Nursing I Test IV

Legal/Ethical, Informatics, Documentation, SBAR, Communication

Informatics defintion

drives innovation in healthcare.

Informatics Nurse

interest or experience in infromatics; super user

Informatics Nurse Specialist

graduate level in informatics

The ANA’s definition of nurisng informatics

the specialty that integrates nursing science with multiple information management and analytical sciences to identify, define, manage and communicate DATA, INFORMATION, KNOWLEDGE, AND WISDOM into nursing practice.

unit testing

performed during design/development; basic testing that occurs initially

function testing

performed after unit testing is complete; uses tests scripts/validates when a system is working (1 function)

integration testing

performed after function testing is complete; uses test scripts/validates systems (entire work flow)

performance testing

performed after integration; seeing if system can handle workload of multiple users

user acceptance testing

after all testing above (unit, function, integration, and performance), nurse test drives the new system EHR to ensure it is working as designed (final phase)

healthcare analytics

information pulled into data base and put in a report

data visualization

data in pictorial or graphical format

predictive analytics

analyze current and historical facts to make predictions about future or otherwise unknown events (ex. identify patients at risk)

big data

from various sources, combines with new technologies; allows data to information, knowledge, and wisdom for better outcomes

in relation to population health

the driving force behind the use by health corporations of analytics and big data is the transition from fee-for-service models to value-based payment models

advantages of telehealth

remote access, saves money, saves time

telehealth

use of electronic information and telecommunications technologies to support and promote long distance clinical healthcare, patient/professional health-related education; public health and health administration

telemedicine

use of telecommunications technologies to support the delivery of all types of medical, diagnostic, and treatment-related services, usually by physicians and NPs

telecare

technology that allows consumers to stay safe and independent in their own homes (easy access to specialists; health/fitness apps; early warning/detection technologies)

Guidelines to patient counseling

makes everyone feel comfortable in the situation and surroundings; counseling may be formal or informal; uses interpersonal skills of warmth, friendliness, openness, and empathy; caring is fundamental

primary sources of information

the patient

secondary sources of information

medical records and the patients family

key points to communication

sincerity and honesty; stick to the basics, ask for questions, be a patient’s cheerleader, simple vocabulary, vary tone of voice, listen and do not interrupt, ensure the environment is conductive to learning and free of interruptions, be aware of the timing for teaching.

teaching plans for older adults

identify learning barriers, allow extra time, plan short teaching sessions, accommodate sensory deficits, reduce environment distractors, relate infor to familiar activities or information

providing CULTURALLY competent patient education

develop culture understanding, work with multicultural team, be aware of personal assumptions or biases, understand core values, develop written material in native language, use testimonials from persons with the same cultural background

promoting compliance

be certain instructions are understandable and support goals, include patient and family, utilize interactive teaching strats, develop interpersonal realationships with patients and their families

assessment parameters

knowledge, attitudes, and skills needed to be independent → readiness to learn → ability to learn →learning strengths →

Factors affecting teaching and learning

age, developmental level, family support, financial resources, cultural influences, language deficits, health literacy level

learning occurs if the

patient can demonstrate what a nurse taught

cognitive

storing and recalling of new knowledge in the brain

psychomotor

learning a physical skill

affective

changing attitudes, values, and feelings

cognitive domain consists of

lecture, panel, discovery, written materials

affective domain consists of

role modeling, discussion, audiovisual materials

psychomotor domain consists of

demonstration, discovery, and printed materials

TEACH

Tune into the patient, Edit patient information, Act on every teaching moment, Clarify often, Honor the patient as partner in the education process

COPE

Creativity, Optimism, Planning, Expert information

Nontherapeutic communication techniques

don’t be cliche or give false assurance, don’t be judgmental, don’t give advice

short term plans are

something i’m planning to see done before I’m gone (i.e. during clinical)

characteristics of communication

appearance, demeanor, behavior; autonomy and responsibility; use of names (call them what their name actually is); courtesy, trustworthiness, assertiveness

helping relationship

established when communication encourages client to express his thoughts and feelings

equally reciprocal

both parties participate simaltaneously

professional nursing relationships

nurse-client helping, nurse-family, nurse health team, nurse-community

symbolic communication

verbal and nonverbal

metacommunication

refers to all factors that influence communication

consent

permission needed

social interations:

permission not needed

intimate personal space

0-18'“ need to have consent before. foley insertion, wound care

personal space zone

18”-4’ interacting with the patient. close friends

social personal space zone

4-12’ - work or social setting

public personal space zone

12’ or great

nonverbal examples

personal appearance, moaning, posture and gait, facial expressions, eye contact gestures, sounds, territorial and personal space.

verbal forms of communication

vocabulary-use language they understand. denotative and connotation meaning - denotative is the definition and connotation is how the word feels, pacing?, intonation - tone of how you speak, clarity and brevity, timing and relevance

referent

motivates one to communicate with another

sender and receiver

one who encodes and one who decodes the message

message

content of the message

channels

means of conveying and receiving messages

feedback

message the receiver returns

interpersonal variable

factors that influence communication

environment element

the setting for sender-receiver interactions

intrapersonal

occurs within an individual

interpersonal

one-to-one interaction between 2 people

caring attributes

sensitive to self and others, promoting/accepting positive/negative feelings, developing helping-trust relationships, instilling faith and hope, promoting a supportive environment, assisting with gratification of human needs, allowing for spiritual expression

interpersonal relationships

to establish helping and healing relationships, relate to others, have both understanding and own experience

ethnics definition

moral principles, right and wrong conduct, good and evil character, just and unjust community organizations, values and virtues, moral rights duties and obligations, principles of human duty.

value clarification

understanding your own values

nursing ethnics

general moral principles to profession and nursing practice

duties//obligations

patients, health, profession, professionals, and the wider public

nursing code of ethics consists of

responsibility, accountability, confidentiality

deontology

defines actions as right or wrong

utilitarianism

usefulness, greater good, outcome

fidelity

agreement to keep promises

beneficence

taking positive actions to help others

justice

being fair

autonomy

commitment to include clients in decisions

(informed consent)

nonmaleficence

avoidance of harm and hurt

successful ethical decision-making

willingness to make decisions (courage and energy), and ability to make good decisions (critical thinking and creativity)

ethics - individuals

“why” (motives and attitudes), enforced by: ethics, committees, professional codes.

law - society (rules/regulations)

“what?” (actions/conduct) enforced by: courts and statutes

sources of law - legal guidelines that come from the constitution, statutory, regulatory, and common law

legal guidelines that come from the constitution, statutory, regulatory, and common law

standards of care

legal guidelines for guidelines for defining nursing practice and identifying the minimum acceptable nursing care

statutory law

legislation (federal/state) criminal, or civil. example is the nurse practice act found in all 50 states

administrative (regulatory) law

decision by administrative bodies. rules and regulations. example: duty to report incompetent or unethical nursing conduct to the board of nursing. presidents, governors, mayors, board of nursing

board of nursing determines

if you can practice in the state

common law

judicial decisions, public policy. example: informed consent and the clients right to refuse treatment

criminal laws

protects society as a whole. examples: crimes (felony/misdemeanor) and “you stole that medicine.

civil laws

protect relationships between private persons; damages/money. example: “you gave the wrong medicine”

intentional torts

assault and battery, slander and libel, restraints when you shouldnt have them on and false imprisonment

unintentional torts

doing wound care and left the side rail down by accident and the patient fell. skin breakdown (falls under negligence)

felony

> 1 year or even death

misdemeanor

penalty of a fine or imprisonment for < 1 year

most common failure (basis for negligence)

failure to follow up on changes in a patients condition. each time there is a change, it should be followed up on with the appropriate intervention and then assessment as to the effectiveness.

common medication errors

not clarifying the order, misreading order, selecting wrong medication, not knowing the rights, lack of knowledge

patients prone to sue

overly dependent, hostile, uncooperative, noncompliant, blames others, insecure

nurses who trigger lawsuits

insecure/shifts blames to others, insensitive to patients complaints, fail to take complaints seriously, more concerned with technology than the patient, delegates to avoid patient, difficulty developing close relationships.

will

may not be carried out the way you want, but you are making your wishes known

a nursing carrying out

inaccurate or inappropriate orders is legally responsible for any harm the client suffers

bioethics

refers to the application of ethics to health and life. addresses dilemmas such as stem cell research, abortion, and acquired immunodeficiency syndrome.

advocacy

support and defend clients health, wellness, safety, wishes and personal rights

responsibility

willingness to respect obligations and follow through on promises

accountability

ability to answer to ones own actions