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78 Cards in this Set
- Front
- Back
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Acute vs Chronic Illness
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Acute- A sudden illness from whic a person is expected to recover
Chronic-An ongoing illness, slow or gradual in onset, has no known cure, can be controlled and complications prevented with proper treatment. |
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Health Promotion
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The goal is to reduce the reisk of physical or mental illnesses. People recieve teaching and counseling about healthy living. This includes diet, exercise, and the warning signs and symptoms of illness. Learning to manage and cope with health problems. Examples: Gyms, wellness classes, weight watchers, etc.
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Determining Nursing care Patterns
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The pattern used depends on how many persons need care, the staff, and the cost.
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Functional Nursing
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Focuses on tasks and jobs. Each person has a specific task and provides that task for all patients.
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Team nursing
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Involves a teach of nursing staff led by an RN. The RN decides the amount and kind of care each person needs, and delegates patient care to certain members of the nursing team.
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Primary Nursing
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Involves total care. The primary nurse (RN) is responsible for the person's total care.
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Case Management
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similar to Primary care. A case manager (RN) coordinates a person's care from admission through discharge and into the home or Long-term care setting.
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Patient-focused care
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Services are moved from departments to the bedside. Example:The nurse may draw blood.
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Purpose of Health Care
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Health Promotion, Disease Prevention, Detection and treatment of disease, Rehabilitation and restorative care.
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Role and Responsibility
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Completed a Community college- 2 year, hospital based- 2-3 years, University-4years. Must obtain a license in each state they provide care. Assess, make nursing diagnoses, plan, implement, evaluate nursing care. Develop care plans, provide care, and make sure plans are followed. Delegate nursing care and tasks to team. Evaluate how the care plans and care affect each person. Teach the patient and family how to improve health and independence. Follow Dr. orders. DO NOT prescribe treatment or drugs. Work as staff nurses, nurse supervisors or managers, DON's, agency administrators, and instructors.
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Roles and Responsibility- Dietitian
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Assess and plan for nutrional needs; teach good nutrition, food selection, and preparation. Requires a Bachelors degree; and regisitered dietitian (RD) must pass registration test, or certificaiton or license test in some states.
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Roles and Responsibilty- Social Worker
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Deals with social, emotional, and environmental issues affecting illness and recovery. Coordinates community agencies to assist patients, residents, and families.
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Roles and Responsibilty- Physician
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Diagnoses and treats diseases and injuries. MD, DO- graduate medical school, residence, and national boards, and state license.
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Paying for Healthcare
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Private Insurance, group insurance, medicare, medicaid.
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Prospective Payment Systems
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Limit the amount paid by insurers, Medicare and Medicaid. The amount paid is determined before care is given. Includes MS-DRG, RUG, CMG, and HHRG. Length of stay and treatment costs are determined for each group, if cost>agency takes loss, if cost<agency keeps extra $$$
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DRG- Diagnosis-Related Groups
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For Hospital related costs(acute care)
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RUG- Resource Utilization Groups
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For skilled nursing facility (SNF) costs
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CMG-Case Mix Group
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For Rehabilitation Centers
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HHRG- Home health resource group
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For home health care costs
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Managed Care
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Limits choice of where to go for healthcare services. limites the care doctors can provide. Some require pre-approval. Has both HMO and PPO
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HMO- Health Maintenance Organization
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for a pre-paid fee, the person receives needed services provided by HMO. HMO's stress disease prevention, and maintaining health. keeping people healthy is cheaper than treating illness
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PPO-Preferred Provider Organization
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A group of doctors and hospitals provides healthcare at reduced rates. Usuall has agreement between PPO, employer or insurance company. Members have reduced rates for services provided. Can choose any Dr. or hospital within the PPO
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Hospital
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Include emergency care, surgery, nursing care, x-ray procedures and teatments, and lab testing,respiratory, physical, occupational, speech and other therapies. all people use hospitals fr Acure illness, chronic, and terminal illnesses
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Rehabilitation and Subacute Care Agencies
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Provide care for needs that fall between hospital care, and long-term care. Complex equipment, and care measures are needed. Some hospitals have them and some are seperate agenices.
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Long-Term Care Centers
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Provide care for people that cannot care for themselves at home but do not need hospital care. Medical, nursing, dietary, recreation, rehabilitation, and social services are provided as well as housekeeping and laundry. Persons in these facilities are residents. The center is temporary or permanent home. Most are older, but some may be disabled, others may be recovering from surgery. Many suffer from chronic diseases, poor nutrition, memory problems, or poor health.
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Assisted Living Residence (ALR)
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Povide houseing, personal care, support services, health care, and social activities in a home-like setting for persons needing help with daily activities. (some are part of Nursing centers or retirement communities) Person has room or apartment, 3 meals a day, housekeeping, laundry and transportation is provided. Help is given with person care, and drugs. Have access to health and medical care.
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Skilled Nursing Facility -SNF
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Provide more complex care than nursing centers. SNF residents need rehab ro time to recover from illness or surgery. Often they return home after a short stay, and others remain residents.
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Mental Health Centers
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Servies provided for people with mental health problems, problems dealing with life events, or being a danger to themselves or others. Outpatient care is common, but some people need short ro long term in-patient care.
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Home Care Agencies
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Services provided to people where they live. Provided by nurses, nursing assistants, and other health team members. services range from health teaching and supervision to bedside nursing care. Physical therapy, rehabilitation, andfood service are common.
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Hospices
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A healthcare agency or program for persons who are dying. People no longer respond to treatment, and usually have less than 6 months to live. Physical, emotioal, social, and spiritual needs are met. The focus is on comfort, not cure. Family and friends assist with care. Provided by hospitals, nursing centers, and home care agencies.
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Acceptance of Assignments
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Make sure your state allows you to do so, it is in your job description, have necessary education and training, and a nurse is available to ask questions and supervise. Must protect person from harm. When a task is accepted you are responsible for your own actions. The task must be completed safely, and report to the nurse what you did and observations made. Ask for help when you are unsure or have questions about a task.
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Refusing a task
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Refuse a task when: i is beyond legal limits of role, not in your job description, not prepared to perform task, task could harm person, condition has changed, don't know how to ue the supplies or equipment, directions are not legal or ethical, directions are against agency policies, directions are unclear or incomplete, a nurse is not available for supervision.
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Meeting Standards
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Healthcare agencies must meet standards set by federal and state governmnts, accrediting agencies. Licensure- A license is issued by the state. must have a license to operate and provide care. Certification- Required to receive Medicare and Medicaid funds. Accreditation- Voluntary, but signals quality and excellence.
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Surveys
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Surveys are done to see if an agency is meeting set standards. Reviews policies, procedures, medical records;interviews staff, patients, and families; observe how care is given, if dignity and privacy are promoted, check for cleanliness and safety. Review Budgets and finances, make sure staff meet state requirements.
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Nursing Assistant Requirements
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OBRA sets minimum traning an competency evaluation requirements for nursing assistants. Must successfully complete NATCP to work. Requires at least 75hours of instruction,and at least 16 hours of supervised practical training. Competency Evaluation has a written and skills test. Once passed, NA must register in the state they will work. Must complete 12 hours fo continuing education every year. Certificaiton is done through your state
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NATCEP areas of study
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Communication, infection control, safety and emergency procedure, resident's rights, basic nursing skills, personal care skills, feeding methods, elimination procedures, skin care, transferring, positioning, and turning methods, dressing, helping the person walk, range of motion exercises, signs and symptoms of common diseases, how to care for cognitively impaired persons (those who have problems with thinking and memory)
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Nursing Assistant Registry
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Keeps information on each nursing student: Full name, Last known home address, date of birth, registry number and date it expires,last know employer, date hired and date employment ended, date the competency evaluation was passed, informaton on findings of abuse, neglect, or dishonest use of property.
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Nursing Assistant Standards
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Perform nursing tasks ithing rand of functions as allowed by law, is honest and shows integrity, bases tasks on education and training and nurses directions, is accountable for behavior and actions, performs delegated aspects of persons nursing care, assists nurse in observing patients, and identifying needs, communicates, asks for clarifications when unsure, uses education and training opportunities, practices safety measures, respects the rights, concerns, decision,s and dignity, functions as member of the health team, respects person's propterty, protects confidential information
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Ethics
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knowledge fo what is right and wrong conduct. is not biased or prejudiced. Follow the codes of ethics
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Nursing assistant code of conduct
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Respect each person as an individual, know the limits of your role and knowledge, perform only tasks that are within legal limits, Perform no act that will harm person, tkae drugs only if prescribed, follow directions and instructions, follow agency policies and procedures, complete each task safely, be loyal to employer and co-workers, act as a responsible citizen at all times, keep person's info confidential, Protect privacy, protect property, consider person's needs before your own, report errors and incidents at once, be accountable.
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Professional Boundary
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Seperate helpful behaviors from behaviors which are not helpful.
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Boundary Crossing
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A brief act or behavior outside of the helpful zone. bay be thoughtless, or something that was not meant to be done. Ex.-Giving a crying patient a hug
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Boundary Violation
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an act or behavior that meets yoru needs, not the person's. behavior is not ethical and violates code of conduct. Ex.-Abuse, keeping secrets with person, giving a lot of info about yourself relationships, and problems.
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Boundary Signs
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acts, behaviors, or thoughts that warn of a boundary crossing or violation. Ex- think about person while not at work, trade assignments to provide care, tell person off color jokes, take/give gifts, etc.
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Standard of Care
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Refers to skills, care and judments required by a health team member under similar circumstances.
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Protecting Privacy
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Person has a right to privacy, all PHI must be protected. Keep info about person confidential, cover person when being moved in hallways, svreen person when giving care, expose only body part involved in task, do not discuss person or treatments with others, ask visitors to leave the room while providing care, do not open person's mail, allow person to visit with others, and use the phone in private, follow agency policies and procedures required to protect privacy.
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Abuse
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The willful infliction of injury, unreasonable confinement, intimidation, or punishment thatresults in physical harm, pain, or mental anguish. Depriving the person (or caregiver) of the goods or services needed to attain or maintain well-being. It is a crime, and must be reported
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Elder Abuse
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any knowing, intentional, or negligent act by a caregiver or any other person to an older adult. The act causes harm or serious risk of harm. Can include Physical abuse, neglect, verbal abuse, financial exploitation or misappropriation, emotionl or mental abuse, sexual abuse, or abandonment
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Neglect
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Failure ot provide the person with the goods or services needed to avoid physical harm, mental anguish, or mental illness. Ex.-leaving persons lying/sitting in urine or feces, keeping persons alone in their rooms or other areas, failing to answer signal lights
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Negligence
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an unintentional wrong in which a person did not act in a reasonable and carefule manner and a person or the person's property was harmed
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Abandonment
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to leave or desert someone. Examples: leave agency before shift ends, and did not tell anyone that you were leaving, do not report to a home care assignment and are the only one providing care, leave a home care assignment without finishing, sleep on the job
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Signs of elder abuse
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unclean, unsafe, inadequate living conditions, lacking personal hygiene, weight loss, assistive devices missing or broken, Medical needs not met, frequent injuries, old and new injuries, complaints of pain or itching in genital area, bleeding and bruising around breasts or genitals, burns on hands, feet, buttocks, pressure ulcers, change in alertness, quiet and withdrawn, etc
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Reporting Elder Abuse
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Report matter at once to administrator, to other officials, all claims must be thoroughly investigated, center must prevent further potential for abuse, investigation results are reported to administrator within 5 days.
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Child abuse
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involves the following: a child 18 years or younger, any recent act or failure to act on part of a parent or caregiver, the act or failure to act results in death, serious physical or emotional harm, secual abuse, or exploitation, the act or failure to act presents a likely or immediate risk
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Types of Child Abuse
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Physical abuse, physical or emotional neglect, sexual abuse (rape, molestation, incest, child pornography, child prostitution), emotional abuse, susbtance abuse, abandonment
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Signs of neglect of a child
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Fails to gain weight, shows great affection to others, wants to eat large amounts of food, steals food, is dirty or has severe body odor, lacks correct clothing for the weather, abuses alcohol or drugs, states that no one is home
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Signs of Emotional Abuse of a Child
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sudden changes in self-confidence, headaches, stomach aches, abnormal fears, nightmares,attempts to run away
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Domestic Abuse
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Occurs in relationships, one partner has power and control over hte other through abuse, may be physical, sexual, verbal, economic, or social, usually more than one type is present, state laws vary about reporting domestic abuse, share concerns with nurse
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Work Ethics
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Involves how you look, what you say, how you behave, how you treat others, how you work with others.
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Quality and Traits for good work ethics
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Caring, dependable, considerate, cheerful, empathetic, trustworthy, respectful, couteous, conscientious, honest, cooperative, enthusiastic, self-aware
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Health
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balanced diet, 7 hours of sleep, use muscles correctly, exercise, having eyes checked, no smoking, take only prescribed medications, never work under influence of drugs or alcohol
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Medical Record
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A written or electronic account of pa person's condition and response to treatment and care. It is a permanent record, a legal document, can be used as legal evidence. Includes: Admisstion Record, Health History, physical exam results, doctors orders, doctors progress notes, graphic sheets, flow sheets, progress notes (nursing and health team), Lab results, x-ray reports, IV therapy record, respiratory therapy record, consult reports, assessments from nursing, social servies, dietary services and recreational therapy, and special concents.
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Policies regardin Medical Records
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who records, when to record, abbreviations, correcting errors, ink color, signing entries. Info must be kept confidential.
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Communication
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the exchange of infomation, a message sent it received and correctly interpreted by the intended person, Use words that mean the same thing to you and the receiver, use familiar word, be brief and concise, give information in logical and orderly manner, give facts and be specific
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Admission Record
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completed when person admitted to agency. contains identifying information, known allergies, diagnoses, date and time of admission, dr name, religiion, place of worship, and employer. form is used to help fill in other forms requiring the same information
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Health History (nursing history)
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completed upon admission. nurse interviews person to learn persons background and health history: person's chief complaint, history of current illness, past health problems, surgeries, and injuries, childhood diseases, allergies, current drugs, family health history, life-style (habits, diet, sleep, hobbies, etc), wearing dentures, eyeglasses, contact lenses, hearing aids, problems with activities of daily living (ADL), and education and occupation
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Graphic Sheet
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To record measurements and observations makde daily, every shift, or 3/4 times a day. vitals, blood pressure, temperature, pulse, respirations, weight, intake & output, bowel movement, and dr visits
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Progress Note
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Describes the care given and hte persons response and progress. Record: signs and symptoms, information on treatments and drugs, info about teaching and counseling, procedures performed by the dr, bisit by other health team members
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Long-Term Care progress note
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done when an unusual event, a problem, or change in condition occur. OBRA requires that summaries be written at least every 3 months.
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Flow sheets (ADL flow sheet)
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Used to record frequent measurements or observations. ex. vital sign, intake and output
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Kardex
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a type of card file which summarizes info in the medical record-drugs, treatments, diagnoses, routine care measures, equipment, and special needs. A quick and easy resourse of information
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Reporting
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Reporting is n oral account of care and observations. Report to a nurse: when there is a change in condition, when asked to do so, when you leave the unit for meals, breaks, or for other reasons, before the end of the shift. When reporting: be prompt, thorough, and accurate, give name, room number and bed number, give the time of oversvations or care, report only what was observed or done yourself, report care measures you expect the pt to need.
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Charting
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When recording on a persons chart communicate clearly and thoroughly. Anyone else that reads it should know what you observed, what you did, and person's response
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Regions for Charting
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Abdominal regions are used to describe the location of body structures, pain or discomfort. Regions are: Right upper quadrant (RUQ), Left upper quadrant (LUQ), Right lower quadrant (RLQ), Left Lower quaadrant (LLQ)
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Directional Terms
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Anterior/ventral- front of the body, Distal- Part farthest from the center or point of attachment, Lateral- away from the midline, Medial, at or near midline, Posterior/dorsal-Back of the body, Proximal, nearest center or point or origin
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Dealing with conflict
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1. define problem 2. collect information about problem 3. identify possible solutions 4. select best solution 5. carry out the solution 6. Evaluate the results
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Guidelines for Conflict
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Ask supervisor for time to talk privately, approach person with conflict, agree on time and place to talk, talk in private, explain problem and what is bothering you, listen to person, identify ways to solve, set a date and time to review matter, thank person for meeting with you, carry out solution, review matter as scheduled
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End of Shift Report
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given to oncoming staff, includes: care given, care to give during other shifts, person's current condition, likes changes in condition
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