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Foundations Unit 2
| Question | Answer |
|---|---|
| Understanding of legal and ethical codes is needed to: | practice safely |
| Permission to do what is usually not permitted; defined by laws | privelege |
| actions and beliefs approved of by a particular group; often not one right action | ethical code |
| rules of right or wrong | ethical principles |
| consider the ethical delima | ethical committee |
| Rules of conduct established and enforced by the government of a society and intended to protect both the general public and individuals | laws |
| Categories of laws: | Constitutional, statuatory, administrative, common, criminal, civil |
| Formal laws within the framework of the Constitution; identifies rights and privileges to which the process of checks and balances, protecting the entire nation | Constitutional Laws |
| Examples of Constitutionl laws: | free speech, right to privacy |
| laws enacted by federal, state, or local legislatures | statutory laws |
| legal term for a law | statute |
| Examples of statutory laws: | state nurse practice act |
| statute that legally defines the unique role of the nurse and differentiates it from that of other health care practitioners, such as physicians | Nurse Practice Act |
| Physician or Health Care Provider Orders | restraints, confidentiality, death and dying, organ and tissue donation, autopsies, advanced directives |
| Legal provisions through which federal, state, and local agencies maintain self-regulation; affects power to manage governmental agencies | Administrative Laws |
| Example of Administrative Laws: | State Board of Nursing is an agency that enforces administrative law. |
| Litigation that falls otside the realm of consititutional, statutory, and administrative law; decidions based on prior cases of similar nature (judicial law); affirms or reverses the order "establishing a precedent" | Common Laws |
| Penal codes that protect the safety of all citizens from people who pose a threat to the public good | Criminal Law |
| Minor criminal offense (example: traffic violation) | misdemeanor |
| Serious criminal offense (example: use of illegal drugs) | felony |
| Statutes that protect personal freedom and rights. | Civil Law |
| (Civil Law) Litigation in which one person asserts that an injury, which may be physical, emotional or financial, related to a consequence of another's actions or failure to act | Tort |
| intentional tort - Threat or attempt to do bodily harm | assault |
| intentional tort - an unatuhorized physical contact | battery |
| intentional tort - interference with a person's freedom to move about at whill without legal authority to do so | false imprisonment |
| intentional tort - failure to leave people and property along | invasion of privacy |
| intentional tort - an act in which untrue (slander or libel) information harms a person's reputation | defamation |
| speaking something untrue about a person | slander |
| writing something untrue about a person | libel |
| unintentional tort - situations that result in: | injury |
| unintentional tort - harm that results because a person (that is a reasonable prudent person would do or would not do) did not act reasonably | negligence |
| unintentional tort - professional negligence (holds professionals to a higher standard of accountability) | malpractice |
| someone who holds a professional license | professional |
| In nursing, a prudent person is one that is: | similarly educated, licensed or experienced |
| Elements of Malpractice that must be proven in court: | you owed a duty to the patient; you breached that duty; the patient was injured; the injury occurred as a result of the breach of duty |
| Protection from Malpractice includes: | participation in Continuing Education Programs (know new information); administration of competent care; communicating a caring and compassionate attitude |
| Professional liability includes: | obtain legal mechanisms such as Good Smaitan Laws, statutes of limitations, principles regarding assumption of risk, appropriate documentation, risk management, incident reports, anecdotal records; obtain liability insurance |
| Making a decision or treating a person based on a class or group to which he belongs, such as race, religion or sex | discrimination |
| unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct in a sexual nature | sexual harassment |
| HIPPA; OSHA | |
| Patient's Rights | rights to privacy, rights are usually posted at the clinic/hospital |
| unexpected patient care event that results in death or serious injury to the patient | sentinal event |
| laws that provide legal immunity to individuals who provide emergency first aid to victims of accidents | Good Samaritan Laws |
| Good Samaritan Laws will protect you as a health care worker if you stop and render aid, if: | aid is within your scope of practice |
| designated time within which a person can file a lawsuit; time is calculated from when the incident occurred | Statute of Limitations |
| a nurse must record all aspects of care provided accurately and completely; records are called: | documentation |
| Records must be: | timely, objective, accurate, complete, and legible |
| A chart is the property of: | the hospital, not the patient |
| The chart is a legal document that begins when the patient: | enters into the healthcare system |
| Safeguarding a person's health information from public discolosure; nurses must not divulge health information to unauthroized individuals without the client's written permission; the duty to protect privacy in written and electronic data | confidentiality |
| Client is forwarned of a potential hazard to his or her safety and chooses to ignore the warning, the court may hold the client responsible | assumption of risk |
| patient's agreement to allow something to happen, such as surgery, based on full disclosure of risks, benefits, alternatives, and conswquences of refusal | informed consent |
| The _________________ is supposed to go over the informed consent with the patient. | physician |
| The _______________ doesn't explain risks/benefits of procedure; should only witness the signature. | nurse |
| Informed consent includes the following: | patient's signature; witnesses' signature; date and time of signing |
| Informed consent also includes: | ver. that the pt voluntarily signed the consent, disucussed the risks, benefits, alternatives and right to refuse procedure w/physician or health care provider; ver. that the pt understands the procedure and has had all questions answered satisfactorily |
| written statement identifying a competent person's wishes concerning terminal care | advance directives |
| written document that identifies a person's preferences regarding medical interventions to use or not use in a terminal condition, coma, or persistent vegetative state | living will |
| designates a proxy for making decisions when the client is incompetent or incapacitated | Durable Power of Attorney |
| manner in which healthcare personnel manage the care of client at the time of cardiac or respiratory arrest | code status |
| There will be decreased legal risk if there is: | competent, well documented care |
| specific knowledge and skills necessary to perform a task | competence |
| ability to form an opinion or draw a sound conclusion; based on knowledge, education and experience | judgment |
| written account of an unusual event involving a client, employee, or visitor; goes in the Safety Officer's office | Incident or Occurrence Report |
| Incident or Occurrence Report should include: | when the incident occurred; where it took place; who was involved; what happned; what actions were taken at the ime |
| The incident report is not a part of the patient's records but is: | admissable in court |
| Incident reports are ____________ mentioned in the patient's chart. | never |
| personal, handwritten accout of an incident; information retained by the nurse in the event a lawsuit is filed; has nothing to do with the hospital - if something happens and you don't like the way it was handled, make your personal notes | anectodal notes (A-notes) |
| JCAHO requires institutions to have guidelines for the number of _________ needed to care for patients. If you are assigned to a unit with not enough staff, immediately notify your ___________ and document this. | staff; supervisor |
| Customs or modes of conduct | ethics |
| list of written statements describing ideal behavior (model for personal conduct) | codes of ethics |
| choice between two undesirable alternatives (occurs when individual values and laws conflict) | ethical dilemma |
| Processing an ethical dilemma is distressing to both the patients and ___________. | caregivers |
| An ____________ will help reach decisions of ethical dilemmas. | institutional ethics committee |
| Questions to ask to help process ethical dilemmas: | Is this an actual ethical delimma? Gather all information relevant to the case; examine and determine your own values and opinions about the issue; state the problem clearly; consider the possible courses of action; negotiate outcome; evaluate the action |
| Ethical decision making is: | based on a nurse's values; a person's most meaninful beliefs; basis of decisions about right or wrong. |
| personal belief about the worth you hold for an idea, custom, or object | values |
| usually refer to judgment about behaviors and ethics is the study of the ideals of right and wrong | morals |
| represents a particular branch of ethics, namely the study of ethics within the field of healt care | bioethics |
| ethical system that defines actions as right or wrong based on their "right-making characteristics sch as fidelity to promises, truthfulness, and justice"; looks to the pure presence of principle | Deontology |
| ethical system that believes in the greates good for the greatest number of people; measures the effect that an act will have | Utilitarianism |
| how ethical decisions affect women | feminist ethics |
| issues of nursing, gender, and ethical dilemma; suggests the health care workers will solve ethical dilemmas by paying attention to relationships and stories of the participants and by the examination and promotion of any fundamental act of caring | ethics of care |
| right to choose that all patients have | autonomy |
| fairness to all | justice |
| maintain commitments | fidelity |
| being honest | veracity |
| promotes taking positive, active steps to help other | beneficence |
| fundamental agreement to do no harm | nonmaleficinece |
| telling the truth, maintaining confidentiality, advocating for ethical allocation of scarce resources, and protecting vulnerable perople from unsafe practices or practitioners are: | ethical issues |
| The client has the right to _____________ and accurate information. | complete |
| Respect the client's right to understand the __________ of his/her health problem, and benefits and risks of _________. They also have the right to understand ____________ forms of treatment, and ______________ if treatment is not administered. | status; treatment; alternative; consequences |
| Set of ethical principles that all members generally accept | Code of Ethics |
| execution of duties associated with a nurse's particular role | responsibility |
| ability to answer for your actions (own up to what you do) | accountability |
| The mission of the Board of Nurse Examiners for the State of Texas (1st sentence) | Protect and promote the wefare of the people of Texas by ensuring each person holding a license as a nurse in the state of Texas is competent to practice safely. |
| The mission of the Board of Nurse Examiners for the State of Texas (2nd sentence) | The Board fulfills its mission through regulation of the practice of nursing and the approval of nursing education programs. |
| The mission of the Board of Nurse Examiners for the State of Texas (3rd sentence) | The mission, derived from the Nursing Practice Act, supersedes the interest of any individual, the nursing profession, or special interest group. |
| It is the purpose and function of the Board of Nursing to establish_________; interpret the NPA and the rules and regulations relating to ____________; to receive and investigate ______________; and to discipline _____________. | standards; nursing educaton, licensure, and practice to nurses, employers and the public to ensure informed personnel; complaints; violators |
| It is also the purpose and function of the Board of Nursing to estalish criteria for ____________ for nurses; to monitor the ____________ results to determie variances in educational effectiveness; and to oversee procedures for nursing licensing ________. | licensing; examination; examinations |
| It is the purpose and function of the Board of Nursing to issue and __________ nursing licenses; and to provide consultation and _________ to nurse education institutions and facilitate self-study, evaluation and development of effective nurse __________. | transfer; guidance; education programs |
| defines the scope of nursing practice; establishes limits to that practice; idetifies the titles that nurses must use, such as LVN or RN;authorizes a board of nursing to oversee nursing practice;determines what consititutes grounds for disciplinary action | State Nurse Practice Acts |
| Responsible for suspending and revoking licenses; reviews applications asking for reciprocity (licensure based on evidence of having met licensing criteria in another state) | Board of Nursing |
| defined by the Nurse Practice Act | Scope of Practice |
| definition of each level of nursing and what the nurses can do or not do at each level | Scope of Practice |
| The Scope of Practice for the LVN is under the Nurse Practice Act Ch: | 301.002 (5) |
| The LVN's function is under Rule ___________. | 217.11 |
| The board has deveoped the "Six-Step Decision-Making Model for Determining Nursing Scope of Practice" to help in determining the scope of practice. | See Notes pg. 6 of 11 for Scope of Practice according to the BON. |
| eligibility determined by the state's board of nursing | licensure |
| Student nurses are: | held to the same standards as a licensed nurse; perform a task with the same outcome to the patient; legally responsible for his/her own actions or inaction |
| Student nurses must: | consult with their instructors; must know the NPA of their state; must not act out of their scope of practice in which they are practicing to remain legal. |
| taking responsibility for one's actions | accountability |
| nurse's responsibility to meet the health care needs of the patient in a safe and caring way | professional accountability |
| assigment of duties to another person (be sure the can do what you are asking them to do) | delegation |
| defined in nursing procedure books, institutional manuals of policies and procedres or protocols, and nursing journals that outline current skills or techniques | Standards of Care |
| done to keep abreast of new information; each nurse is required 20 hours every 2 years (by the BON) | continuing education |
| The nursing care for vocational nursing is governed by: | Rule 217.11 |
| Nursing also includes standards of _________. These describe a common level of care required to judge the quality of nursing practice. Institutions may adopt a _________ set of standards for nursing care such as ______________. | practice; general; protocols, policies and procedures |
| Standards of care are important in the case of a _________; they help determine whether a nurse practiced ___________ in a situation. | lawsuit; appropriately |
| Written collections of information about a person's health problems, the care provided by health practitioners, and the client's progress | medical records |
| forms of the medical records are placed in the client's _________ | chart |
| Many members of the health care team contribute to the client's medical record by: | charting, recording, or documenting on the agency's forms |
| only those who provide care tothe patient need to access this record | confidential |
| purpose of documentation | permanent account; sharing information; quality assurance; accredidation; reimbursement; education and research; legal evidence |
| Serves as a permanent record of a person's illness or injury; kept in chronological order from the time of admit to the time of discharge or death | permanent record |
| allows all members of the health care team to shar information; prevents duplication of care and promotes the continuity of care | sharing information |
| provides the institution a means of achieving quality assurance; A sample of the chart is reviewed, if it is found to be deficient, measures are suggested to correct the problem | Quality Assurance |
| The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is a private organization that has established criteria that: | reflect the high standards for institutional health care. |
| JHACO inspects health care organizations periodically to make sure that they are: | living up to the standard set by JCAHO. |
| Accreditation includes an initial assessment and reassessments of physical, psychological, social, environmental, and self care; education; and ___________. | discharge planning. |
| Accreditation - JHACO also checks for: identifying nursing diagnoses or client _______; planned nursing __________ for nursing standards of care for meeting the client's nursing care needs; and nursing care _________. | needs; interventions provided |
| If documentation is incomplete, _________ may be delayed. | reimbursement |
| Charts can be used for educational and research purposes. Studends can read charts of pts with specific disease processes to learn more about that specific disease and its ___________. Charts are used for research purposes with the _____________. | treatment; patient's permission |
| Charts can be a legal document and used in a lawsuit as ___________. Anyone who writes in the chart can be called upon to ___________. The handwriting needs to be legible without being scribbled out or white out used. | evidence; testify |
| Clients have the right to view their medical record. How that happens is the decision of the __________. | institution |
| What is in each chart? | admission data; signed consent for treatment; physician's/health care provider's care; med. history and dr's physical exam; nurse's documentation, med records, physicians progress notes; progress notes from other disciplines; lab results; discharge info |
| Methods of charting: | narraatve charting; problem-oriented medical records (SOAP, Focus, PIE); source records; charting by exception; computerized charting |
| Documentation of the Nurse's Process includes: | charting organized by diagnosis; init. assessment each shift; flow chart & narrative abnormality; nursing care plan created at admission (reviewed and updated every 24 hours); interventions documented on flow sheet or nurse's notes; eval. in nurse's notes |
| Narrative charting involves writing client information in ________________. This way is similar to writing in a __________. This format is time ___________ and hard to find quickly when needed and hard to read if handwriting is ________. | chronological order; journal; consuming; not legible |
| Narrative charting - depending on the skill of the person documenting, important information can be left out and ___________ can be included. | insignificant information |
| structured method of documentation that emphasizes the patient's problems; organized in a way to correspond to the nursing process and facilitates communication of patient needs; organized by problem or diagnosis | Problem-oriented medical records |
| SOAP Charting | S - Subjective Data O - Objective Data A - Analysis of data P - Plan of care I - Implementation R - Revision of plan of care |
| uses the word "focus" instead of "problem" due to the negative connotation of "problem". This method uses the DAR method. | Focus Charting; DAR D - Data A - Analysis R - Response |
| PIE Charting; Each problem in this method is given a # to correlate the charting with. | P - Problem I - Intervention E - Evaluation |
| Each discipline has a separate section in which to recrd data; does not organize by patient problem; advantage is that caregivers are able to easily locate the section they need; disadvantage is care is fragmented. | Source Records |
| With this method, the nurse only charts or elaborates on the abnormal findings in the chart | Charting by Exception |
| Advantages of charting by exception: | highlights abnormal data and patient trends; decreases time; eliminates duplication |
| Disadvantages of charting by exception: | development of detailed protocols and procedures; retraining of staff; data is omitted |
| Computer used to do all charting; most effective when terminal at each pt's bedside; may use a touch screen or a keyboard to enter data | Computer Charting |
| Advantages of computer charting: | information always legible; automatically records data and time of documentation; abbreviations and terms consistent with agency approved lists; eliminates trivia; omissions are fewer; reduces overtime; requires less storage space and quickly retrievable |
| disadvantages of computer charting: | initial expense of system and training; power failure - nurses have to paper chart until back online |
| Other uses of computer in healthcare: | generate care plans; develop staffing patterns that meet current unit cencus; analyze assesment data from monitoring equipment;call attention to drugs newly ordered or not administered;alert nurse imcompatibilities or contraindications to prescribed drugs |
| When charting, be ______ and definite in using words or phrasaes that convey the meaning you wish. | specific (See Table 7-3, pg. 97) |
| can be used to shorten length of documentation | abbreviations |
| Abbreviations can never take priority over: | completeness and accuracy |
| All abbreviations are ___________ the same universally. | interpreted |
| Each agency provides a written or computerized list of ___________ abbreviations and their meanings. | approved |
| When charting, ___________ are not necessary. ___________ may be omitted. The word "patient" may be _________. ____________ abbreviation may be used. If an ____________ or change is noted, then it should be ____________. | sentences; articles; left out; Acceptable; abnormality; charted |
| Charting must be legible. A nurse may be called upon to read in a _____________. Continue complete __________, chart _____________. | legal case; thoughts; thouroughly |
| What needs to b charted? | Box 7-2, pg 100 |
| Quick reference for current information about the client and his or her care. It is used to locate the clients by name and room number; identify each client's doctor and medical diagnosis; serve as a reference for a change of shift operator | Nursing Kardex |
| The nursing Kardex can: | serve as a guide for making nursing assignments; provide rapid resource for current medical orders on each client; specify the client's code or DNR status; check quickly on client's diet; alert nursing personnel to client's schedules tests for preparation |
| The Kardex can inform staff of the client's current level of _________. It can identify comfort of ________________ a client may require. It also provides a tool for estimating the _____________ ratio for a nursing unit. | activity; assistive measures; personnel-to-client |
| The information on a Kardex changes __________, sometimes several times a day. It not part of the permanent record. Nurses can write in pencil and __________ on it. | frequently; erase |
| A form of documentation with sections for recording frequently repeated assessment data. Some provide room for recording numbers or brief descriptions | Flow sheets |
| Most institutions use ____________ time based on a 24-hour clock. This avoids ____________ because no number is ever duplicated, and the labels am and pm, midnight and noon are not needed. | military; 24-hour |
| SBAR was created to help prevent: | risk of important information being lost during handoff. It is helpful when communicating with physicians due to both fields of learning communicating differently. |
| SBAR | S - Situation B - Background A - Assessment R - Recommendation |
| S - Situation | identify yourself and position, patient's name and the current situation. Describe what is going on with the patient. |
| B - Background | state the relevent history and physical (H&P), physical assessment pertinent to the problem, treatment/clinical course summary and any pertinent changes |
| A - Assessment | offer your conclusion about the present situation |
| R - Recommendation | explain what you think needs to be done, what the patient needs and when. |
| Verify any __________ information recieved when on the phone with the physician. Review the __________, seek _____________, ask questions, and read back critical test results. | critical; history; clarification |
Created by:
akgalyean
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