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34 Cards in this Set
- Front
- Back
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What do we do during diagnosis? |
analysis of pt data to identify strengths and health problems that independent nursing intervention can prevent |
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Why is care planning important ? |
-central source of pt information -benefits for pts -benefits for healthcare team -nurses role |
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What are some problems in planning care? |
-failure to involve pt/or family -insufficient/inaccurate data -outcomes to broad; unrealistic -failure to evaluate |
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What are types of data? |
-objective data -subjective data |
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Objective data? |
-observable and measured -can e seen, heard |
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Subjective data? |
based on how they feeling |
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Medical diagnosis? |
-physician -identifies disease/injury |
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Nursing diagnosis? |
-nurses -identify pts responses to disease/injury; risks -we look at symptoms |
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What does SMART goals stand for? |
-Specific: to problem -Measurable -Attainable by pt -Relevant tp pt -Time-bound: have a date |
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What is a nurse-initiated intervention? |
-nurse prescribed, from assessment data or identified pt needs -follows scope of nursing practice |
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collaborative intervention? |
performed jointly with healthcare providers -ex involve the therapist, dietitians |
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What is delegation? |
transfer of responsibility for the performance of an activity to another individual while retaining accountability for the outcome -RNs-LPN- CNA/CMA or Unlicensed Assistant |
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What is PIE charting? |
system is unique in that it does not develop a separate care plan. Problem Intervention Evaluation |
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What does SBAR stand for ? |
Situation Background Assessment Recommendation |
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Assertive behavior? |
ability to stand up for oneself and others using ope, honest and direct communication |
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What are four basic components for assertive behavior? |
1. confident, open body posture 2. eye contact 3. use concise, clear "I" statements 4. the ability to share effectively one's thoughts, feelings, and emotions |
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What are some ways to give reports? |
-face to face -phone convo -written message -computer messsage |
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What are a few things to put in a change shift report? |
-changes in pts status during my shift and the previous 24 hrs -pertinent lab, radiology, or other therapy -irregular data or data that is now normal -pain level and management |
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What are some things to say in a bedside report? |
-med changes and how well pain meds work -diet, changes, likes, dislikes -family and pt being involved in report |
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why would us as nurses need to delegate? |
-can't do all the work -staffing mixes have changed -must be able to use staff available to get the care delivered |
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What is autocratic leadership? |
directive leadership or authorian leadership, involves the leader assuming control over the decisions and activities of the group |
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What is transactional leadership? |
-based on a task-and-reward orientation -team members agree to a satisfactory salary and working conditions in exchange for commitment and compliance to their leader |
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What is transformation leadership? |
-can create to revolutionary change -often described as charismatic, transformational leaders are unique in their ability to inspire and motivate others |
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What is laissez-faire leadership? |
-nondirective leadership, the leader relinquishes power to the group, such that an outsider could not identify the leader in the group. -this approach encourages independent activity |
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What do medical records contain? |
-physicians orders and progress notes -consultation reports -nursing flow sheets -laboratory, therapy reports -Discharge or transfer reports -pts care plan -discharge and transfer reports |
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Types of physician orders? |
-written orders -telephone orders -faxed orders -verbal orders |
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What do we do as nurses for telephone orders? |
-verify correct info by repeating order the the physician before call ended -we receive and transcribe -physician must sign within 24 hrs |
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What happens during verbal orders? |
-allowed only in medical emergencies -read back order to verify accuracy |
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What are source-oriented pt care? |
-data organized chronologically -seper sections of data section in chart -easy to find data -narrative nursing notes written chronologically |
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What are some methods of documentation? |
-POMR -SOAP -PIE -Focused |
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What is Problem-Oriented Medical Record? |
POMR is organized around a pts problem rather than around sources of information |
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What are Subjective, Objective, Assessment, Plan documentations? |
Soap is used most often by physicians when writing a progress note on the pt |
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What is PIE charting system? |
the plan of care is incorporated into the progress of notes, which identify problems by number |
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What is focused charting? |
-focus of care is on the pt and pt concerns -holistic emphasis -uses format of Data, Action, and Response |
