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FUN 9,10,11

Plan of Care/Admit, Xfer, Disch/Documentation

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