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PN Exam 2 Class #89

Chapters 5-8

What is Documentation? The act of recording pertinent medical info. in a patient's medical record, which may be handwritten on a paper chart or keyboard in an electronic health record (EHR).
What is the EHR? The electronic health record: online documentation and medical charts.
What are the 4 purposes of written documentation? 1. To communicate pertinent data, provide continuity of care. 2. To provide a permanent record for patients.3. To serve as a record of accountability for quality assurance, accreditation, and reimbursement purposes.4. To serve as a legal record.
In the health-care setting, what kind of care do nurses provide? 24 hour patient care (continuous 24/7 care).
What makes patient care effective? It must be delivered and evaluated continuously, systematically, and smoothly from one hour to the next, including through the staffing changes next shift.
What organization sets standards for quality of health care? The Joint Commission.
Does the Joint Commission act as an insurance company? No, not at all, it sets standards and reviews medical practices in facility care.
How does the Joint Commission relate to nurse documentation?
What is Charting by Exception? Limits charting to only ABNORMAL findings, situations, conditions, or results.
Who does the information in a medical record belong to? The information itself, belongs to the patient. They have a right to all the information in a copied form.
How does HIPAA enforce patients right's to their health information (chart)? HIPAA enforces the patient's right to view and obtain a COPY of the medical record, but the patient does not have a right to take the original chart copy itself. AND the right to amend his or her own health info.
What must the patient do to obtain a copy of his/her own health info.? They must sign a consent form for the health care facility and it must be verified for release.
What is Confidentiality? The maintenance of privacy by not sharing with a third party privileged or entrusted info.
What do you need to confirm an individual is a patient in your facility? MUST have specific permission from the patient.
What must you be overly cautious of when dealing with physical copies of patient info.? Nurses must avoid leaving patient care notes, lab results, medication administration records (MAR's), an patient charts lying open and accessible to other facility employees and the public.
What must a nurse do with any copies or handwritten notes including confidential info. once their purpose has been fulfilled? They must be shredded and disposed of in the proper receptacle.
What should you do as a Nurse before faxing any documents to another facility? Call/telephone the other facility recipient before sending any documents.
What is an incident report/variance report? A document reporting any unusual occurrence.
What are "Pocket brains"? Additional notes taken by the nurse throughout the shift which include assessment findings and to-do lists and important info. often self-designed by each nurse to best serve them.
What is the ideal method to ensure documentation accuracy? Consistently chart immediately after care is provided, data is obtained, and after any event or occurrence that has the potential to affect the patients.
Are incident reports included on a patients health record? No, they are independent of the record, and do not need to be included on the care plan.
What are 3 areas that should be included on an incident report? 1. Any out-of-the-ordinary events that happen in a facility. 2. The report must be Objective. 3. It must include the incident itself and the resulting actions taken/ care provided after the occurrence.
What is the purpose of a Care Plan? Serves to communicate the patient's problems
What are 4 points to remember when documenting in a patients chart or medical record? 1. Avoid taking shortcuts. 2. Use only approved abbreviations. 3. Be accurate. 4. Be objective.
What are the 2 types of medical records? 1. Source-oriented records. 2. Problem-oriented records.
How is a source-oriented record organized? According to the source or type of data, with each section designed by a labeled tab.
Sections of a source-oriented record include? Nurses notes, Health-care providers progress notes, vital signs, rehab therapy, MAR's, Lab results, and X-ray results.
What is Narrative Charting? Tells the story of a patient's experiences and most time-consuming, written in chronological order, and relates the patient's health status from admission through all changes in condition, up to and including their discharge status.
What does the acronym SOAPIER stand for in charting? Subjective data, Objective data, Assessment data, Plan/Intervention, Evaluation, and Revision.
EHR must be protected, what are ways you can ensure protection as a nurse? Never allow any other individual to see or use your password to access patient info. for any reason. A computer password does not grant permission to access other patients records for whom you do NOT care for.
What is the first thing you should do when you are finished using EHR access? You should always Log Out as soon as possible.
What is a Kardex? 1. A snapshot of everything for a specific resident. 2. Used as a quick reference about each residents care.
Guidelines for paper documentation? Use black ink, write legibly, sign each entry, include date and time, use chronological order, make timely entries, be succinct, use punctuation, do not leave blank space, use cont. notes, correct mistakes, keep med record intact.
How would you make a correction while documenting? Draw a single straight line through the middle of the space, extending from the last word to your signature, the ndign your name and credentials.
How often are MDS charts checked in LTC facilities? Weekly
Do LPN's have the authority to make changes to MDS charts? No, they do not. LPN's only reference MDS charts.
What are 5 documentation mistakes that carry increased risk of malpractice? 1. Assessment Findings 2. Meds Administered 3. Pertinent Health History 4. Physician's Orders 5. Documenting on the wrong chart or MAR
What is the Communication Process? An exchange of info, feelings, needs, and preferences between two people.
What is Feedback? When the receiver sends a return message, that indicates the message has been received, processed and comprehended.
What is Shared Meaning? Meaning of a message, that indicates the message was communicated as intended.
What is Verbal Communication? Is a conscious use of words, either spoken or written.
What is Non-verbal Communication? Conveyed by body language- facial expressions, posture, body position, behavior, gestures, touch, and general appearance.
What is one form of non-verbal communication that improves the nurse-patient relationship? Smile: has a positive effect.
What is Proxemics? The distance, or personal space, people place between themselves and others.
What are the 4 different space-distance zones? 1. Intimate: contact to 18inches 2. Casual-personal: 18inches to 4ft 3. Social-consultative: 4-12ft 4. Public: 12ft if possible
How should nurses communicate with patients? Avoid using medical jargon, to promote better understanding.
How should a nurse communicate with patients of different ages? The nurse should adapt communication strategies to coincide with the patient's stage of development.
What are the two layers of meaning in language? 1. denotative meaning 2. connotative meaning
What is Denotative Meaning? Is literal meaning.
What is Connotative Meaning? The emotional association.
What is Active Listening? Uses all the senses to interpret verbal and non-verbal messages.
What characterizes Aggressive behavior style? Putting ones own needs, rights, and feelings above those of others.
What characterizes Assertive behavior style? Standing up for ones self, without violating the basic rights of others.
What is the DESC Method? Describe the behavior, Explain the impact of the behavior, State the desired outcome, Consequences should grab the persons attention.
What is the most effective communication style for nurses to practice? Assertive communication style.
What is Therapeutic communication? Patient-centered communication.
What are factors that lead to un-successful communication? Asking Q's that can be answered with a "yes" or "no". Giving False Reassurance. Asking too many personal, probing Q's. Giving advice. Belittling a patient's feelings. Expressing disapproval.
What are restatement and seeking clarification methods of? Therapeutic Communication Techniques.
What is Restatement (Validation)? Restates in different words the heart of what the patient said.
What is Seeking Clarification? Helps to verify that the message sent was what was intended.
What is Upward Communication? Communicating with a superior.
What is Downward Communication? Communicating with an inferior, someone you supervise.
What is the best method to give shift report? Face-to-face reporting often done at the bedside, or outside of each patient's room.
What does Written Communication include? Care plans, progress notes, emails, reports and assignments.
Tip for Written communication? Keep It Short and Simple, KISS!
What is Expressive aphasia (Broca's aphasia)? When a person cannot produce fluent speech.
What is Receptive aphasia (Wernicke's aphasia)? Patient can hear but not understand what is said.
What is Global aphasia? Both expressive and receptive aphasia's, person has trouble understanding and expressing themselves.
What is Aphasia? Inability to speak or understand language.
What is the Wellness/Illness Continuum? The movement up and down a scale with exceptional wellness at the top and severe illness at the bottom.
What is H.L Dunn's theory of high-level wellness? Includes a continuum of health and wellness, or Health Axis AND a vertical axis to represent the persons environment.
What is Dr. Joyce Fitzpatrick's model of wellness? Rhythm model: Health is a dynamic state that results from the interaction of a person and their environment. This state of health changes continuously throughout their lifespan.
What is Healthy People 2020? Sets goals that work toward improving the prevention of disease and promoting health in the United States.
What are the 4 goals of Healthy People 2020? 1. Attain high quality, longer lives free of preventable diseases. 2. Achieve health equity for all people groups. 3. Create social and physical environments that promote good health for all. 4. Promote quality of life.
What is Health Literacy? The ability of individuals to understand basic health info. and use this info. to make good decisions about their health.
What is referred to as the "newest vital sign"? Assessing health literacy
What is a common way to asses health literacy? Using an ice cream label: ability to use numbers, make calculations, identify potentially harmful ingredients, and make informed decisions.
How much of the population has proficient health literacy? Only 12%
What is an Acute illness? Strikes suddenly and lasts for a limited time.
What is a Chronic illness? One that lasts for 6 months or longer and is characterized by intensifying or improving symptoms.
What are Remissions? Periods of time with either complete absence of symptoms or minimal symptoms.
What are Exacerbations? Periods of time with worsening symptoms.
What are the 5 Phases of illness? 1. Prodromal phase 2. Symptomatic phase 3. Seeking help phase 4. Dependency phase 5. Recovery phase
What is the Prodromal phase? First stage in becoming ill, often just feeling "under the weather" with general body aches and fatigue.
What is the Symptomatic phase? Second stage in becoming ill, there are present observable symptoms.
What is the Seeking Help phase? Third stage in sickness, when a person turns to a medical professional for help.
What is the Dependency phase? When a person relies on others for help in diagnosis and treatment.
What is the Recovery phase? The final phase, when a person is slowly able to resume independence and regain his or her health.
What are Risk Factors? These are physiological, psychological, or genetic elements that contribute to he development of an illness or disease.
What are the 2 types of Risk Factors? 1. Modifiable 2. Nonmodifiable
What is Stress? A nonspecific response of the body to any demand made on it.
What is Adaptation? Ability to positively adjust to changes that occur in an individual's world.
What is a Fight-or-Flight response? Messages sent from your body to the brain, when there is a perceived threat, to either stay and fight or run away.
What are the 3 phases of Stress? 1. Alarm phase 2. Resistance phase 3. Exhaustion phase
What is the Alarm phase of Stress? The first phase, the body's fight-or-flight response engages, often lasts for only a short period of time.
What is the Resistance phase of Stress? The second phase of continued stress: when the body continues to try to resist the threats of stress and simultaneously attempts to prevent illness. May last for weeks, moths, or years.
What is the Exhaustion phase of Stress? When your body can no longer keep up with the pace of dealing with stressors and fighting off illness.
What is the General Adaptation Syndrome? AKA GAS describes the body's attempts to adapt to the stressors we encounter defined by Selye's theory of stress and illness.
Can stress be positive and negative? Yes, it can be both.
What are Coping Strategies? The actions people utilize to combat stress, these vary from person to person.
What are Defense Mechanisms? Unconscious reactions to decrease stress in ones life.
What is Homeostasis? The body's desire for internal balance.
What is Avoidance? Unconsciously staying away from situations that might open up undesirable emotional reactions.
What is Conversion Reaction? Anxiety channels into physical symptoms.
What is Denial? Unconscious refusal to see reality, often the first defense mechanism learned, not consciously lying,
What is Displacement (Transference)? Transferring anger and hostility to another person or object that is perceived to be less powerful: the "kick the dog" syndrome.
What is Intellectualization? Separates self from uncomfortable emotions by focusing on facts and logic.
What are some common Symptoms of Stress? Frequent feelings of anger or despair; headaches; hiding true feelings; hurting loved ones; constant worry; panic attacks; isolation; indecisiveness; overuse of alcohol, drugs or food.
Does stress ever completely go away? No, it is a characteristic of existence, but we do get to chose our response to it.
What is Ethnicity? The categorization of a group of people by a distinctive trait.
What is Culture? The way of life that distinguishes a particular group of people from other groups.
What is Cultural Competence? Being considerate of the cultural background of each patient in order to provide appropriate care specific to the individual.
What is Transcultural Nursing? Care that crosses cultural boundaries or combines the elements of more than one culture.
What must one do to be aware of the whole person as a nurse? Provide care that is both culturally based, and specific to the individual.
What are the 7 barriers to health care? 1. Economics 2. Education 3. Geography 4. Language 5. Stereotyping 6. Prejudice and Discrimination 7. Misunderstandings
How does Economics affect individual health care? Individuals who are not insured or under-insured may delay going to seek professional medical help for fear of not being able to afford it.
How does Education affect individual health care? Its shown the more education someone has, the more healthcare is obtained. This makes health literacy a very important part of healthcare.
How does Geography affect individual health care? Many rural areas have limited access to health care, this is also true for low-income communities.
How does Language affect individual health care? Obviously, communication is crucial in a person understanding and receiving the care the need. When there is a language barrier, it may cause confusion on where to even start to get desired healthcare.
How does Stereotyping affect individual healthcare? Stereotyping may prevent people from seeking or obtaining the health care they need. It can cause a nurse to see the person through "preconceived ideas" and not as an individual.
How does Prejudice and Discrimination affect individual healthcare? Creates lack of sensitivity among healthcare staff and causes a patient to feel disrespected and reluctant to seek further professional help.
What is required of you as a nurse if you observe an individual (patient) being discriminated against? It is the nurses responsibility to intervene in an appropriate manner on behalf of you patient's rights.
How does Misunderstanding affect individual healthcare? A patient may fear further encounters with the health-care system. This stresses the importance of nurses verifying a patient's understanding during ALL communication and patient teaching.
What are 3 elements of humanity? 1. Body 2. Mind 3. Spirit
What is the body? The physical biological part of a person.
What is the mind? The part of a person that thinks, makes decisions and feels.
What is the spirit? The essence of a person, the vital force or energy, that is distinct from physical matter.
What is Spiritual Care? Understanding the differences between spirituality and religion, as well as understanding one's own spirituality, beliefs and values.
What is Spiritual Distress? A questioning or abandonment of spirituality, beliefs, values and relationship with himself or herself, others and God.
How should nurse respond to a patient who seems to be experiencing Spiritual Distress? With compassion and not being judgmental or biased. Offer your presence and a listening ear, with a goal to restore the patients comfort and views of how they relate to themselves, their higher power and others.
What are 5 common nursing interventions? 1. Offering presence 2. Allow patient to express their feelings 3. Use therapeutic communication 4. Contact appropriate religious or spiritual personnel 5. Allow religious rituals, within reason
What are MDS's? Minimum Data Sets are extensive assessment forms that must be completed for each resident within 4 days of admission to a facility and u[dated every 3 months.
Created by: merelisen3
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