203 Final Exam

telephone order

given over the phone; must read back and documented, often require co-signature by provider

verbal order from provider

given in person; often during emergencies; require read-back and timely documentation

narrative charting

story-like, chronological

charting by exception

only documented deviations from the norm

SOAP

subjective, objective, assessment, plan

PIE

problem, intervention, and evaluation

DAR

data, action, response (focus charting)

protection for research participants

involves ethical guidelines and regulations that ensure the safety, confidentiality, and rights of individuals participating in research studies. IRB approval, right to withdraw, minimal risk

teaching plans for patients and families

tailored to health literacy, includes objectives, teaching methods, evaluation of understanding

six sigma

focused on eliminating waste, mistakes, and rework: define, measure, analyze, control, improve

Lean

decreases waste, increases value added processes

fishbone diagram and Root Cause Analysis

PDCA

process for implementing change; plan-do-check-action

deontology

formalism, categorical imperative

an action to be right or wrong regardless of its consequences

beneficence

is the duty to do or promote good. at one end of the continuum is the duty to bring about positive good, and other is the duty to do no harm

nonmaleficence

is the twofold duty to do no harm and to prevent harm. both actual harm and risk of harm, as well as intentional and unintentional harm

autonomy

refers to a person’s right to choose and ability to act on that choice. based on respect for human dignity

justice

obligation to be fair. implies equal treatment of all patients

HIPPA (health insurance portability and accountability act)

was passed by congress in 1996:

• protect health insurance benefits for workers who lose their jobs

• protect coverage to persons with preexisting medical conditions

• establish standards to protect the privacy of personal health information

EMITALA (emergency medical treatment and active labor act)

requires healthcare facilities to provide emergency medical treatment to patients who seek healthcare in the ED, regardless of the ability to pay

HITECH (health information technology for economic and clinical health)

health care agencies are required to notify clients of breaches without unreasonable delay and by no longer than 60 days; enhanced enforcement provisions increase civil penalties

ADA (Americans with disabilities act)

provides protection against discrimination of individuals with disabilities; employers must provide reasonable accommodations within the work setting to allow employees with disabilities to perform their jobs

inductive vs deductive reasoning

• specific → general (ex: trends)

• general → specific (ex: applying rules or known facts)

subjective vs objective

• patients report (pain)

• observable/measurable (vital signs)

malpractice

is one source of legal liability. professional person has failed to act in a reasonable and prudent manner

libel

written defamatory statements; defamation of character

negligence

failure to perform as a reasonable, prudent person would

failure to follow standards of practice

no intent to harm is present

slander

oral defamatory statements; is the spoken or verbal form of defamation of character

stress and anxiety

physical symptoms without a medical cause; (conversion disorder, hypochondriasis)

whistleblowing

reporting unethical/illegal practices; legal protections may apply but risk of retaliation exists

PSDA (patient self-determination act)

recognizes the clients right to make decisions regarding his own healthcare, based on the information provided to them by the healthcare provider regarding the medical or surgical treatment options available

ACA (affordable care act)

access to care

incident report’s purpose

document unusual events for risk management- not part of medical record

ethical dilemmas, ethics terms, ethics committee

document unusual events (falls, errors) for risk management— not part of medical record

nonverbal communication characteristics

facial expression, posture and gait, personal appearance, gestures, touch, and territoriality, personal space

Florence Nightingale

environment theory affects patient healing

Jean Watson

science of human caring; caring means from a nursing perspective

Hildegard Peplau

Interpersonal Theory; health could be improved for psychiatric patients if there were a more effective way to communicate with them

Roy?

adaption model

Dorothea Orem

self-care deficit

standards of practice in nursing

established by ANA: assessment, diagnosis, outcomes, planning, implementation, evaluation

SBAR

communication tool: situation, background, assessment, recommendation

nurse practice acts

state-specific laws regulation nursing scope, licensing, and disciplinary actions

types of care facilities

acute: short-term treatment for severe or urgent medical conditions

long term: ongoing care for chronic illness or disabilities

assisted living: residential option provides personal care services and limited medical help

rehab: therapy-based care to recover physically or mentally

hospice: symptom treatment for life-limiting illness, terminal

home health: medical or personal care delivered at home

Nursing process elements

ADPIE: assess, diagnosis, plan, implement, evaluate

confidentiality

legal and ethical obligation to protect patient information. governed by HIPAA

medication process in the body

absorption, distribution, metabolism, excretion (ADME)

Madeleine

transcultural nursing

Patricia Benner

novice to expert theory

Virgina Henderson

need theory