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HESWK2
Essentials of Nursing Care: Health Safety
| Question | Answer |
|---|---|
| Discharge planning | the process of anticipating and planning for client needs after discharge |
| Standards of care | the skills an learning commonly possessed by members of a profession |
| Protocols | a predetermined and preprinted plan specifying the procedure to be followed in a particular situation |
| Policies | rules to govern the handling of frequently occurring situations |
| Standardized care plans | formal plan that specifies the nursing care for groups of clients with common needs |
| Nursing outcomes classification | [NOC] a taxonomy for describing client outcomes that respond to nursing interventions |
| Priority setting | the process of establishing a preferential order for nursing strategies |
| Goals | desired outcomes |
| Desired outcomes | see “Goals” |
| Nursing intervention | any treatment that a nurse performs to enhance client outcomes, based on clinical judgment and knowledge |
| Cognitive skills | intellectual skills that include problem-solving, decision-making, critical thinking and creativity |
| Interpersonal skills | all verbal and nonverbal activities people use when communicating directly with one another |
| Technical skills | hands-on skills suca as those required to manipulate equipment or administer injections |
| Delegation | the transfer of responsibility for the performance of n activity from one person to another while retaining accountability for the outcome |
| Quality assurance | an ongoing systematic process designed to evaluate and promote excellence in providing health care |
| Confidentiality | any information a subject relates will not be made public or available to others without the subject’s consent |
| Source-oriented clinical record | a record in which each person/department makes notations in a separate area of the record |
| Problem-oriented medical record | client data are recorded and arranged according to the client’s problems |
| Focus charting | a method of charting that uses key words or foci to describe what is happening to the client |
| PIE | an acronym for a charting method that follows a recording sequence of problem, intervention, and evaluation of the effectiveness of interventions |
| Charting by exception | a documentation system in which only significant findings or exceptions to norms are recorded |
| Computer-based client records - - electronic client data retrievable by caregivers and other person who require the data | |
| Case management model | a method for delivering nursing care in which the nurse is responsible for a caseload of clients across the health care continuum |
| Kardex | trade name for a method using a series of cards to organize and record client data and instructions for daily care |
| Progress notes | chart entries made by all health professionals involved in patient care for the purpose of describing client problems, treatments, and progress toward desired outcomes |
| Flow sheet - a record of the progress of data, often charted in graph form | |
| Change-of-shift report | a report given to nurses on the next shift |
Created by:
razots
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