Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
59 Cards in this Set
- Front
- Back
|
The law
|
view it as the foundation for understanding what society expects from professional nurses.
|
|
|
Standards of care
|
Legal guidelines for defining nursing practice and identifying the minimum acceptable nursing care
|
|
|
Sources of law
|
Legal guidelines that come from statutory, regulatory, and common law
|
|
|
Federal Statutory Issues
|
American with Disabilities Act, Mental Health Parity Act, Living wills, durable power of attorney, health insurance portability and accountability act, emergency medical treatment and active labor act, advance directives, uniform anatomical gift act, restraints
|
|
|
State Statutory Issues
|
Licensure
Good Samaritan laws Public health laws The Uniform Determination of Death Act Physician-assisted suicide |
|
|
Civil and Common Law Issues
|
Torts(is a civil wrong made against a person or property)
Intentional: Assault, battery, false imprisonment Quasi-intentional: Invasion of privacy, malice, slander, libel Unintentional: Negligence, malpractice |
|
|
Malpractice Insurance
|
A contract between the nurse and the insurance company
Provides a defense when a nurse is in a lawsuit involving negligence or malpractice insurance |
|
|
Risk Management
|
A system of ensuring appropriate nursing care that attempts to identify potential hazards and eliminate them before harm occurs
Steps involved: Identify possible risks. Analyze risks. Act to reduce risks. Evaluate steps taken |
|
|
Communication and Nursing Practice
|
An essential attribute of professional nursing practice
Builds relationships with clients, families, and multidisciplinary team members |
|
|
Communication and Interpersonal Relationships
|
The means to establish helping and healing relationships.
The ability to relate to others is important for interpersonal communication. Developing communication skills requires both an understanding of the communication process and of one’s own communication experience. |
|
|
Interpersona
|
One-to-one interaction between two people
|
|
|
Intrapersonal
|
Occurs within an individual
|
|
|
Environment
|
The setting for sender-receiver interactions
|
|
|
Channels
|
Means of conveying and receiving messages
|
|
|
Sender and receiver
|
One who encodes and one who decodes the message
|
|
|
Feedback
|
Message the receiver returns
|
|
|
Referent
|
Motivates one to communicate with another
|
|
|
Message
|
Content of the message
|
|
|
Interpersonal variable
|
Factors that influence communication
|
|
|
Professional Nursing Relationships
|
Nurse-client helping relationships
Nurse-family relationships Nurse-health team relationships Nurse-community relationships |
|
|
Elements of Professional Communication
|
Appearance, demeanor, and behavior
Courtesy Use of names Trustworthiness Autonomy and responsibility Assertiveness |
|
|
Communication Within the Nursing Process
|
Assessment
Physical and emotional factors Developmental factors Sociocultural factors Gender Diagnosis Many clients experience difficulty with communication Lacking skills in attending, listening, responding, or self- expression Inability to articulate, inappropriate verbalization Difficulty forming words Difficulty with comprehension Planning: Goals and outcomes: Specific and measurable Setting of priorities Continuity of care: Collaboration with other health care providers Implementation: Therapeutic communication techniques Nontherapeutic communication techniques Adapting communication techniques Evaluation: Nurses and clients need to determine whether the plan of care has been successful. Nursing interventions are evaluated to determine which strategies or interventions were effective. If expected outcomes are not met, the plan of care needs to be modified |
|
|
Confidentiality
|
Nurses are legally and ethically obligated to keep client information confidential.
Nurses are responsible for protecting records from all unauthorized readers. HIPAA act requires disclosure or requests regarding health information. |
|
|
Guidelines for Quality Documentation and Reporting
|
Factual: descriptive, objective info about what a nurse sees, hears, feels, and smells from direct observation and measurement
Accurate: use of exact measurements establishes accuracy Complete: info within a recorded entry or a report needs to be complete, containing appropriate and essential info Current: timely entries are essential in the client's ongoing care Organized: communicate info in a logical order |
|
|
Incident or Occurrence Reports
|
Incident: any event that is not consistent with the routine operation of a health care unit or routine care of a client.
Analysis of incident reprts helps with the identification of trends in systems and unit operations that provide justification for changes in policies and procedures or for in-service seminars Quality-improvement program |
|
|
Clinical Decision
|
Separate professional nurses from technical and ancillary staff
Nurses need to seek knowledge, act quickly, and make sound clinical decisions |
|
|
Critical thinking
|
active, organized, cognitive process used to carefully examine one's thinking and the thinking of others
Recognizing an issue exists, analyzing info, evaluating info, and making conclusions |
|
|
Levels of Critical Thinking
|
Basic: trusts experts have right answers
Complex: separates themselves from authorities by analyzing and examining choices independently Commitment: anticipates need to make choices w out assistance from others |
|
|
Scientific Method
|
way to solve problems using reasoning
systematic approach to gather data and solve problems |
|
|
Problem solving
|
obtain info and then use the info plus what we already know to find a solution
|
|
|
Decision Making
|
product of critical thinking that focuses on problem resolution
|
|
|
Diagnostic Reasoning and Inference
|
process of determining client's health status after you assign meaning to the behaviors, phys signs,and symptoms presented
inference is the process of drawing conclusions from related pieces of evidence by forming patterns of info from data before making a diagnosis |
|
|
Clinical Decision Making
|
problem-solving activity focusing on defining client problems and selecting appropriate treatment that requires careful reasoning so that you choose the options best for client outcomes on the basis of the client's condition and the priority of the problem
|
|
|
Nursing Process as Competency
|
identify a client's health care needs, clearly define a nursing diagnosis or collaborative problem, determine priorities of care, and set goals and expected outcomes of care
|
|
|
Knowledge Base
|
varies
includes initiative a nurse shows in reading the nursing literature so as to remain current in nursing science |
|
|
Experience
|
necessary to acquire clinical decision making skills
|
|
|
Nursing Process Competencies
|
applies critical thinking components during each step of the nursing process
|
|
|
Attitudes
|
11 attitudes
define how successful a critical thinker approaches a problem confidence, thinking independently, fairness, responsibility and authority, risk taking, discipline, perseverance, creativity, curiosity, integrity, humility |
|
|
Standards
|
Intellectual: 14, guideline for rational thought
Professional: ethical criteria for nursing judgements, evidence-based criteria used for eval, and criteria for professional responsibility |
|
|
Developing Critical Thinking Skills
|
Reflective journaling: used to clarify concepts through reflection by thinking back or recalling a situation
Concept mapping: visual representation of client problems and interventions that illustrates an interrelationship |
|
|
Critical Thinking Synthesis
|
reasoning process used to reflect on and analyze thoughts, actions, and knowledge.
Requires a desire to grow intellectually Requires the use of nursing process to make nursing care decisions |
|
|
Critical Thinking Approach to Assessment
|
Nursing assessment: collection and verification of data and analysis of data
Database: client's perceived needs, health problems, and responses to problems |
|
|
Data Collection
|
Subjective: verbal descriptions
Objective: observations or measurements of a client's health status Sources: Client, family and SO, health care team, and medical records |
|
|
Methods of data collection
|
Interview: an organized convo w the client
Nursing health hx: data about the client's current level of wellness |
|
|
Physical Exam
|
observation of client behavior
diagnostic and lab data interpreting assessment data and making nursing judgements |
|
|
Data Documentation
|
last component of assessment
Legal and professional responsibility requires accurate and approved terminology and abbreviations |
|
|
Medical Diagnosis
|
clinical judgment about the client in response to an actual or potential health problem
|
|
|
Nursing Diagnosis
|
identification of a disease condition based on specific eval of signs and symptoms
|
|
|
Collaborative Problem
|
actual or potential complication that nurses monitor to detect a change in client status
|
|
|
Diagnostic Reasoning
|
process of using assessment data to create a nursing diagnosis
|
|
|
Defining Characteristics
|
clinical criteria or assessment findings that support an actual nursing diagnosis
|
|
|
Clinical Criteria
|
objective or subjective signs and symptoms, clusters of signs and symptoms, or risk factors that lead to a diagnostic conclusion
|
|
|
Actual Nursing Diagnosis
|
Describes human responses to health conditions or life processes
|
|
|
Wellness Nursing Diagnosis
|
Describe human responses to levels of wellness that have a readiness for enhancement
|
|
|
Risk Nursing Diagnosis
|
Describes human responses to health conditions/life processes that may develop
|
|
|
Components of a Nursing Diagnosis
|
Diagnostic Label: name of the nursing diagnosis as approved by NANDA International that describes the essence of a client's response to health conditions in as few words as possible
Related Factors: condition or etiology identified from the client's assessment data Etiology: always within the domain of nursing practice and a condition that responds to nursing intervetions Definition: for each diagnosis following clinical use and testing Risk Factors: environmental, physiological, psychological, genetic, or chemical elements that increase the vulnerability of an individual, family, or community to an unhealthful event Support of the diagnostic statement: nursing assessment needs to support the diagnostic label and the related factors need to support the etiology |
|
|
Concept Mapping Nursing Diagnosis
|
Concept maps promote problem solving and critical thinking skills by organizing complex client data, analyzing concept relationships, and identifying interventions
|
|
|
Sources of Diagnostic Errors
|
Data collection: be knowledgeable and skilled in all assessment techniques
Interpretation and analysis of data: review your database to decide if it is accurate and complete, review data to validate that objective supports subjective Data clustering: identify nursing diagnosis from data, not the reverse Diagnostic statement: word the diagnostic statement in appropriate, concise, and precise language Documentation: once identified, list client's nursing diagnosis on the written plan of care |
|
|
Nursing Diagnosis: application to care planning
|
by making accurate nursing diagnoses, your care plan will help communicate the client's health care problems to other professionals
A nursing diagnosis will ensure that you select relevant and appropriate nursing interventions |
