NCM 101: Fundamentals of Nursing Finals Reviewer

Flashcards covering the key terms and definitions from the NCM 101 Fundamentals of Nursing lecture notes.

Nursing (American Nursing Association, 2003)

The protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities and populations.

Nursing (Florence Nightingale)

Act of utilizing the ENVIRONMENT of the patient to assist him in his recovery.

Nursing (Virginia Henderson)

The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge, and to do this in such a way as to help him gain independence as rapidly as possible.

Promoting Health and Wellness

A process that engages in activities and behaviors that enhance quality of life and maximize personal potential. Activities that enhance lifestyle includes improvement of nutrition and physical fitness, preventing drug and alcohol misuse, restricting smoking, and preventing accidents and injury at home and workplace.

Preventing Illness

Goal of illness prevention program is to maintain optimal health by preventing disease, which includes immunizations, prenatal and infant care, and prevention of STIs.

Restoring Health

Focuses on the ill client and it extends from early detection of disease through helping the client during recovery period. Activities include providing direct care to the ill patient, performing diagnostic and assessment procedures, teaching clients about recovery activities and rehabilitating clients to their optimal functional level.

Caring for Dying

Comforting and caring for people of all ages who are dying which includes helping clients live as comfortably as possible until death and helping support persons to cope with death.

Assessment

Collect comprehensive data pertinent to the patient’s health or situation.

Diagnosis

Analyzes the assessment data to determine the diagnose or issue.

Outcome Identification

Identifies expected outcomes for a plan individualized to the patient or the situation.

Planning

Develops a plan that prescribe an alternative to attain expected outcomes.

Implementation

Implements identified plan.

Evaluation

Evaluates progress towards attainment of outcomes

Quality of Practice

Systematically enhances the quality and effectiveness of nursing practice.

Education

Attains knowledge and competency that reflects current nursing practice.

Professional Practice Evaluation

Evaluates one’s own practice in relation to professional practice standards and guidelines, relevant statutes, rules and regulations.

Collegiality

Interacts with and contributes to the professional development of peers and colleagues.

Collaboration

Collaborates with patients, family and others in the conduct of nursing practice.

Ethics

Integrates ethical provision in all areas of practice.

Research

Integrate research findings into practice.

Resource Utilization

Consider factors related to safety, effectiveness, cost and impact on practice on the planning and delivery of nursing services.

Leadership

Provides leadership in the professional practice setting and profession.

Caregiver

Encompasses activities that assist the client physically a psychologically while preserving the dignity of the client.

Communicator

Communicates the identified problem of the client to other health care team.

Teacher

Nurse teaches client about their health and procedures they need to perform to restore their health.

Client Advocate

Acts to protect client. Nurse assist clients in exercising their rights and help them speak for themselves.

Counselor

Nurse provides emotional, intellectual and psychological support.

Change Agent

Nurse assists clients to make modification in their behavior.

Leader

Influences others to work together to accomplish a specific goal.

Manager

Nurse plans, gives direction, develops staffs, monitors operation, gives rewards fairly and represents both staff members and administration as needed.

Case Manager

Works with multidisciplinary health care team to measure the effectiveness of the case management plan and monitor outcomes.

Researcher

Nurse participates in scientific investigation and uses research findings to improve client care.

Collaborator

Nurse works in combined effort with all those involve in care delivery.

Nurse Practitioner

Nurse who has advanced education & graduated from a nurse practitioner program. Employed in health care agencies or community-based settings Deals with non-emergency acute or chronic illness & provide primary ambulatory care.

Clinical Nurse Specialist

Has an advanced degree or expertise and is considered to be an expert in a specialized area of practice. Provides direct client care, educates others, conducts research, and manages care.

Certified Registered Nurse Anesthetist (CRNA)

Completed advanced education in an accredited program in the anesthesiology. Carries out pre-op and post-op visits and assessment. Administers general anesthesia for surgery under the supervision of a physician prepared in anesthesiology and also assesses the postoperative status of clients.

Nurse-Midwife

RN who has completed a program in midwifery and gives prenatal & postnatal care and manages deliveries in normal pregnancies. May also conduct pap smears, family planning and routine breast exams.

Nurse Researcher

Investigates nurse problems to improve nursing care and to refine and expand nursing knowledge. Employed in academic institutions, teaching hospitals and research center, and usually has advanced education at the doctorate level.

Nurse Administrator

Manages client care, including the delivery of nursing services. Functions include Budgeting, Staffing, and Planning programs.

Nurse Educator

Responsible for classroom and clinical teaching.

Nurse Entrepreneur

Manages health-related businesses

Novice (Stage I)

No experience (student nurse). Performance is limited, flexible, and governed by context-free rules and regulations rather than experience.

Advanced Beginner (Stage II)

Demonstrates marginally acceptable performance. Recognizes meaningful “aspects” of a real situation and experienced enough real situations to make judgements about them.

Competent (Stage III)

2-3 years of experience, demonstrates organizational and planning abilities and differentiates important factors from less important aspects of care. Coordinates multiple complex care demands.

Proficient (Stage IV)

3-5 years’ experience, perceives situations as a whole rather than in terms of parts and uses maxims as guides for what to consider in a situation. Has holistic understanding of the client, which improves decision making and focuses on long term goal.

Expert (Stage V)

Performance is fluid, flexible, and highly proficient. No longer requires rules, guidelines, or maxims to connect an understanding of the situations to appropriate actions. Inclined to take certain action because “it felt right”.

Verbal Communication

Uses spoken or written words

Non-Verbal Communication

Uses gestures, facial expression, posture/gait, body movements, physical appearance, eye contact and tone of voice.

Sender

Is the person who encodes and delivers message.

Message

The content of the communication, may contain verbal, nonverbal, and symbolic language.

Receiver

The person who receives and decodes the message.

Channel

Means conveying and receiving messages through visual, auditory and tactile senses

Response/Feedback

Message returned by the receiver to the sender.

Simplicity

Use commonly understood words.

Pace and Intonation

Modifies the feeling and the impact of the message.

Clarity and Brevity

Message is direct and simple.

Timing and Relevance

Require choice of time and consideration of client’s interest and concern.

Adaptability

Messages need to be altered in accordance with behavioral cues from the client.

Credibility

Means worthiness of belief, trustworthiness, and reliability.

Humor

Used to help clients adjust to difficult and painful situation.

Documentation

Written or computer-based and serves as a permanent record of client’s information and progress care. Formal, legal document that provide evidence of a client’s care.

Source-Oriented Medical Record (SOMR)

Each person or department makes notations in a separated section of client’s chart. Specific information is easier to locate.

Problem-Oriented Medical Record (POMR)

Data about the client are recorded and arrange according to the sources of the information. Records integrates all data about the problem, gathered by members of health team.

Components of SOMR

Admission sheet, Fact sheet, Medical history and physical examination and sheet, Diagnostic finding sheet, TPR graphic sheet, Doctor’s treatment and order sheet, Therapeutic sheet, Special flow sheet, Medication record, Nurses notes, Client discharge plan and referral summary, Initial nursing assessment

Database

Contains all information from the patient when he first entered the agency. It includes nursing assessment, physician’s history, social and family data, result of physician’s examination.

Problem Lists

Contains all the aspect of the person’s life requiring health careKept in front of the chart; Problems are listed in the order, which they are identified; Continually updated as new problems are identified and others are resolved.

Initial Lists of Orders or Plan of Care

Made with reference to the active problems and are generated by the person who lists the problem.

Progress Notes

Which includes nurses narrative notes (SOAPIE, SOAPIER)

SOAPIE

Charting method commonly used for template nursing notes. Subjective, Objective, Assessment, Plan, Implementation, Evaluation

Subjective

Documentation that should include what the patient says or information that only the patient can provide personally. Example: perceived pain, symptoms such as feelings of numbness or tingling, medical or family history, and allergies.

Objective

Record what the nurse observes, hears, sees, and feels during the patient assessment. The type of assessments performed is dependent on the facility the patient is in (inpatient versus outpatient) and on the medical diagnoses and patient complaints.

Analysis

After subjective and objective assessment data is collected, the nurse should make an initial analysis of the patient’s condition and identify any appropriate nursing diagnosis.

Plan

Once an initial nursing diagnosis has been identified, the nurse must create a plan of action which may include repositioning, requesting pain medication from the providers, applying oxygen per protocol, or providing emotional support.

Implementation

After the plan of action has been decided, the actions (intervention) should be put into motion.

Evaluation

Finally, the outcomes of the interventions need to be evaluated. The evaluation often includes reassessing the patient.

Kardex

Provides a concise method of organizing and recording data about the client, making information readily accessible to all members of the health care team. May be written in pencil to ease in recording frequent change in details of client care.

FDAR (Focus, Data, Action, Response) Charting

Charting method nurses use to help focus on a specific patient problem, concern or event. It is geared to save time and decrease duplicate charting and is often found to be easier to read by other professionals.

Focus

The subject/purpose for the note. The focus can be: Nursing diagnosis, event (admission, transfer, discharge teaching etc.) and patient event or concern (code blue, vomiting, coughing).

Data

Written in the narrative and contains only subjective (what they patient says and things that are not measurable) and objective data (what you assess/findings, vital signs and things that are measurable).

Action

In this section, you are going to write here what you did about the findings you found in the data part of the note. This includes your nursing interventions (calling the doctor, repositioning, administering pain medication etc.)

Response

Where you write how the patient responded to your action. Sometimes you won’t chart the response for several minutes or hours later.

SBAR (Situation, Background, Assessment, Recommendation)

A verbal or written communication tool that helps provide essential, concise information, usually during crucial situations. In some cases, SBAR can even replace an executive summary in a formal report because it provided focused and concise information.

Situation

What prompted the communication.

Background

Pertinent information, relevant history, vital signs.

Assessment

The nurse’s assessment of the situation.

Recommendation

Request for prescription or action from the HCP.

Reporting

Takes place when two or more people share information about client care, either face-to-face or via telephone.

Change-of-Shifts Report

For continuity of care of clients by providing quick summary of health care needs and details of care to be given. EX: KARDEX.

Telephone Reports

Provide clear, accurate and concise information including date and time, name of the person giving the information, subject of the information received, and name and signature of the receiver.

Telephone Orders

Only RN’s may receive telephone orders. Another RN should listen in another telephone line to countercheck the details and the order should be countersigned by the physician who made the order within the prescribed period of time (within 24 hours).

Assessment in the Nursing Process

Is a systematic and continuous collection, organization, validation and documentation of data about the client health status which helps to establish a database.

Nursing Diagnosis

Is a statement of potential or actual alteration in the client's health status

Planning in the Nursing Process

Deliberative, systematic phase of nursing process that involves decision making and problem solving.

Implementation in the Nursing Process

Doing and documenting the activities that are specific nursing actions needed to carry out the interventions (or nursing orders).

Evaluation in the Nursing Process

Collecting data, comparing data and relating nursing activities to outcomes.

Primary Prevention

To encourage optimal health and to increase the person’s resistance to illness. Seeks to prevent a disease or a condition at pre-pathologic state.

Secondary Prevention

It is also known as health maintenance. Seeks to identify specific illnesses or conditions at an early stage with prompt intervention to prevent disability.

Tertiary Prevention

Occurs after a disease or disability has occurred and the recovery the proves has begun. Intent is to halt the disease or injury process and assist the person in obtaining an optimal health status.

Core Temperature

Temperature of the deep tissues of the body such as abdominal and pelvic cavity (rectal, oral, tympanic).

Surface Temperature

Temperature of skin, SQ tissue and fat which rises and falls in response to the environment (axillary).