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DCCC 110 Test 1

DCCC Model 1.

Holistic Nursing An approach based on meeting the needs of the whole person, taking into account mental, physical, emotional, social, cultural and spiritual factors, not just symptoms of a disease.
Assessment needs and preferences of patient. Systematic collection of data. Establishing a data base through: nursing history, physical assessment, Review of records and consult with HCP. Validate the data continuously.
Objective Data Information that is perceptible by the senses. May be verified by another person.
Subjective Data Symptoms perceived by the affected self. Symptoms, covert data
Problem Identification Nursing Diagnosis. Problem as related to medical diagnosis as evidence my "assessment data". Identify strengths and weaknesses. Use NANDA Language. Prioritize list of diagnoses
Planning Establish patient centered goals to prevent, reduce, or resolve the problems. Identified and determination of the related nursing interventions. Individualized measurable goals: Patient will....
Implementation Carrying out a plan to achieve goals. Determine the level of assistance needed. Use of verbs.
Evaluation Measurement of the extent to which the patient has achieved goals specified in the plan of care. Factors that positive or negatively influence the goal achievement. Plan of care is terminated or revised.
Nursing Plan of care Written guide to direct the efforts of the nursing team as they work with the patient to meet health goals. Specifies prioritized nursing diagnoses, patient goals, and nursing orders.
Hierarchy of needs Defined by Maslow, certain needs are more basic than others. Person strives to meet some needs before others.
Physiological Needs Oxygen, water, food, elimination, temperature, sexuality, physical activity, and rest. Most basic of Hierarchy. Nursing interventions: evaluate Oxygen needs, measuring in/out take, measuring Temperature, Physical therapy, and Rest.
Safety and Security Needs Physical & emotional components. Examples of physical safety: cane; emotional safety: security blanket. Nursing Interventions: Proper hand hygiene, & sterile technique, administer medication knowledgeably, skillful ambulation, teaching patient dangers.
Love and Belonging Needs Understanding & acceptance of others in both giving and receiving love, feeling of belonging to groups. Nursing intervention: Mother & baby skin to skin, including family in care, nurse to patient relationship based on trust, referral to support group
Self Esteem Needs Need to feel good about oneself. Pride, sense of accomplishment, self confidence, and independence Nursing intervention: facilitating support from family, remembering perceptions change, setting attainable goals.
Self Actualization Needs Need to reach full potential through development of unique capabilities. Nursing intervention: creativity as a guideline for solving problems, respect for all people, autonomy.
Evidence Based Practice Provide nursing care that is supported by sound scientific rationale. Only 20% of clinical based on EBP. Build scientific foundation. Prevent disease and disability. Manage and eliminate symptoms. Enhance palliative care.
Quantitative research Basic and Applied research. Example: Clinical Trials.
Basic Research Pure or laboratory research. Designed to generate and refine theory. Not often directly useful in practice.
Applied research Practical research. Designed to directly influence or improve clinical practice.
Qualitative Research Methods of research conducted to gain insight by discovering meanings. To understand Human behavior. Descriptive, correlational, Quasi-experimental, or experimental
Variable Something that varies and has different values that can be measured.
Dependent Variable Variable being studied, determined as a result of a study.
Independent variable Causes or conditions that are manipulated or identified to determine the effects on the dependent variable.
External Evidence Systematic reviews, randomized control trials, best practices, and clinical practice guidelines that support change in clinical practice.
Internal Evidence Derived from health care institution based quality improvement projects, outcome management initiatives, and clinical expertise.
PICO Format P: Patient, Population or Person of Interest. I: Intervention of Interest. C: Comparison of Interest. O: Outcome of Interest.
How do you implement EBP? 1) develop and answerable ? using PICO format. 2) Search Literature. 3) Evaluate evidence found. 4) Apply Evidence and provide patient with evidence. 5- Evaluate the outcome
Communication A distinct interpersonal interaction that is a process for the creation of shared meanings. a dynamic process through symbols and symbolic expression. continuous, interactive activity
SBAR Consistent, clear, structured and easy to use method of communication between HCP. Organizes communication in to categories of: Situation, Background, Assessment, and Recommendations
Situation Describe the situation. Complaint, diagnosis, treatment plan, and patients wants/needs What is going on? who? where? what? when?
Background Information relevant to the situation. Vitals, mental and code status, meds, lab results
Assessment Current providers assessment of the situation. Analyze situation and isolate the problem. I am concerned......
Recommendation Recommendation of action. What actions can resolve the situation. Pending labs, what needs to be done in the next few hours, other recommendations of care. Should we....?; I need you to come...
QSEN Quality & Safety Education for Nurses. Joint Commission. Prepares future nurses with Knowledge, Skills, and Attitudes (KSAs). Necessary to continuously improve the quality and safety of Health Care Systems.
Health Promotion Encompasses health, wellness, disease, and illness
Health A state of complete physical, mental, and social well-being, not nearly the absence of disease or infirmity. Optimum functioning.
Wellness An active process by which and individual progresses towards the maximum possible potential, regardless of current state of health.
Disease Pathological change in the structure or function of the body or mind.
illness Abnormal process in which any aspect of a person's functioning is altered, in comparison to the previous condition of health.
Primary Preventive Care Care directed toward health promotion and specific protection against illness. Health Education for optimal: nutrition, exercise, immunizations, living and working environments, avoidance of harmful situations, stress management, health risk assessment.
Secondary Preventive Care Health maintenance for those with health issues or to prevent complications or disabilities. Screening & early detection. Assess for normal growth & development. Regular exams and screenings. Direct intervention; wound care and meds.
Tertiary Preventative Care Helping rehabilitate and restore to max level of functioning after an illness. Minimizing the effects of a disease, teaching about disease, PT, support groups, improve quality of life, Meds, therapy, surgery, job training.
Prevention Decreasing occurrence of a disease.
Promotion Educating people and giving them awareness to change their behaviors.
Physical activity and Exercise fall into what Levels of Prevention? Both primary and tertiary because it can optimize health for all.
Healthy People 2020 Objectives 1. High-quality long lives free of preventable disease, disability, injury & premature death. 2. Health equality & eliminate disparities, improve health for all. 3. Social & physical environments that promote good health. 4. Quality of life, all stages
Disparity Particular health difference that is closely linked with social, economic, and/or environmental disadvantages.
Nursing Practice act State statute designed to: Protect patients or society. Define the scope of nursing practice, Identify the minimum level of nursing care to be provided to clients. Regulation of practice by a board, including licensing, credentials, disciplinary
Patient Education Process of assisting people to learn health relates behaviors so that they can incorporate these behaviors into everyday life. Domain of learning should match teaching method.
Cognitive Learning Literature, lecture or discussion.
Psychomotor Learning Skills practice. Touch and manipulative with equipment.
Affective Learning Change attitudes. Lifestyle modifications.
Risk Factor Something that increases a person's chance for illness or injury.
Age risk Factors School age= communicable diseases. Menopause= cardiovascular disease. Teen driving accident.
Genetic risk factors Family history of cancer or diabetes. Predisposition.
Physiological Risk Factors Obesity = increased risk of heart disease. pregnancy = mother and child at higher risk.
Health Habits Risk Factors Smoking increased lung cancer. Poor nutrition. Alcohol can cause liver abscess.
Lifestyle risk factors Multiple sexual partners increased for STDs. Stressors such as: divorce, work/school pressure.
Environmental Risk Factors Hazardous materials. poor situations; either working or living.
Advance Directive Written directive that allows people to state in advance what their choices for health care would be if certain circumstances develop.
Confidentiality The process of keeping information private or secret. Respecting privileged information.
Durable Power or Attorney Health care proxy. An appointed agent the person trust to make decisions in the event of subsequent incapacity.
Living Will An advance directive specifying the medical care a person would want or refuse should that person lack the capacity to connect to or refuse treatment.
Informed Consent Knowledgeable, voluntary permission obtained from a patient to perform a specific test or procedure written agreement to participate in a study
Libel Defamatory statement made in writing.
Commission Doing the wrong thing.
Omission Not doing the right thing.
execution Doing the right thing incorrectly.
Adverse event Unintended harm by either commission or omission.
Near Miss Error, commission, or omission that could have a harmed a patient but didn't occur as a result of chance, prevention, or mitigation
Sentinel Event Unexpected occurrence involving death, serious physical or psychological injury, or the risk thereof.
Negligence Performing an act that a reasonably prudent person under similar circumstances would NOT do, or failure to perform an act that a reasonable prudent person under similar circumstances would do. Failure to meet the standards of care
Active Errors Occur at the point of contact between a human & aspect of a larger system. Generally readily apparent (pushing an incorrect button, ignoring warning light), involve someone at frontline. Referred to as Sharp end.
Latent Error Refer to less apparent failures of organization or design that contributed to the occurrence of errors or allowed them to cause harm to patients. Blunt end. Referring to layers of the health care system that affect the person "holding" the scalpel.
Autonomy Right to self-determination, independence, and freedom. Make health care decisions for oneself. Not always absolute.
Nonmaleficence Do no harm, either intentional or not. Protect those who cannot protect themselves. Some harm may be inflicted for the greater good; (chemo or surgery)
Beneficence Obligation to do good by acting in ways that promote the welfare and best intentions of others. Promote good and prevent harm. Patients good may differ from HCP.
Justice To be fair to all people. 1st code of ethics: the nurse practices with compassion and respect for the inherent dignity, worth, and personal attributes of every person; without prejudice.
Fidelity Act in ways that are loyal. Keeping promises, within boundaries of the law, trustworthiness. Main support for accountability.
Veracity Truthfulness. Basic foundations for a trusting relationship.
Slander Defamatory statement made while talking.
Assault Threat, or attempt, to make bodily contact with another person without that person's permission
Battery Bodily contact with another person without that person's permission.
Autocratic Leadership When the leader makes all the decisions. Often used in emergencies or when decisions need to be made in a hurry. Motivate through threat of punishment. rewards as incentives Maintain a distance from followers
Democratic Leadership Leaders involve followers in decision making process; Participatory. Useful when followers are experienced.
Laissez-Faire Leadership Does not interact with followers. Followers left to make own decisions and intervene during crisis . Often the result in employee apathy, inefficiency and chaos.
Transactional Leadership Daily operations focused. Develop exchange relationships with followers. Reward followers when they perform & correct when necessary.
Transformational Leadership Long term focus and high interaction with followers. Transform and change individuals organization and vision.
Shared Leadership Focus on teamwork. Employee empowerment. Project focused or work groups
Trust Vs Mistrust Infant, Birth to 1 years. Biological needs predominant. warmth, food, & comfort. Trust = basic needs meet with consistency . Mistrust = inconsistent, inadequate, or unsafe care.
Autonomy vs Shame & Doubt Toddler, 1-3 years. Motor skills & Language, learn through environment and caregivers encouragement. Autonomy = self control and making choices. Shame & Doubt = over protective, expectations too high, punishments severe. separation anxiety 18-24m
Initiative vs Guilt Preschool, 3-6 years. Environment explored, hows & whys of activities, conscience develops. Initiative = confidence gained as toddler leads to new role exploration. Guilt = restrictive & reprimand with new experiences. hesitant with more challenges
Industry vs Inferiority School-age, 6-11 years. Working with peers. Industry = learn skills valued by society = higher self esteem, Gains pleasure, from finishing tasks and projects. Inferiority = skills are too difficult and learning not supported. lacks self worth.
Identity vs Role Confusion Adolescence, 11-18 years. Matures sexually. Identity = trying new roles, rebellion is normal, develops sense of self and life direction. Role Confusion = unsure of direction and self.
Intimacy vs Isolation Young Adulthood, 18-25 years. Intimacy = commitment to relationships and careers, acting with freedom and responsibility. Isolation = fear of commitment, becomes self absorbed.
Generativity vs Stagnation Middle Adulthood, 25-65 years. Involvement with family, friends, & community. Generativity = expands, kids, ideas, services, products; preserve future generation. Stagnation = no involvement, obsessed with own needs or regress to earlier level to cope.
Integrity vs Despair 65 years - death. Adjust to life changes and losses. Integrity = finds order, meaning, and value in life; may not fear death. Despair = believes one's life has been a series of missed directions or failures.
Adaptive Development Gaining of skills that enable independence @ home and in community. dressing/undressing, eating/feeding, toileting, grooming, functioning within community, crossing street, going to store, or politeness when interacting with others.
Cognitive Development Sensory reception, processing and use of information about environments and object within. Understanding relationships between self and information. learning, understanding, problem solving, reasoning, & remembering. Moral & spiritual.
Communication Development Express completely one's thoughts, ideas, and emotions. Receptive language function- understanding what others say. Articulation-pronunciation. Voice-sound by vocal cords. Fluency-rhythm. Language-shared rules to share ideas,thoughts & feelings.
Physical Development Growth & changes to body tissues & organ systems, that result in changes to body proportions. Bilaterally and symmetrical.
Cephalocaudally Growth from head to tail.
proximodistally Growth from midline to periphery.
Refinement Skills developing in order from gross to fine motor skills.
Social/Emotional Development Personality. Interacting with others. Having relationships. Cooperation and responding to feeling of others.
Development Sequence of physical, psychosocial, and cognitive development changes that take place over the human lifespan.
Growth Quantitative changes which increases cell number and size resulting in an increase in over all size or weight of body or any of it's parts.
Differentiation Process by which initially formed cells and structures become specialized. Qualitative changes.
Maturation Qualitative changed associated with aging.
Milestones Functional set of age specific tasks that most children can complete at a certain age.
Tasks Specific set of skills that happen at certain ages that aid individuals in coping with the environment.
Arrest Cessation of 1 or more phases before development reached normal completion.
Delay Failure to meet expected level. Usually 2.5 standard deviations in 1 or more areas.
Community A specific population or group of people in the same geographic area under similar regulation and having common values, interest and needs.
Family Any group of people who live together and depend on one another for physical, emotional, and financial support
Family Dynamics Interrelationships between and among family members. The way a family lives and interacts with one another.
Family Systems Theory The family is part of a larger supra system and is composed of many subsystems. Family as a whole is great that individual members. Change in 1 family member affects everyone. Behaviors best understood in circular view.
Structural-Functional Theory Family is a social system and each member has specific roles to play; i.e. father, mother, daughter... equilibrium established through dynamics function as a family unit and is society
Internal family stress Change in family structure, psychological defenses, and philosophical values and beliefs. Can be controlled by family.
External family stress Family has no control over. Culture of larger society. Time in history. Economic state of society. Maturity of family members. Genetic inheritance. Success of coping with stressors.
Family Life cycle Pass through stages. Relationships with members irreplaceable. Development stressors can disrupt process.
Health Belief Model Focuses on what people perceive to believe to be true about themselves in relation to their health. Perceived susceptibility, seriousness, and benefits of action. Affected by: demographics, sociopsychological, structural and cues to action.
Self efficacy Own belief in the ability to reach goals and complete tasks.
Health Promotion Model How people interact with their environment as they pursue health. Based on: Individual characteristics, behavior, activity, commitment to plan, and immediate competing demands or preferences.
Health-illness continuum Views health as a constantly changing state. Adapting to changes in internal and external environments to maintain a state of well being. How well one is functioning with an illness.
Family cohesion Emotional bonding that couples/families have towards on another. From the extreme of disengaged to overly connected.
Family coping Actions to manage stressors that tax on families resources. Confronting problems. Involving members in decision making. Seeking assistance. Family centered stress reduction.
Family functioning Capacity of the family system to meet the needs of its members through developments transitions. The quality of functioning is proportionate to the quality of communication and interaction.
Acute Rapid onset of symptoms and last for a short period of time. Can still be life threatening.
chronic Permanent change with 1 or more: Irreversible alteration in normal anatomy or physiology, Special patient education for rehabilitation, Long periods of care or support.
illness Behaviors stage 1- experience of symptoms. stage 2- assuming the sick role. stage 3- assuming the role of a dependent. stage 4- achieving recovery and rehabilitation.
Biological Risk for Families Birth defects. Mental retardation. Genetic predispositions to certain diseases, including cardiovascular disease and cancer.
Developmental Risks for Families Families with new baby, especially when there is not a support system. Elderly, living alone or on a fixed income. Unmarried adolescent mothers lacking personal, financial and educational resources.
Environmental Risk for families Air, water, or food pollution. Work and social pressures that cause stress. Lack of knowledge or finances to provide safe and clean living conditions.
Lifestyle Risk for Families Lack knowledge about sexual/marital roles, teenage pregnancy, divorce, STD. Child, spouse, or elder abuse. Lack of prenatal or childcare. Alterations in nutrition. Chemical dependency. Inadequate dental care & hygiene unsafe or unstimulating home
Psychosocial Risk for Families Inadequate child care resources, both parents work (preschool/school aged kids). Inadequate income to provide safe housing, food, clothing, and health care. Conflict between family members.
Functional ability Physical, psychological, cognitive and social ability to carry out the normal activated of life. fulfill roles in family, workplace & community maintain health and well-being
Impairment Varying degrees of an individuals inability to perform the tasks required to complete normal life activities without assistance.
Performance Under what circumstances, with or without assistance, in how much time, and to what degree of effort can a person do an activity.
dependency The amount of assistance of an adaptive device or another person an individual needs to complete a task.
Basic Activities of Daily Living (BADLs) Self care activities and mobility. Eating, hygienic and grooming activities, dressing and toileting.
Instrumental Activities of Daily Living (IADLs) Complex skills essential to living in the community. Managing money, grocery shopping, cooking, house cleaning, laundry, taking medications, using the phone, accessing transportation.
Primary Problem Problems when the ability to perform a function never develops.
Secondary Problem Problem that occurs after functional ability has been attained and then lost.
Functional Ability Assessment The testing on the ability to perform a particular task.
Culture A pattern of shared attitudes, beliefs, self definitions, norms, roles, & values that can occur among those who speak a particular language or live in a defined region. Guides: social relationships, expressions of thought, emotions & morality, religion.
Enculturation A process by which a person learns the norms, values and behaviors of a culture. Similar to socialization.
acculturation Process of acquiring new attitudes, roles, customs, or behaviors as a result of contact with another culture.
Assimilation Process by which a person gives up their original identity and develops a new cultural identity by becoming absorbed into the more dominant culture group.
Biculturalism duel pattern of identification Chose which aspects of the new culture to adopt and which aspects of the old culture to retain.
Ethnicity Common ancestry that leads to shared values and beliefs.
Ethnic identity Transmitted over generation by family and community.
Cultural Competency Conveying acceptance of the patients health beliefs while sharing information, encouraging self-effecency, and strengthening the patient's coping resources.
Cultural Diversity People of varying cultural background, racial and ethnic origin, religion, language, physical size, gender, sexual orientation, age, disability, socioeconomic status, occupational status, and geographical region.
Subculture Large group of people who are members of the larger cultural group, but who have certain ethnic, occupational, physical characteristics that are not common in the larger culture. ie/ nursing subculture of health system culture
Culture shock Feelings person has when they are placed in a new culture when it is perceived as strange.
Race Usually categorized based on a specific physical characteristic, such as skin color, body stature, facial features, or hair texture.
Stereotyping Assuming characteristing to a group without considering specific individuality.
Cultural imposition Belief that everyone should conform to your belief system.
Cultural blindness When one ignores differences and acts as if they don't exist
Cultural conflict Aware of cultural differences and feel threatened, then respond by ridiculing those in different culture to make themselves feel more secure in their own beliefs.
Personal space The area around a person regarded as the person. Individualized to each person.
Ethnocentrism Belief that one's culture ideas, values, and beliefs are superior to others.
Motivation Encompasses self-regulatory process involving the selection, activation, and sustained direction of behavior towards certain goals.
Intrinsic Motivation Act a certain way because of feeling of enjoyment and competence, rather that because of obligations, pressures or rewards.
Extrinsic Motivation Relies on attainment of an award or independent outcome. Self-determined or not. Example: Physical therapy because of the outcome of independence (self) Physical therapy because of pressure from family (not self)
Self Efficacy Proximal determinants of human motivation, affect, and action. HIGH Self-efficacy = approach tasks instead of avoiding. LOW Self-efficacy = anxiety, stress, depression. Determined by level of motivation and how long one will persevere.
Intentions A course of action that once intends ti follow. Based on: individual beliefs, normative beliefs, and control beliefs.
Compliance The degree of consistency and accuracy with which a patient follows ta prescribed regimen.
Adherence A self-inited action taken to promote wellness, recovery, and rehabilitation. Ranging from total lack of adherence, or omission, to total adherence
Created by: mamajewels