PNVN 1811 Part B Study Guide

Nursing care plan

Problem -> Goal -> Action -> Result/Evaluate

Know about Incident reports

When to fill on out: a mistake happens, patient gets hurt, unusual event occurs. Used to: improve safety, document facts, protect patient and STAFF

Know processes to employ to protect the pt information, and HIPAA information using electronic equipment

Never share passwords, Log out of computers, Do not leave charts open, Only access records for patients you care for, Do not text/share patient info, Keep screens private

Who has primary responsibility for initial assessment

RN

Know the process to rectify an error on paper data tracking

Draw ONE line through error, Write “error”, Initial it, Write correct info

SATA, list of documentation bxs, pick which one is inadequate, which one will get u sued

Bad charting, charting before doing care, false documentation, etc.

Legal, course of action if you fill a prescription order from another nurse

Loss of license, sued

Need to know 2 basic purposes of written pt records

Communication between healthcare workers, Legal proof/documentation of care

Which one is not a HIPAA violation and allow me to access to the pts medical records

If you are directly caring for the patient, for treatment purposes

Know the charting requirements to prove an intervention was implemented

what you did, when you did it, patient response/outcome

S in SBAR

Situation

B in SBAR

Background

A in SBAR

Assessment

R in SBAR

Recommendation

Know the therapeutic response when you observe a pt with pain but denying it to you

I notice you seem uncomfortable. Can you tell me more?, no arguing

Def for assertive communication

Clear, respectful, direct communication.

Need to identify active listening

eye contact, nodding, focusing, repeating/paraphrasing, not interrupting

Know non verbal communication techniques to provide comfort

touch (if appropriate), sitting near patient, eye contact, calm voice, smiling, therapeutic silence

Identify what an open ended question is

Question needing more than yes/no.

Know the nursing bxs when communicating with an unresponsive pt

Speak to patient normally, Explain care before touching, Use gentle touch, Assume patient can hear you, Use sternal rub/triceps pinch only to assess responsiveness, part of brain that dies last is the part to process sounds

Understand the major problem with one way communication

No feedback or confirmation if the patient understood

Eventually will have to invade their personal space, how will I do that without stressing the pt out.

Explain before touching, Ask permission, Move slowly/calmly, Respect privacy, Maintain professionalism

Another example on assertive communication (2x total on test)

I need clarification on this medication order before giving it. (EX)

Understand why you should not use medical language with the pt

Patients might not understand. Use simple language

Understand how to enhance communication with an older adult

Lower your tone and talk in a deeper way, older people cannot hear higher frequencies, only lower frequencies, get in front of them so they can read your lips

If a nurse keeps on checking the time, what does it mean for the pt?

In a rush, negative bx

SATA, talking to someone from different culture, how can I modify my communication style if dealing from a different culture

Be respectful, Avoid assumptions, Ask preferences, Use interpreter if needed, Be aware of eye contact/touch differences, Speak clearly/simple

Understand the value of silence of therapeutic communication, what is true about it (SATA)

Silence can let people think, encourage sharing, show support, allow emotions, reduce pressure to speak