306 test 2
Terms
undefined, object
copy deck
- anything written/printed that can be used as record or proof for authorization
- Documentation
- Permanent document of all information relevant to health care
- Record
- non governmental or legal agency/professional organization that gives recognition to an institution
- Accredidation
- people that look at medical record and check to see if it meets the standards
- utilization review
- Nursing Documentation must be: ACFCTSO
- Accurate, Concise, Factual, Complete, Timely, Specific, Organized
- a confidential, permanent legal documentation of information relevant to a patients health care
- Medical Record
- how is the patient's needs and progress communicated?
- through progress notes and nurse's notes
- an effective way to learn the nature of an illness and the patients response is to read the medical record
- Education
- objective and subjective data are:
- Factual
- exact, precise, concise, spelling, and abbreviations
- Accurate
- thorough communication
- complete
- timely immediate documentation
- Current
- logical order
- organized
- the nurse is documenting on the client's record and notes that she made an error. The action that the nurse should take is to:
- Draw a straight line through the error and initial it
- Client is wheezing and experiencing some dyspnea on exertion. This is an example of
- The P of PIE
- patients chart is organized so that each discipline has a section
- Source Records
- used to eliminate redundancy, ensure concise documentation of routine care, emphasize abnormal findings, and identify trends in care
- Charting by exception
- the case manager advises nursing staff on specific nursing care issues, coordinates the referral to services provided by other disciplines, and ensures client education is completed
- Case Management
- tool used in managed care that incorporates the treatment interventions from all disciplines.
- critical pathways
- allow quick and easy assessment of patient status
- Flow Sheets and graphic record
- provides current orders, treatments, and diagnostic testing that are ongoing
- Client care summary or KARDEX
- provides a method of determining the hours of care and staff required
- Acuity recrd
- preprinted, established guidelines that are used to care for patients with similar health problems
- standardized care plan
- discharge summary -- discharge planning begins when?
- on admission
- Recording a nurse's description of the teaching provided to the client on performance of self medication administration is found in a:
- discharge summary form
- can an LPN take a telephone order?
- NO
- given mass dissolved in a known volume
- solution
- a client is nauseated, has been vomiting for several hours, and needs to receive an antiemetic medication. the nurse recognizes that which is accurate?
- a parenteral route is the route of choice -parenteral=intradermal, subQ, intramuscular, intravenous
- intradermal angle
- 15 degrees
- how is insulin administered?
- subQ
- what would a patient who's toxic on morphine look like?
- respiratory depression and decreased urinary output
- synergistic effect
- two meds combines better than 1
- proprietary patent (good for how long?)
- good for 7 years
- Pharmacokinetics
- the body's action on drugs -absorption -distribution -metabolism -excretion
- Pharmacodynamics
- the drug's action on body
- presaline
- antihypertensive
- the nurse is teaching the client how to prepare 10 units of regular insulin and 5 units of NPH insulin for injection. The nurse instructs the client to:
- inject air into both vials and withdraw the regular insulin first
- a client has an order for 30 U of U-500 insulin. The nurse is using a U-100 syringe and will draw up and administer:
- u-500 insulin is 5 times as strong as u-100 insulin. 30 units of u-500 insulin = 6
- must be a documented Dx, condition, or indication for each medication ordered
- prescriber
- responsible for filling prescriptions accurately and for being sure prescriptions are valid
- pharmacist
- responsible for knowing what medications are prescribed, their therapeutic and nontherapeutic effects, and the associated nursing implications
- nurse
- standing orders
- til dr. changes it or has stop order
- prn orders
- as needed
- single orders
- only once
- stat orders
- immediately
- stock supply
- historical, medications are available in large multidose containers
- unit dose
- current system, uses portable carts containing 24 hour supply of patients medications
- computer controlled
- automated medicine dispensing systems used primarily for narcotics
- six rights
- right medication, right dose, right client, right route, right time, right documentation
- tetrogenetic effect
- adverse affect on fetus
- how do you recognize a nurse statement that reflects the scientific method?
- "The client doesn't look the same today. I think something is wrong."
- during an admission history you have a client that has trouble breathing at night. in obtaining data for a problem-oriented database, the nurse should first question the client about:
- the onset and duration of his present breathing problem
- when a 53 yr old client is seen at the clinic for a yearly physical exam, that evaluating the client's weight, the nurse also considers the age and height.
- comparing data with normal health patterns.
- what is the long term goal for a tailor who is admitted for eye surgery?
- returning to sewing
- perferred injection site for a 1 year old
- ventrogluteal
- how much time does it take for regular insulin to take effect?
- 2-4 hours
- how would you interpret ii gtts OD?
- two drops to the right eye
- how would you calculate a medication order from 80mg/tsp to the correct amt of ml
- 5ml
- where do you inject heparin?
- abdomen
- medications used to wash out a body cavity delivered with a stream of solution
- Irrigation
- the primary source of data for elevation is the:
- client
- when a client-centered goal has not been met in a projected time frame, the most appropriate action would be to:
- repeat the entire sequence of the nursing process to discover needed changes
- to find out what's real and what's truth
- scientific method
- using info to develop a solution
- problem solving
- determine health status from patient's symptoms
- diagnostic reasoning and inference
- drawing a conclusion based on pieces of evidence
- clinical decision making
- three parts of a diagnosis
- 1. nanda 2. related to 3. as evidenced by
- skills that are necessary of a nurse
- 1. interpretation-assess 2. analysis-critiquing 3. evaluation-assessing results 4. inference-considering alternatives 5. explanation-presenting arguments 6. self regulation-reflecting on experiences and how to improve
- five types of nurse levels
- 1. novice 2. advanced beginner 3. competent 4. proficient 5. expert
- a systematic and scientifically based process used by nurses to identify and make decisions about client needs
- the NURSING PROCESS DAMNIT!!!!
- a series of steps or acts that leads to accomplishment of some goal or purpose
- friggin PROCESS
- to provide individualized, holistic, safe, quality, effective, and efficient care to clients
- purpose of a nursing process
- systematic data collection, validation, and interpretation
- assessment
- components of critical thinking
- 1. specific knowledge base 2. experience 3. competencies 4. attitudes 5. standards
- Maslow's Hierarchy of basic human needs is a:
- common method of selecting priorities
- Leinninger's sunrise model
- culturally congruent care
- watson
- connecting patient caring
- benner
- personal experience; 5 nursing competencies
- NEUMAN
- systems model: we are a system of parts, all parts important, if one part goes wrong, the whole system is affected; primary, secondary, tertiary care
- nursing diagnosis
- to tell you why you need to do the things in your care plan
- care plan
- to-do list
- gather data
- subjective=what the patient says; what can't be measured objective=measurable
- drug names
- 1. generic -- official name 2. chemical 3. trade -- pharmaceutical co has a patent of the name
- meds have 3 classifications
- 1. systemic 2. organ 3. symptom
- medication formed determines:
- route of administration and there are 20 diff. forms
- #1 reason for toxic effects (accumulation of a med beyond therapeutic index):
- hydration level
- what affects circulation?
- hypertension in diabetes