Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/77

Click to flip

77 Cards in this Set

  • Front
  • Back
Define:

ASSESS
To systematically and continuously collect, validate, and communicate patient data
Define:

CONSULTATION
Meeting of two or more physicians or surgeons to evaluate the nature and progress of disease in a particular patient and to establish diagnosis, prognosis, and/or therapy.
Define:

CRITERIA
A standard or rule for judging; usually plural (criteria) denoting a set of standards or rules.
Define:

CRITICAL THINKING
1. The practice of considering all aspects of a situation when deciding what to believe or what to do.

2. nursing reflective and reasoned thinking, leading to judgments about what to believe or actions to take in any given situation.
Define:

DATABASE
A collection of information on a given topic, stored digitally for rapid search and retrieval.
Define:

DISCHARGE PLANNING
A nursing interdisciplinary, collaborative process that involves evaluating patients' needs and developing and implementing a comprehensive plan for continuing, follow-up, or rehabilitation care.
Define:

EMPATHY
The ability to sense the emotions, feelings, and reactions intellectually and emotionally that another person is experiencing and to communicate that understanding to the person effectively.
Define:

EVALUATE
A part of the nursing process in which the extent to which the established goals of care have been met is determined and recorded.
Define:

EVIDENCE BASED PRACTICE
(EBP)
The formulation of treatment decisions by using the best available research evidence and integrating this evidence with the practitioner's skill and experience.
Define:

FLOW SHEET
Graphic record of abbreviated aspects of patient's condition (e.g., vital signs, routine aspects of care)
Define:

FOCUSED ASSESSMENT
Assessment conducted to assess a specific problem; focuses on pertinent history and body regions.
Define:

GOAL
An aim or an end.
Define:

IMPLEMENT
A step of the nursing process. It follows assessment, nursing diagnosis, and planning. In this stage, the nursing actions are carried out.
Define:

KARDEX Care Plan
Trade name for a care plan documentation system that encompasses (1) prescriptions for nursing care related to activities of daily living (2) nursing diagnoses and related patient goals and nursing orders; and (3) the nursing care related to diagnostic measures and the medical regimen.
Define:

LEARNING READINESS
Patient's willingness to engage in the teaching-learning process (emotional readiness) and experiential readiness to begin the challenge of learning.
Define:

MEDICAL DIAGNOSIS
Statement about a specific disease process using terminology from a well-developed classification system accepted by the medical profession.
Define:

MINIMUM DATA SET
Smallest number of data that can be collected and still positively identify the patient
Define:

NURSING CARE PLAN
Care plan created by a nurse for patients as a result of assessment of patient needs. The plan of care is focused on nursing interventions, not medical interventions
Define:

NURSING DIAGNOSIS
The process of assessing potential or actual health problems, including those pertaining to an individual patient, a family or community, that fall within the scope of nursing practice; a judgment or conclusion reached as a result of such assessment or derived from assessment data.
Define:

NURSING HISTORY
A comprehensive set of information about a patient's medical history, including the history of the present illness, as well as the person's psychosocial and spiritual history; used as the basis for nursing diagnosis and development of a care plan.
Define:

NURSING INTERVENTION
Treatments that nurses perform in all settings and in all specialties; activities nurses perform; nursing care measures.
Define:

OBJECTIVE DATA
Information perceptible to the senses; may be verified by another person
Define:

PEDAGOGY
Science of teaching that generally refers tot he teaching of children and adolescents.
Define:

PEER REVIEW
Assessment of research proposals, manuscripts submitted for publication, or a physician's clinical practice by other physicians or scientists in the same field.
Define:

PLANNING
The act of formulating or drafting a plan.
Define:

PROFESSIONALISM
A way of being/commitment to secure the interests and welfare of those entrusted to one's care.
Define:

PROGRESS NOTES
Records kept by health care workers to indicate the course of the patient during care.
Define:

PROTOCOLS
A precise and detailed plan for the study of a biomedical problem or for a regimen of therapy, especially cancer chemotherapy and radiation therapy.
Define:

QUALITY IMPROVEMENT
The commitment and approach used to continuously improve every process in every part of an organization, with the intent of meeting and exceeding customer expectation and outcomes
Define:

REFERRAL
Any health care services that are ordered or arranged.
Define:

SBAR COMMUNICATION
Consistent, clear, structured, and easy-to-use method of communication between healthcare personnel; it organized communication by the categories of : S - Situation, B -Background, A-Assessment, and R - Recommendations.
Define:

STANDARD
Something that serves as a basis for comparison; a technical specification or written report by experts
Define:

STANDARDS
The levels of performance accepted and expected by nursing staff or other health team members.
Define:

STANDING ORDERS
Document that details the nursing care to be implemented in specific nursing situations, frequently when a physician is not present/ may expand scope of nursing responsibilities.
Define:

SUBJECTIVE DATA
Information from a patient in the patient's words.
Define:

THERAPEUTIC TOUCH
An alternative therapy that involves using one's hands to consciously direct and energy exchange from the practitioner to the patient to facilitate healing or pain relief.
Define:

VALIDATION
Act of confirming or verfying.
Define:

VARIANCE REPORT
Report used by healthcare agencies to document the occurrence of anything out the the ordinary that results in, or has the potential to result in, harm to a patient, employee or visitor.
Also called Incident or occurrence report
Define:

CLICHÉ
A stereotyped, trite, or pat asnwer
Define:

CONCEPT MAPPING
Instructional strategy that requires learners to identify, graphically display, and like key concepts
What are the 5 steps the nursing process?
1. ASSESS the patient to determine the need for nursing care.
2. Determining NURSING DIAGNOSES for actual and potential health problems.
3. identify EXPECTED OUTCOMES and plan care
4. IMPLEMENT the care
5. EVALUATE the results.
What are the 4 types of nursing assessments?
1. Comprehensive Initial Assessment
2. Focused Assessment
3. Emergency Assessment
4. time-lapsed Assessment
When is an Comprehensive Initial Assessment performed?
Shortly after the patient is admitted into a healthcare agency or service.
What is the purpose of a Comprehensive Initial Assessment?
To establish a complete database for problems identification and care planning.
When is a Focused Assessment performed?
May be done during the initial assessment if patient health problems surface, but it is routinely part of of ongoing data collection.
What is the purpose of a Focused Assessment?
Identify new or overlooked problems.
When is an Emergency Assessment performed?
In a crisis situation to identify life-threatening problems.
When is a Time-lapsed Assessment performed?
This is a scheduled assessment to compare a patients' current state to baseline data obtained earlier.
What is subjective data?
Is data that is perceived by the patient, this information can not be verified or perceived by another person. (e.g.; pt states that they are nervous, in pain, can't eat, nauseated.)
** Also referred to as symptoms or covert data.
What is objective data?
Data that is observable and measurable, can be seen, heard, or felt by someone other that the person experiencing them. (e.g.; elevated temp, skin that is moist.)
** Also reffered to as signs or overt data.
What are the two key components of data collection?
1. Nursing History
2. Nursing physical assessment.
T/F
Nurses are responsible for alerting the appropriate healthcare professional whenever assessment data differ significantly from the patients baseline, indicating a serious problem.
True


Pg. 237 Box 12-4
What are the 5 types of nursing diagnoses?
1. Actual nursing diagnoses
2. Risk nursing diagnoses
3. Possible nursing diagnoses
4. Wellness diagnoses
5. Syndrome nursing diagnoses
The formulation of nursing diagnosis statements contains 3 parts, what are they?
1. Problem
2. Etiology
3. Defining Characteristics.

Pg. 255 Table - 13-3
Define the purpose of the PROBLEM STATEMENT In the formulation of a nursing diagnosis statements.
Describes the health state or health problem of the patient as clearly and concisely as possible.
Define ETIOLOGY with regards to the formulation of a nursing diagnosis statements.
Identifies the physiologic, psychological, sociological, spiritual and environmental factors believed to be related to the problem as either a cause or a contributing factor.
What are the 3 steps in comprehensive planning?
1. Initial Planning
2. Ongoing Planning
3. Discharge Planning
What are Maslow's Hierarchy of Human Needs?
Self - Actualization Needs
Self-Esteem
Love and Belonging
Safety Needs
Physiologic Needs
What is a nursing intervention?
Any treatment, based on clinical judgement and knowledge, that a nurse performs to enhance outcomes. There are 3 types: nurse-initiated, physician-initiates, and collaborated interventions.
What are collaborative interventions?
Collaborative Interventions are treatments initiated by other providers such as pharmacists, respiratory therapists, or physicians assistant.
What type of intervention is targeted to promote and preserve the health of populations, to include health promotion, maintenance and disease prevention?
A. Indirect Care
B. Community
C. Direct Care
B. Community intervention
Define:

DELEGATION
Transfer of responsibility for the performance of an activity to another individual while retaining accountability for the outcome.
If an RN delegates vital signs to the CNA, ultimately who is responsible for the accuracy of the results and charting?
The RN
What are the 4 types of OUTCOMES?
1. Cognitive Outcomes - involves increasing the patient knowledge.
2. Psycho motor Outcomes - describes the pateint's actievement of a new skill.
3. Affective Outcomes - pertains to changes in patient values, beliefs, and attitudes and are more complex to evaluate.
4. Physiologic Outcomes - physical changes in the patent .
True/False

According to documentations guidelines, you should always document interventions before carrying them out so you don't forget.
FALSE
How would you document that you gave Mr. James Smith Tylenol at 3:30pm?
Today's Date
1530
Provided J.S. 200mg Tylenol.
True/False
It is ok to discuss your patients in an elevator, as long as you don't use names?
FALSE
What do the initials HIPPA stand for?
Health Insurance Portability and Accountability Act
What is the purpose of patients records?
Serve as a central location for communicating with other healthcare professionals, recording of diagnostic and therapeutic orders, care planning, quality-of-care reviewing, research, decision analysis, education, legal documentation, reimbursement and historical documentation.
In what circumstances can an attending physician issue a verbal order?
During an emergency situation.
The order must be given directly by the physician to a registered professional nurse or register professional pharmacist.
True/False

Faxed orders are accepted as long as they are legible and issued from a credentialed and privileged individual.
TRUE
What is a SOAP note? And what information does it contain.
A SOAP note is written by a doctor to discuss a specific problem of a patient.

Subjective Data,
Objective Data,
Assessment and
Plan
True/False

It is OK to leave your terminal unattended for a minute while you run to the store room for additional supplies.
FALSE: NEVER leave a computer terminal unattended after you have logged on.
What are the methods in which a Change-Of-Shift Report can be done?
1. Face-to-face
2. Telephone
3. Written Messages
4. Audio-Taped messages
5. Computer Messages
True/False
It is OK to use white-out or correcting fluid to completely erase a mistaken entry.
FALSE:

If a mistake is made draw a SINGLE LINE through the entry ensuring it is still legible, above line write mistaken entry, and your initials.
What is the correct abbreviation for a medication that is given "AS NEEDED"?
P.R.N.
What method of documentation used the categories data, action and response (DAR) to facilitate charting?
Focus Charting