NSG 212 exam 1

What are the phases of the nursing process?

Assessment, diagnosis, planning outcomes, planning interventions, implementation, and evaluation

What is assessment?

First step in the nursing process; gathering of data

What is diagnosis?

Second step in the nursing process; identifying the client's health needs

What is planning outcomes?

Deciding on goals which you want to achieve with your nursing activities

What is planning interventions?

Choose interventions to help the client achieve stated. goals

What is implementation?

Action phase when you carry out or delegate actions you previously planned

What is evaluation?

Final phase; judge whether your actions have successfully treated or prevented the client's health problems

What is the difference between medical and nursing assessments?

Medical focuses on disease and pathology; nursing focuses on the client's responses to illness

Can a nurse delegate assessments?

NO, a professional nurse must perform the assessment portion of the nursing process

What can a nurse delegate?

Any task that does not require assessment, interpretation, or independent decision making during its performance or at completion

Where can information be collected from during assessment?

The patient, secondary sources (charts or other healthcare providers), interpreting information, and validating the information (supporting subjective findings)

What is subjective data?

What the patient/others say; "I feel..."

What is objective data?

What can be observed or measured (BP, temp, pulse, lung sounds, lacerations, urinalysis, facial expressions)

What is primary data?

Data obtained directly from the client

What is secondary data?

Data obtained secondhand through the medical record or another person

What are the types of assessment?

Initial (by RN), ongoing (back through system), comprehensive (entire body), focused (specific care about a specific complaint), or special needs

What is special needs assessment?

Nutritional, pain, cultural, spiritual health, and psychosocial

What are the steps to making a nursing diagnosis?

Made during the analysis phase, RN reviews clients assessments, formulates a plan, find more information id necessary (ex. reassess the client), and create a plan of care

What are the prioritized nursing problems?

Maslow's Hierarchy of Need and the ABCs (airway, breathing and circulation!)

What are the different problem urgencies?

High priority (life threatening, ex. GSW), medium priority (not a direct threat to life but may cause destructive physical or emotional changes, ex. increased risk for falls), and low priority (requires minimal supportive nursing intervention)

What are the types of nursing diagnosis?

Actual (__ related to __ because of __), wellness (no evidence, there is no problem), and potential (risk: "think he is going to fall because he drinks and takes benadryl")

What is the diagnostic statement?

PES! P (problem), E (etiology/related factors), and S (signs and symptoms)

What is a client goal?

Changes in client health status you hope to achieve

What is a nursing-sensitive outcome?

One that can be influenced by nursing interventions

What are long-term goals?

Goals to be achieved over a longer period of time (week, month, or more --> at HOME)

What are short-term goals?

Goals to be achieved within a few hours or days (hours or overnight --> in the HOSPITAL)

What are the components of a goal statement?

Subject, action, performance criteria, target time, and special conditions

What is Bloom's psychomotor domain of learning?

Involves physical movement (do, increase, move)

What is Bloom's cognitive domain of learning?

Involves knowledge and intellectual skills

What is Bloom's affective domain of learning?

Involves emotions, feelings, values, and attitudes

What are the 3 types of nursing interventions?

Independent (do not require supervision or direction by others; nurse-initiated), dependent (require written orders or supervision of another health professional), and interdependent (require nurse to collaborate or consult with another health professional before carrying out the action

Why is evaluation critical?

It identifies if the problem is resolved, in the process of being resolved, or unresolved and how to make changes to goals or care to meet the goals outcomes

What is evidence based practice (EBP)?

The integration of clinical expertise, best research evidence, and patient values and preferences

Why is EBP important?

Client outcomes improved nurses experience increased professional satisfaction, the cost of health care is often lowered, and nurses are provided a framework to execute clinical judgement

What is the inquiry in nursing?

The desire to clarify complex issues through research and trends that influence client outcomes

What is the scientific method?

A research process whereby new knowledge is applied to nursing practice and outcomes are re-evaluated

What is empirical data?

Assessments and measurements used to discover new knowledge that can be applied to larger groups of clients

How can nursing processes be used as a tool for EBP?

This process helps to determine if the new interventions are relevant and successful in improving client outcomes

What are clinical guidelines?

Methodical statements that focus on a specific plan of care for specific client population

What is documenting/reporting?

Factual, legal documents that reflect the standards of nursing care and practice with data, client outcomes, and accuracy

What does HX stand for?

History (medical/family)

What are the ethical and legal considerations of documentation?

Confidentiality of all patients, protection of a client's record, and using records for education and research responsibly

What must the IT personell install to protect a server from unauthorized access?

A firewall

What are the purposes of client records?

Communication, planning client care, auditing health agencies, research, education, reimbursement, legal documentation, and health care analysis

What is an occurrence/incident report?

A formal record used to create safer practices used by risk management, reports all errors (not part of a health record!)

What are common reasons for incidence reports?

Medication errors, falls, needle stick injury or staff injury, visitor injury, unsafe staffing situation, lack of supplies, inadequate response to emergency situation, and incorrect procedure

What are the 4 common issues in malpractice caused by inadequate documentation?

Not charting the correct time when events occurred, failing to record verbal orders/having them signed, charting actions in advance to save time, and documenting incorrect data

What are source-oriented records?

Each department/discipline has their own section to make notations, record particular information, and narrative charting

What are problem-oriented medical records?

Data is arranged according to the client's problem, health teams contribute to the progress of the analysis, and encourages collaboration

What are the 4 basic components of problem-oriented medical records?

Database, problem list, plan of care, and progress notes

What is charting by exception?

Charting only abnormalities or significant findings in narrative form

What is the biggest problem of charting by exception?

Inadvertent omissions, people forget to chart their actions

What does SOAPIER represent?

Subjective data, objective data, assessment, plan, interventions, evaluation, and revision

What is PIE charting in the nursing process?

Categorizing information into problems, interventions, and evaluations

What is focus charting?

Focuses on the client concerns and strengths into a DAR format (data, action, and response)

What is an admission database?

Documentation of the chief complaint/reason for admission, physical assessment data, vital signs, allergies, meds, ADL status, and data about support systems of the client

What are Kardexes?

The summary of the patient data on a portable index or computer-generated form for easily accessible data; organized into sections of allergies, code status, daily treatments, diagnostic procedures, physical needs, and stated goals

What is a flow sheet?

Graphic record of abbreviated aspects of the patient's condition (e.g., vital signs, routine aspects of care, i&o, medication, skin assessment)

What does PO stand for?

By mouth/oral

What are nursing discharge/referral summaries?

Provide information about the patient's hospitalization and their future care

What is long-term care documentation?

Based on professional standards, federal and state regulations, policies of health care agency

What is home care documentation?

Home health certifications and plan-of-treatment forms that include updated medical and patient information

What is a surgical safety checklist?

Goals which decrease errors, increase teamwork, and increase communication

How should units be written on medical documents?

Unit

How should international units be written on medical documents?

International units

How would QD/daily be written?

Daily

How should 4.0 mg be written?

4 mg

How should .4 mg be written?

0.4 mg

How should MS/MSO4 be written?

Morphine sulfate (pain) or magnesium sulfate (other)

What are general guidelines for recording?

Accuracy, sequence, and appropriateness

What is the documenting ABC?

Accurate, Bias-free, Complete, Detailed, Easy to read, Factual, Grammatical, and Harmless (legally)

How should change-of-shift reports be given?

Communicated in a consistent manner with basic identifying information using the SBAR tool

Which way to communicate change-of-shift reporting is best?

Two way, face-to-face communication with written support tools and content which captures intention

What are nursing rounds?

Procedures in which 2 or more nurses visit selected patients at the bedside to obtain information that helps plan nursing care, to provide patients the opportunity to discuss their care, and to evaluate the nursing care the patients have received

What is included in a handoff report?

Client demographics, medical history, assessment findings, treatments, upcoming procedures/diagnostics, restrictions, plan of care, and concerns

What does CUBAN, a standardized format in reporting, mean?

Confidential, Uninterrupted, Brief, Accurate, and Named nurse

What does PACE, a standardized format in reporting, mean?

Patient/Problem, Assessment/Actions, Continuing/Changes, and Evaluation

What does SBAR, a standardized format in reporting, mean?

Situation, Background, Assessment, and Recommendations

What is the best way to provide telephone orders?

Concise and accurate, everything written down beforehand, have the primary care provider verbally acknowledge the read-back and counter-sign the provider in 24 hours

What is a care plan conference?

A meeting of a group of nurses to discuss possible solutions to certain problems of a client

What are health informatics?

The intersection of info science, computer science, and health care which deals with optimizing use of health information (tele-health, e-health records)

What are the benefits of healthcare informatics?

Minimizing errors with EHRs that use computerized functions (barcoding, alerts/reminders for patient care, provider order entries, and medication reconciliation)

What are some issues surrounding EHRs?

They bring potential risks to privacy and confidentiality

What does HIPPA stand for?

Health Insurance Portability and Accountability Act

What is the purpose of HIPPA?

To establish standards for protection and disclosure of patient health information

When is patient authorization not needed?

In situations where the law requires it including reports of abuse, neglect, domestic violence; when it is needed to facilitate organ donation; when t may lessen a serious threat to a person or the public; when the law requires it for reporting information (HIV, STDs)