprofessional team members, and resources required to provide all client care activities |
| Shared Governance Principal 1 | Professional governance is grounded in accountability. obligation to outline its work, establish standards, set the collective obligation, and expect consistency within the standards |
| Shared Governance Principal 2 | The processes for organizational work and decision-making are designed around accountability. professionals are accountable to the populations they serve, taking ownership for their own decisions and actions, and are liable for the outcomes. |
| Shared Governance Principal 2 | Professional governance structures demonstrate shared decision-making. Professions have a duty to four fundamental accountabilities, practice, knowledge, competence, and quality. |
| Nursing Process Steps (ATI Edition) | -Assessment -Analysis -Planning -Implementation -Evaluation |
| CJAM Nurse Process | 1. Recognize Cues (Assessment) 2. Analyze Cues (Analysis) 3. Prioritize Hypotheses (Analysis) 4. Generate Solutions (Planning) 5. Take Actions (Implementation) 6. Evaluate Outcomes (Evaluation) |
| Assessment | The application of nursing knowledge to the collection, organization, validation and documentation of data about a client's health status. The nurse thinks critically to perform a comprehensive assessment of subjective and objective information. |
| Objective Data | Data that can be observed by the nurse through the senses. |
| Subjective Data | Data that is based upon the client's feelings, perception and assumptions. |
| Time Management Matrix | A tool that divides activities into four quadrants: important, not important, urgent, not urgent. |
| Organizational Skills | Activities that allow the nurse to be efficient and accurate in delivering client care such as making a to-do list. |
| SMART Goals | Acronym for goal setting: specific, measurable, attainable, realistic, timely. |
| SBAR Reporting | Acronym for a communication tool to relay relevant client information to other medical professionals: situation, background, assessment, recommendation. |
| SOAP Charting | Acronym for a documentation tool: subjective, objective, assessment, plan. |
| Client Assignments | Process of dividing responsibility for care of multiple clients among the nursing staff. |
| Acuity Levels | The requirement of nursing services and the amount of nursing time to meet those requirements. Complexity of a client's condition. |
| Discharge Planning | Procedure for determining what additional support a client needs in order to be transferred from one care facility to another or home. Coordinating detailed planning for client's discharging, or leaving a facility. |
| Teachback | A technique to determine the client's level of understanding by having the client explain back to the nurse the information that was taught. |
| IDEAL Discharge Planning pt.1 | I: Include the client and caregivers. D: Discuss the five key areas—medications, home life, warning signs, test results, and follow-up. |
| IDEAL Discharge Planning pt.2 | E: Educate the client on the condition, the discharge process, and next steps. A: Assess the effectiveness of the education. L: Listen to the client’s goals and preferences. |
| Delegatee | A person whom a task is entrusted to. |
| Delegator | A person who entrusts a task to another. |
| Delegation | involves assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel while retaining accountability for the outcome. |
| Managing a Group of Clients | Nursing process of organizing delivery of client's care tasks among a group of people. |
| Team Nursing | A group of nurses working together to achieve client care tasks. |
| What are Client Care challenges? | Abuse, Chemical Impairment and Nonadherence. |
| Maslow’s Hierarchy of Needs | A theory that suggests there are five categories of needs that motivate human beings. The five categories are psychological, safety, love and belonging, esteem, and self-actualization. |
| Maslow's; Physiological Needs | Physiological needs comprise the essential physical needs required for survival. These needs include food, water, air, shelter, sleep, clothing, and reproduction. |
| Maslow's; Safety and Security | individuals turn their attention toward meeting their safety and security needs. These include security of the environment, personal security, employment security, health, and property. |
| Maslow's; Love and Belonging | Once both physiological and safety needs have been met, the individual’s attention turns to meeting social needs. Social needs involve feelings related to love and belonging. Ex; social relationships, such as friendships, family relationships, intimacy. |
| Maslow's; Self-Esteem | the desire to feel good about oneself and having the respect of others. Feeling good about oneself—that is, having a high sense of self-esteem. |
| Maslow's; Self-Actualization | self-actualization refers to the desire for self-fulfillment—for reaching one’s greatest potential, whatever that may be. It is the desire to be whatever it is that one wants to be, and to achieve the most that one can achieve. |
| ABCDE Priority | Airway, Breathing, Circulation, Disability, and Exposure The purpose of the ABCDE framework is to recognize and stabilize the client’s most critical issues first, and then move to the next vital system |
| Direct Care | Client care activities that are performed at the bedside. |
| Indirect Care | Client care activities performed by the nurse away from the bedside. |
| Safety & Risk Reduction | Priority is given to whatever finding poses the greatest or immediate risk to the client's physical or psychological well-being |
| Least Restrictive/Invasive | Interventions are selected that maintain client safety while producing the least amount of restriction to the client; the nurse chooses interventions that are the least invasive. |
| Survival Potential | Priority is given to the client who has a reasonable chance of survival with immediate intervention. This framework is typically used in situations where resources are limited, such as with mass casualties and disaster triage. |
| Triage | To sort and rank treatment of clients according to the urgency of their need for care. |
| Resource Allocation | The distribution of resources to a service or department. |
| Emergent or Immediate (red) | includes clients who must be transported away from the scene immediately. Clients classified as emergent have life-threatening injuries but a high probability of survival with treatment. |
| Urgent or Delayed (yellow) | includes clients who have a serious injury that does not pose an immediate threat to life. For example, a client who has an open fracture without major bleeding would be tagged as delayed. |
| Nonurgent or Minimal (green) | includes clients who have only minor injuries. To warrant this classification, clients must be able to wait for treatment until all other clients have been treated. aka "The Walking Wounded" |
| Expectant (black) | who are either deceased or not expected to survive. Such a client might be unable to breathe spontaneously or might have severe damage to multiple body systems. |
| CURE Priority pt.1 | Critical client care needs require the nurse to intervene immediately to prevent the client from deteriorating Urgent client care needs are when the client could suffer mild harm or discomfort if there is a delay in addressing the client’s needs. |
| CURE Priority pt.2 | Routine client care needs include tasks such as administering routine medications and performing required shift tasks Extra client care needs involve activities that are not essential to client care but can promote client comfort |
| Acute v. Chronic Priority | A framework in which acute conditions are prioritized over chronic conditions. |
| Urgent v. Nonurgent Priority | Priority is given to the client who has an urgent need over a client with a nonurgent need. |
| Stable v. Unstable Priority | Priority is given to the client who has an unstable condition versus the client with a stable condition. A client was admitted to a medical–surgical unit at 0900. The client reported experiencing abdominal pain during |
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