Exam 1 Funds

Steps of nursing process

• assessment

• analysis

• planning

• implementation

• evaluation

What is done in assessment of the nursing process?

collect subjective and objective data about the client

What is done in analysis of the nursing process?

interpret data to identify client needs and health problems

What is done in planning of the nursing process?

establish priorities, goals, and expected outcomes

What is done in implementation of the nursing process?

perform nursing interventions and document care

What is done in evaluation of the nursing process?

determine if goals and outcomes were achieved

Maslow’s hierarchy of needs

• physiological needs

• safety security

• love and belonging

• self-esteem

• self-actualization

Roles of nurses

• caregiver

• advocate

• educator

• communicator

• manager/coordinator

• change agent

• collaborator

What is critical thinking?

Using judgement to make safe decisions

What practice does critical thinking use?

Evidence-based practice

Before making decisions what should nurses do?

Analyze client data

How should care be prioritized?

Based on client needs

What can a nurse delegate?

• Bathing, grooming, feeding stable clients

• ambulation

• bed making

• measuring I&Os

• Routine vital signs for stable clients

What are standards of professional practice?

Expectations for nursing behavior that was created to establish expectations for professional behavior to protect the nurse and the client in the facility where clint care is practiced

What does ANA stand for?

American Nurses Association

What is ANA?

Professional organization for registered nurses

What is NPA?

Nurse Practice Act

What does NPA regulate?

Nursing practice in each state

What is scope of practice?

Duties nurses can legally perform

What does the BON do?

Enforces nursing regulations and rules

Who approves nursing education programs?

Board of Nursing

What are requirements for licensure?

Graduate with BSN and pass NCLEX

What does QSEN stand for?

Quality and Safety Education for Nurses

What is patient-centered care?

Care based on client needs and preferences

What is teamwork and collaboration?

Partnership with healthcare team and nurses aware of their own strenth adn limitations

What is evidence-based practice?

Use research and data for care decisions

What is quality improvement?

Develop plans to improve care

What is safety?

Minimize risk of harm

What is informatics?

Use technology to support client care

What does NLN stand for?

National League for Nursing

What is the purpose of NLN?

to build a strong and diverse nursing workforce to advance the health of our nation and global community

What are NLN core values?

Caring integrity diversity excellence

What are NLN graduate competencies?

Human flourishing nursing judgment professional identity spirit of inquiry

What does AACN stand for?

American Association of Colleges of Nursing

What is person-centered care?

Care focused on individual and family

What is population health?

Improve health outcomes for populations

What is a APRN?

Nurses who have earned, at a minimum, a masters degree, in nursing in one of four recognized roles

What does NCLEX-RN emphasize?

Management of care

What is licensure?

Authorization to practice nursing

What is the Nurse Licensure Compact?

One multistate nursing license

What is reciprocity?

Transfer license to another state

What are the CJAM steps?

• Recognize cues

• Analyze cues

• Prioritize hypothesis

• Generate solutions

• Take action

• Evaluate outcomes

What is done in recognize cues with the CJAM?

filter information from different sources

What is done in analyze cues with the CJAM?

link recognize cues to a client clinical presentation and establish probable client needs, concerns, and problem

What is done in prioritize hypothesis the CJAM?

established priorities of care based on the clients health problems

What is done in generate solutions the CJAM?

identify affected outcomes are related nursing interventions to ensure clients needs are met

What is done in take actions the CJAM?

implement appropriate intervention, based on nursing knowledge, priorities of care, and planned out outcomes to promote, maintain, and restore clients health

What is done in evaluate outcomes the CJAM?

evaluate a client response to nursing interventions and reach a nursing judgment regarding the extent to which outcomes have been met

What is subjective data?

Client statements

What is a plan of care?

Shared healthcare team document

What influences decision making?

Client status goals options routines education

What is delegation?

Assigning tasks to qualified individuals

What is priority setting?

Care based on urgency of needs

What is the ABCDE framework?

• Airway

• Breathing

• Circulation

• Disability

• Exposure

What oxygen saturation is expected for COPD?

88% to 92%

What does circulation assessment include?

• BP

• capillary refill time

• pulse rate

• urine output

• LOC

• changes in skin tone

What is disability assessment?

Neurologic status

What is exposure assessment?

Head-to-toe assessment while maintaining privacy

When is the survival potential framework used?

Mass casualty incidents

What color is emergent triage?

Red

What color is urgent or delayed triage?

Yellow

What color is nonurgent or minimal triage?

Green

What color is expectant triage?

Black

Which is priority acute or chronic?

Acute

Which is priority urgent or nonurgent?

Urgent

Which is priority unstable or stable?

Unstable

What is resource allocation?

Distributing staff and materials

What is rationing of care?

Missed care due to limited resources

What are professional characteristics?

• Accountability

• responsibility

• competence

• integrity

• Commitment to lifelong learning

• advocacy

What is professional commitment?

Continuing education and certification

Leadership styles

• democratic

• autocratic

• laissez-faire

• situational leadership

Democratic leadership

• Encourages participation

• Useful when cooperation and creativity are needed

Autocratic leadership

• Leader makes decisions

• Effective during emergencies and crises

Laissez-faire leadership

• minimal direction

• appropriate with experienced, self-motivated staff

What is situational leadership?

Adapt style to situation

Conflict resolution techniques

• Avoidance

• Accommodation

• Compromise

• Competition

• Collaboration (best for win-win outcomes

What are the ethical principles?

• Autonomy

• beneficence

• nonmaleficence

• justice

• fidelity

• veracity

When are restraints used?

• When less restrictive measures fail

• when provider orders it

What should be assessed when restraints are in use?

circulation, skin integrity, and need for use

What is RACE?

• Rescue

• Alarm

• Contain

• Extinguish/Evacuate

What is PASS?

• Pull

• Aim

• Squeeze

• Sweep

What are seizure precautions?

• Pad rails

• Keep oxygen suction available

• Lower client to floor if standing

• do not restrain or place objects in clients mouth

What are client identifiers?

Name, DOB, and medical record number

What is autonomy?

Respect client decisions

What is beneficence?

Act for client benefit

What is nonmaleficence?

Do no harm

What is veracity?

Tell the truth

What is fidelity?

Keep promises and commitments

What is justice?

Fair and equal treatment

What is altruism?

Selfless concern for others

What is human dignity?

Respect all individuals

What is integrity?

Honesty and ethical behavior

What is social justice?

Support health rights for all

Provisions 1-3 of the Code of Ethics

• the nurse should provide compassionate care and respect for the client

• the nurse should recognize that each client is unique, has worth, and deserves to be treated with dignity

• the nurse should be an advocate for each client's rights and needs

• the nurse should promote and protect the health and safety of each client

Provisions 4-6 of the Code of Ethics

• the nurse should demonstrate authority, accountability, and responsibility for promoting best practices

• the nurse should promote health and provide the best care they can for each client

• the nurse should maintain competence, practice the accepted values of the nursing profession, and promote a healthy and safe practice environment

• the nurse should adhere to the ethical principles of the nursing profession

Provisions 7-9 of the Code of Ethics

• the nurse should promote the profession of nursing through research and inquiry

• the nurse should participate in the development of standards of practice and policies governing nursing and health care

• the nurse should collaborate with other members of the interprofessional team to protect the rights of all individuals and decrease health disparities

• the nurse should promote integrity of the nursing profession

Ethical decision making process

• is there an ethical dilemma?

• identify ethical dilemma

• identify possible solutions

• apply ethical principles to solutions

• include all relevant individuals and factors

• decide on solution

• review decision

• put decision into action

What does EMTALA stand for and what is its purpose?

emergency medical treatment and labor act provides equal emergency care regardless of insurance or ability to pay

Three major provisions of EMTLA

• All clients must have a medical screening evaluation (MSE)

• If the client is, in fact, experiencing an emergency, the hospital must stabilize the client. If the hospital cannot provide the specific level of care of the emergency condition, they must transfer the stabilized client to a facility that can.

• In the event, the client cannot be stabilized and said ED, a physician or another qualified medical professional must verify inside off transfer, clearly indicating that the benefits of transfer outweigh the risk of transferring in an unstable client

What is HIPAA?

Health insurance portability and accountability act that provides patient privacy