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81 Cards in this Set

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(NCLEX-PN) designates 4 catorgories of the client needs as the structure for the test plan
1) safe, effective, care enviroment, 2)health promotion and maintaince, 3)psychosocial intergrity and 4) physologic integrity
the 4 basic roles nurses perform to meet the clients needs
caregiver, educator, collaborator, and delegator.
is one who performs health related activities that a sick person cannot perform independently.
association between two or more people.
an intuitive awareness of what a client is experiancing.
one who provides information
one who works with others to achieve a common goal.
one who assigns a task to someone, he or she must know what tasks are legal and appopriate for particular health care workers to perform.
introductory phase
period of getting acquainted.
working phase
period during which tasks are performed.
terminating phase
period when the relationship comes to an end. occurs when the task or goal has been reached.
exchange of information
therapeutic verbal communication
using words and gestures to accomplish a particular objective. It is extremly important, especially when the nurse is exploring problems with the client or encouraging expressions of feelings.
is as important during communication as speaking. It is important to not give off signals, or sighs, just to be at ones eye level and listening is most appropriate.
intentionally withholding verbal commentary, it plays an important role in communication.
non verbal communication
exchange of information without using words, involves what is NOT said.
kinesics refers to
kinesics refers to body language, those collective nonverbal techniques like facial expressions, posture, and body movements.
vebal communication
communication that uses words, includes speaking, reading, and writing.
Therapeutic verbal communication
using words and gestures to accomplish a partiular objective, is extremly important especially when the nurse is exploring problems with the client or encouraging expressions of feelings.
Intimate space
is reserved for making love, confiding secrets, and sharing confidential information.
listening is just important during communication as speaking. it gives the client your full attention as long as you are not acting bored.
intentionally withholding verbal commentary, it plays an important role in communication.
non verbal communication
exchange of information without using words, involves what is NOT said. words can be choosen with care, but a facial expression in harder to control.
body language, includes nonverbal techniques such as facial expressions, posture, gestures, and body movements. some add that clothing and accessories such as jewerly also affect the context of communication.
vocal sounds that are not actually words, also communicates a message. EX: drawing in deep breaths in indicate suprise, clucking the tongue to indicate disappointment, and whistling to get someones attention. crying, laughing, and moaning are additional forms of paralanguage.
tactile stimulus produced by marketing personal contact with another person or object, occurs frequently in nurse, client relationships.
task oriented touch
involves the personal contact required when performing nursing procedures.
affective touch
is uded to demonstrate concern and affection. most the time this touch is only used when the client is lonely, uncomfortable, near death, anxious, insecure, or frightened, disoriented, disfigured, semiconscious or comatose, visually impaired, or sensory deprived.
4 progressive stages of learning, from nurse to client
1) recognition of whats been taught, 2) recall or description of information to others, 3) explanation or application of information, and 4) independent use of the new learning (bruccoliere 2000)
to implement effective teaching, the nurse must determine the clients:
preferred learning style, age and devopmental level, capacity to learn, motivation, learning readiness, learning needs.
style of learning
how a person prefers to acquire knowledge.
3 learning styles
cognitive domain, affective domain, psychomotor domain.
cognitive domain learning style
is a style of processing information by listening or reading facts and descriptions. EX: listening, identifying, locating, labeling, summarizing, and selecting.
affective domain learning style
is a style of processing that appeals to a persons feelings, beliefs, and values, EX: advocating, supporting, accepting, promoting, refusing and defending.
psychomotor domain learning style
is a style of processing that focuses on learning by doing. EX: assembling, changing, emptying, filling, adding, and removing.
informal teaching
is unplanned and occurs spontaneously at the bedside.
formal teaching
is planned and requires a plan. without a plan teaching becomes haphazard.
3 steps in teaching an adult client
assessment, planning and implemantation.
find out what the client what to know, establish what the client should know to remain healthy, determine the clients learning style.
collaborate with the client on content goals, and realistic time frame, develop a written plan that builds from simple to complex, familiar to unfamiliar and normal to abnormal, divide information into manageable amounts, select teaching stategies and resources that are compatible with the clients preferred style of learning, use a variety of instructional methods from the cognitive, affective and psychomotor domains, review the content that will be used during teaching.
teach when client appears interested and physically and emotiionally ready to learn, if possible, provide an enviroment that promotes learning, identify how long teaching sessions will last, begin the basic concepts, review previously taught information, use vocabulary withing the clients personal level of understanding, explain why and all new terms, involve the client actively by encouraging feedback and handling equipment, stimulate as many senses as possible, invent songs, rhymes, or a series of key terms that correspond with the teaching content, use equipment as similar as possible to what the client will use at home, allow time for questions and answers, summurize the key points covered during the current teaching, determine the clients level of learning, identify the time, place and content for the next teaching session, arrange an opportunity for the client to use or apply the new information as soon as possible after it was taught, document the info. taught and evidence demostrating the clients understanding, review with the client the progress made towards goals, evaluate the need for further teaching.
is the science of teaching children or those with cognitive ability comparable to children
is the principles of teaching adult learners.
is the techniques that enhance learning among older adults.
generation Y
refers to young adults who graduated from college in the late 1990's
generation X
refers to those born between 1961 and 1981.
ability to read and write
cannot read or write
functionally illiterate
posses minimal literacy skills, which means they can sign their name and perform simple mathematical task, but read at or below a ninth grade level.
optimum learning
takes place when an individual has a purpose for acquiring new information. the desire for new learning may be to satisfy intellectual curiosity, to restore indepence, to prevent complications, or to faciltate discharge and return to the comfort of home. other, less desirable reasons for learning are to please others and to avoid critism.
ace inhibitors, Lisinopril medication for hypertension
dizziness, headache, and hypotension are all common adverse effects of lisinopril and other ace inhibitors.
medical record, also referred to as health records or clients records
are written collections of information about a persons heath problems, the care provided by health practitioners, and the clients progress.
binder or folder that promotes the oederly collection, storage, and safekeeping of a persons medical records.
charting, recording, or documenting
process of writing information on the health agency forms.
quality assurance, continous quality improvement, or total quality improvement
an agencys internal process for self improvement to ensure that the level of care reflects or exceeds established standards.
inspectors who examine client records, survey medical records to determine if the care provided meets established criteria for reimbursement, indocumented, incomplete, or inconsistent documentation of care may result in a denial of payment.
source oriented record
organized according to the source of documented information. this type of record contains seperate forms on which physicans, nurses, dietitians, physcial therepists, and so on make written entries about their own specific activities in relation to the clients care.
problem oriented record
organized accordingly to the clients health problems. they contain 4 major componenets: the data base, the problem list, the plan of care, and the progress notes.
narrative charting
style of documentation generally used in source oriented records. there is no established format for narrative notations; the content resembles a log or journal.
soap charting
documentation style more likely to be used in a problem oriented record. s=subjective data, o=objective data, a=analysis of the data, and p=plan of care.
focus charting
modified form of the SOAP charting, focus charting follows a DAR model, D=data, A=action and R=response.
pie charting
method of recording the clients progress under the headings of problem, intervention, and evaluation. when nurses use pie method, they document assessments on a separate form and give the clients problem a corresponding #.
minimum disclosure
information necessary for the immediate purpose only, in other words, it is inappropriate to release the entire healther record when only portions or isolated pieces of info. is needed.
benefical disclosure
exemptions when agencies can release private health info. without the clients prior authorization. excemptions for benefical disclosure: reporting vital statistics (birth and deaths), informing the food and drug administration of adverse reactions to drugs, disclosing info. for organ or tissue donation, notifying the public health department about communicable diseases.
nursing care plan
is a written list of the clients problems, goals, and nursing orders for the client care. It promotes the prevention, reduction, or resultion of health problems.
is a quick reference for current info. about the client and his or her care. The kardex forms for all the clients are kept in a folder that allows caregivers to flip from one to another. The kardex is used to: locate client by name and room #, identify each clients physician and medical diagnosis, serve as a refernece for a chage of shift report, serve as a guide for making nursing assignments, specify the clients code or DNR, check quickly on a clients diet, etc.....
is a form of documentation in which the nurse indicates with a check mark or initials the performace of routine care. this charting technique is especially helpful when the care is similar each day and the clients condition does not differ much for extended periods.
flow sheet
is a for of documentation with sections for recording frequently repeated assessment data.
Some flow sheets provide room for recording #'s or brief descriptions.
those practices that decrese or eliminate infectious agents, their reservoirs, and vehicles for transmission
medical asepsis
those proactices that confine or reduce the numbers of microorganisms. It is also called cleaned technique.
infection control precautions
are physical measures designed to curtail the spread of infectious diseases. they are essential when caring for clients.
standard precautions
are measures for reducing the risk for microorganism tansmission from both reconized and unreconized sources of infection.
incubation period
infectious agent reproduces, but there are no recongnizable symptoms. The infectious agent may however, exit the host at this time and infect others
prodromal stage
initial symptoms appear, which may be vague and nonspecific. They may include mild fever, headache, and loss of usual energy.
acute stage
symptoms become servere and specific t the tissue or organ that is affected, for example tuberclulosis is manifested by respiratory symptoms.
surgical asepsis
is bases on the underlying princle that equipment and area that are free of microorganisms must be protected from contamination.
hand washing
is the most frequentl used medical asepic practice in the health care agencies. It is the most effective way to prevent nosocomial infections.
aerobic microoganism
a microbe that requires free oxyen in order to exist
anaerobic microoganism
depends on an enviroment without oxygen to survive.
the reservoir
is a place on which or in which microorgasims grow and reproduce
the host
a person or animal on which or in which microogasims lives