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68 Cards in this Set
- Front
- Back
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Known as the lady with the lamp.
Theory - Patients Environment |
Florence Nightingale
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Self Care Deficit theory. Nursing care becomes necessary when the patient cannot take care of themselves.
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Orem
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Transcultural theory
Sunrise Theory Caring is the central focus |
Leininger
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Adaption theory based on physiological, psychological, sociological, and independence- dependence adaptive models
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Roy
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National Assoc. of Practical Nursing Education
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NAPNE
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Established home health care
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Lavina Dock
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Founded the NFLPN in 1949, in New York
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Lillian Kuster
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National Federation of Licensed Practical Nursing
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NFLPN
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Nursing
Patient Health Environment |
4 Bases of all nursing model for care
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Physiological
Safety Love and Belongingness Esteem Self Actualization |
Maslow's Hierarchy of needs
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Provides specific services to the patient under direct supervision of a licensed physician or dentist, or RN
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LPN
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Acquire specialize knowledge or skill
Graduate of a state approved practical nursing program Take and pass NCLEX-PN Acquire state license to practice |
Objectives of vocational nursing education
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Competency in a specific "area" in nursing
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Certification
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1st school to train practical nurses
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Ballard School
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absence of disease or abnormal conditions
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Health
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prevention of disease and maintenance of good health
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medicine
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pertaining to whole considering all factors
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holistic
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father of medicine
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Hippocrates
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Private duty, school nursing, industrial nursing, nurse anesthesia, and nurse-midwifery
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Contemporary Nursing
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A dynamic state of health in which an individual progresses toward a higher level of functioning, achieving an optimal balance between internal and external environment
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Wellness
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A diminished or impaired state of health
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Illness
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Document that outlines the individual needs of the patient and the approach of the health care team in meeting these needs
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Care plan
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a person who takes care of the sick
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nurse
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Developed a program at Columbia University to train and develop teachers of nursing
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Isabelle Hampton Robb and Mary Adelaide Nutting
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First laws were established in 1903
Protect the public North Carolina, New Jersey, and New York were first states |
Nursing Licensure
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I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession, and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling. With loyalty will I endeavor to aid the physician, in his work, and devote myself to the welfare of those committed to my care.
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The "Nightingale Pledge"
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a set of learned values, beliefs, customs, and practices that are shared by a group and are passed from one generation to another.
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Culture
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shares many characteristics with the primary culture but has characteristic patterns of behavior and ideals that distinguish it from the rest of a cultural group
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Subculture
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Understanding and integrating the many variables in cultural and subcultural practices into all aspects of nursing care
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Transcultural Nursing
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A group of people who share a common social and cultural heritage based on shared traditions, national origin and physical and biological characteristics
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Ethnicity
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A group of people who share biologic physical characteristics
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Race
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A person believes that the beliefs and practices of his or her particular culture are best.
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Ethnocentrism
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men make most of the decisions.
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Patriarchal
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women make most of the decisions.
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Matriarchal
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Western cultures have almost universally used the biomedical method of treating illness and maintaining health.
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Biomedical health belief system
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This belief system encompasses many different traditions in cultures around the world. It often includes native healers who use a variety of methods in treating disorders.
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Folk health belief system
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This system operates on the premise that natural forces govern everything in the universe, including human beings and their illnesses. Methods are used to manipulate the environment to improve health.
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Holistic health belief system
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North American Nursing Diagnosis Association
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(NANDA)
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Basic Guidelines for Documentation
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quality and accuracy of the nurse’s notes
Excellent writing skills Information recorded in the chart should be clear, concise, complete, and accurate. The registered nurse (RN) has primary responsibility for the initial admission nursing history, physical assessment, and development of the care plan based on the nursing diagnoses identified. |
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Charting Rules
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All sheets should have the correct patient name, date, and time. (TIME IS VITAL)
Use only approved abbreviations and medical terms. Be timely, specific, accurate, and complete. Write legibly. Follow rules of grammar and punctuation. Fill all spaces; leave no empty lines. Chart consecutively, line by line. Do not indent left margin. Chart after care is given, not before (never in advance) Chart as soon and as often as possible. Chart only your own care, observations, and teaching; never chart for anyone else. Use direct quotes when appropriate. Describe each item as you see it. Be objective in charting; write only what you hear, see, feel, and smell. Chart facts; avoid judgmental terms and placing blame. Sign each block of charting or entry with full legal name and title. Write only what you observe, not opinions. When the patient leaves a unit, chart the time and method of transportation on departure and return. Chart all ordered care as given or explain deviation. Note patient response to treatments and response to analgesics or other medications Use only hard-pointed, permanent black ink pens; no erasures or correcting fluids are allowed on charts. If charting error is made, draw one line through the faulty information, mark error, initial if required, and make the correct entry. When making a late entry, note it as a late entry and then proceed with your notation. Follow each institution’s policy and procedures for charting. Avoid using generalized empty phrases such as “status unchanged” or “ had a good day.” If order is questioned, record that clarification was sought. |
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Charting by exception (CBE)
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is a format used by several facilities in which the beginning shift assessment is documented and only additional treatments, changes in the patient’s condition, and other pertinent data are recorded, data that deviates from the norm for that patient.
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Five Basic Purposes for Written Records
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Written communication
Permanent record for accountability Legal record of care Teaching Research and data collection |
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Auditors
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People appointed to examine patients’ charts and health records to assess quality of care
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Peer Review
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An appraisal by professional co-workers of equal status
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Quality Assurance/Assessment/Improvement
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An audit in health care that evaluates services provided and the results achieved compared with accepted standards
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Diagnosis Related Groups (DRGs)
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are classification systems utilized for reimbursement by Medicare, Medicaid, and insurance companies.
A system that classifies patient by age, diagnosis, and surgical procedure; producing 300 different categories used in predicting the use of hospital resources, including length of stay |
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Nurse’s Notes
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The form on the patient’s chart on which nurses record their observations, care given, and the patient’s responses
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Traditional Chart
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Chart is divided into specific sections or blocks.
Typical sections are -admission sheet -physician’s orders -progress notes -history and physical examination data -nurse’s admission information -care plan and nurse’s notes -graphics -laboratory -x-ray reports. |
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Narrative charting
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is a descriptive format of documentation
Written in an abbreviated story form Includes the basic patient need or problem data, whether someone was contacted, care and treatments provided, and the patient’s response to treatment |
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Problem-Oriented Medical Record (POMR)
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This is based on the scientific problem-solving system or method.
Principal sections are database, problem list, care plan, and progress notes. |
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Database
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The accumulated data from the history and physical examination, and diagnostic tests are used to identify and prioritize the health problems on the master medical and other problem lists
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problem list
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contains possible problems for documentation
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SOAPIER is..
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an acronym to apply the Problem-Oriented Medical Record.
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SOAPIER acronym
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S – Subjective information
O – Objective information A – Assessment P – Plan I – Intervention E – Evaluation R – Revision |
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Focus charting
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Instead of problem lists, a modified list of nursing diagnoses is used as an index for nursing documentation.
This format uses the nursing process and the more positive concept of the patient’s needs rather than the medical diagnoses and problems. |
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DARE is an acronym for four different aspects of charting using the focus format
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Data (Pt says I have pain)
Action (whats ur intervention- positioned pt) Response (Did intervention work) Education( Pt teaching) |
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Kardex/Rand
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Card system used to consolidate patient orders and care needs in a centralized, concise way
Kept at the nursing station for quick reference |
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Nursing Care Plan
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Preprinted guidelines used to care for patients with similar health problems
Developed to meet the nursing needs of a patient Based on nursing assessment and nursing diagnosis |
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Incident Report
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Form that is filled out with any event not consistent with the routine care of a patient
Used when patient care was not consistent with facility or national standards of expected care Give only objective, observed information Do not admit liability or give unnecessary details Do not mention the incident report in the nurse’s notes |
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Home health care
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Documentation by home health care nurses has become the largest problem area: 50% of the nursing time is spent in documentation.
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Discharge Summary Forms
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Information is provided that pertains to the patient's continued health after discharge.
Discharge summary forms make the summary concise and instructive. |
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Omnibus Budget Reconciliation Act of 1987
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a regulation for long-term care facilities regarding standards for patient care. ( to protect patient to be sure quality care is given)
Department of health for each state governs the frequency of written nursing records Long-term care documentation supports a multidisciplinary approach in the assessment and planning process of the patients. |
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Record Ownership and Access
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Doctors Office
Hospital A lawyer can gain access to a chart with the patient’s written permission |
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Admission
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Entry of a patient into the health care facility
Be aware - Culturally sensitive The first contact with nurses is important; anxiety and fears can be lessened and a positive attitude regarding the care to be received can be initiated. Read page - 219 |
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A Patients Common Reactions from Patients
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Fear of the unknown
Loss of identity Disorientation Separation anxiety Loneliness |
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Nurse may help reduce common reactions by..
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Have a warm, caring attitude and be courteous
Show empathy Treat patients with respect Maintain their dignity Involve them in the plan of care Whenever possible, adjust hospital routine to meet their desires |
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Information usually includes
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Name, address, telephone number
Age, birth date Social Security number Next of kin Insurance company, policy number Place of employment Physician’s name Reason for admission |
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ID band Information includes
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Patient’s name
Age Admitting number Physician’s name Room number |
