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48 Cards in this Set
- Front
- Back
- 3rd side (hint)
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What are the three topics of health education or purposes for health education?
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health promotion/maintenance/illness prevention
restoration of health coping with impaired functioning |
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Successful education takes into consideration the clients: -------, -----, and ------ values AND their desire to _______________.
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psycho social
spiritual cultural values and their desire to participate |
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Teaching a client about their new meds is an example of this purpose for teaching.
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restoration of health
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Teaching a client to use First Aid for an injury is an example of this purpose for teaching.
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health promotion/maintenance/illness prevention
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Teaching a smoking cessation clinic would be an example of this topic/purpose for health education.
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health promotion/maintenance/illness prevention
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Effective teaching requires the nurse to do this with the client.
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respect the client
involve the client practice with the client communicate with client |
CRIP
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When should you teach a client?
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Seize the moment....when they ask.
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When preparing your content, sequence it this way....
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start with something the client is concerned with
review what the client knows address any areas creating anxiety teach the basics, then the hard stuff schedule time for review and questions |
SRATS - how to teach
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What are the three learning theories?
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BEHAVIORISM
COGNITIVE HUMANISM |
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What is the focus of the behaviorism theory?
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learning occurs in response to environmental stimuli
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What is the focus of the cognitive learning theory?
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learning is a mental or thinking process where the learner structures/processes information
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What is the focus of the humanism learning theory?
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focuses on self development...achieving full potential. Learner identifies learning needs and takes responsibility for meeting them.
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What are three reasons to document effectively?
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1. ensures continuity of care
2. saves time 3. minimizes risk of errors |
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Who regulates documentation?
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jcaho
drg (set by medicare) |
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JCAHO mandates that all clients have what?
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assessment of physical, psycosocial, environmental, selfcare, client education, discharge planning needs
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What are the SIX purposes of charting?
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1. COMMUNICATION -communicate care
2. EDUCATION - help id patterns/responses of change in status 3. RESEARCH - provide basis for evaluation, research and improvement of quality of care 4. LEGAL DOCUMENTATION - create a legal document 5. FINANCIAL BILLING - supply validation for insurance purposes 6. AUDITING - MONITORING |
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Who can access the chart of a client?
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health care team and client....not friends and family.
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What do you chart?
1. 2. 3. 4. 5. |
assessments
interventions client responses instructions referrals |
OAMI
RIR |
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Make sure you __________ verbal orders, and have them ___________.
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Make sure you chart verbal orders and have them signed.
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What does the term "source records" mean?
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each department has its own record in the chart
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What is the form called that is a multidisciplinary plan that includes: client problems, key interventions and expected outcomes within an established time frame?
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critical/clinical pathways
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What is the purpose of an admission nursing history form?
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provides a baseline nursing history and physical assessment on admission
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What does POMR stand for?
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problem oriented medical record. Its emphasis is on client problems
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What does a POMR include?
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database
problem list plan of care progress notes |
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What does the term SOAP mean?
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it is a type of note taking that is included in the progress notes of a POMR. SOAP means the way you organize those notes: subjective, objective, assessment, plan
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What are the various options for charting progress notes in a POMR?
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soap
pie narrative |
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What is another name for the nursing notes?
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flow sheet record
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What is the purpose of acuity records?
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to determine the nurse client ratio and how it affects this patient. it is a level of how much nursing this client needs. based on many factors: LOC, IV, Pain, etc. Based on the type and number of interventions needed.
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What is the purpose of a discharge summary form?
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provides written evidence of all discharge instructions given to the patients. It is mandated by JCAHO. Not a necessary form, but if you don't use it, make sure you document your discharge plans and Level of Patient's cognition on the instructions at discharge.
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When giving a verbal change of shift report, what do you cover with the next nurse?
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*info they need for first hour of care of patient
*things that are abnormal *change in client's status (good or bad) *new orders *pending orders |
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When accepting a verbal order, what must you immediately do?
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repeat the order back to the person.
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What do you need to know when accepting a verbal order?
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name of person giving order
info given (repeat it back) action taken |
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Who can not take a verbal order? both telephone or verbal
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YOU (no student nurse, has to be RN or LPN)
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What does the RN do with the verbal or telephone orders?
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write them on the physician's order sheet
have a second nurse listen have them sign the form within 24 hours |
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All behavior communicates, and all communication influences __________.
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behavior
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The nurse client "helping" relationship has these three qualities:
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1. goal directed
2. specific time frame 3. high expectations of confidentiality |
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Who is in control of the nurse client relationship?
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the nurse. She takes control, establishes, directs and takes responsibility
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What is this the definition of:
personal tendencies that interfere with accurately perceiving and interpreting messages from others. |
perceptual biases
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What are perceptions based on?
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five senses
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Differentiate between these two terms:
intrapersonal interpersonal |
intra-within the person
inter-one on one talk....this is the most used type of communciation of a nurse |
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List the four zones of touch.
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1. social
2. consent zone 3. vulnerable zone 4. intimate zone |
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Where is the social zone of touch?
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hands, arms, shoulders, back
(no permission needed) |
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Where is the consent zone of touch?
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mouth, wrists, feet
(permission needed) |
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Where is the vulnerable zone of touch?
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face, neck, front of body
(special care needed) |
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Where is the intimate zone of touch?
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genitalia and rectum
(great sensitivity needed) |
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What zone of personal space do you conduct the health history?
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personal space (18" to 4 ft)
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Therapeutic communication techniques of active listening:
-A -S -O -L -E -R |
Attention to client verbal and nonvebal
Sit facing client Observe open posture Lean toward client Establish & maintain intermitten eye contact Relax |
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What do you NOT write on a chart?
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patient, patient, patient (it is their chart)
"appears to be" judgments broad statements (c/o headache) something someone else did liquid stool without a measurement |
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