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11 Cards in this Set

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  • Back
Utilize a basic working knowledge of confidentiality and its application to nursing
defined as providing only that tinformation needed to provide care for the client to other health professionals directly involved in the care of the client
*it meanst that nurse must have express permission to share private information from the nurse-client relationship, unless the withdrawal of information would result in harm to the client or someone else, or in cases whre abuse is suspected.
*Nurse has legal responsibility to ensure agains invasion of privacy related to the ff:
*Releasing information about the client to unauthorized parties
*Unwanted visitations in the hospital
Discussing client problems in public placesor what people not directly involved pt care
*Taking pictures of the client without consent or using the photographs without the client's permission.
*Publishing data about a client in any way that makes the client identifiable without the client's permission
Stage in Nursing Process
1. Assessment-gather and analyzing data about the client from the client, family and significant others, and relevant health care providers. Collect data about: the current problem which the client seeks treatment, client's perception of his or her health patterns; and presence of other health risk and protective factors, client's past history
*Subjective data-client's perception of data, and what client's said
*Objective-are directly observe
2) Diagnosis-developing relevant nursing diagnoses
a)identify the problems or alterations in the client's health
b)causative or risk factor
c) clinical evidence
*Outcome-the change in health status bet. a baseline time point and final time point
Stage in Nursing Process
3. Planning
-planning of intervention (action, treatment, nursing care)
*Nursing care planning
*Goal setting
*Priority Setting
*Matching interventions to unique client needs
4. Intervention
-implementation of the intervention
-administration of care
-delegation of care
-Provision of nursing care by:
*Administering a medication or treatment prescribed by a physician
*administering medication or treatment prescribed by a physician
*Health education
*Coordinating services
5) Evaluation
-evaluation of all interventions
-present response
-validity of future care
Nursing Practice Act
legal document developed at the state level that define professional nursing's scope of the practice and outline nurses' rights, responsibilities,and licensing requirements in providing care to individual clients, families, and communities
Scope of Practice
refers to the legal and ethical boundaries of a nurse's competence are based on the nurse's education, special skill training, supervised experience, state and national professional credentials, and appropriate prefessional experience
Define Inform Consent and the three elements
defined as giving the client enough information wn which to base a knowledgeable decision is another aspect of legal considerations in the nurse client relationship
Three element
1)Consent must be voluntary
2)the client must have full disclosure about ther risk, benefits, cost, potential side effects or adverse reactions,and other alternatives treatment
3) the client must have the capacity and competency to understand the information and to make an informed choice
Advance Directive
is a written statement or document executed by a competent adult that is designed to provide medical personnel, family members,a nd others with information as to the person's wishes regarding the nature and extent of medical care to be provided in the future should he or she lose decision-making capacity
nurses are responsible for careful,accurate documentation of nursing assessments, the care given, and the behavioral responses of the client.Failure to document in written form any of these elements means the action were not taken
HIPAA (Health Insurance Portability and Accountability Act)
*designed to protect the privacy of client records.
*all providers hould clients with a written notice of their privacy practices and procedures.
is a broad term used to describe all of the factors that influence how the message is perceived.
Example 1: play fighting observed in animals and children
Example 2: during conversation, the nurse conveys a verbal message of caring to her Caucasian, middle-class client by making appropriate, encouraging responses, and a nonverbal message by maintaining direct eye contact; presenting a smooth face without frowning; and using a relaxed fluid body posture
is the use of body space, or the individ\ual's perception of what is a proper distance to be mainta\\\\\\\\\\\\\\\\\\\
ined between the person's body or possessions and others.