FON 2

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DNR: Do Not Resuscitate order. This may be a legal document, usually signed by patient and his or her physician, which states that the patient has a terminal illness and does not wish to prolong life through resuscitative efforts. A DNR is one type of Advance Directive, because it is written and signed in advance of any event where resuscitation might be undertaken.
appeal: request a review of the decision which askes a higher court to review the lower courts decision
HIPAA: The Health Insurance Portability and Accountability Act, a federal law protecting the privacy of patient-specific health care information and providing the patient with control over how this information is used and distributed.is a legislation passed by Congress in 1796, and revised in 2001/2002.States that all healthcare organizations must take special precautions to protect patient information (PHI).
health care proxy: person designated by the patient to make health care decisions when the patient is incapacitated (not able to make those decisions). Usually part of the Advance Directive
deliberation: decides the guilt or innocense of the defendant
Scope of nursing practice: each licensed practical/vocational nurse must be familiar with his/her scope of practice, nurses cant use ignorance as an excuse, each nurse needs to know what the nurse can and cannot do while providing nursing care
If a nurse doesn't understand a spoken language of the patient, what should she do?: The nurse should speak slowly and clearly. Keep messages short and simple. be alert for words the resident understands. Also be akert for signs that the resident is only pretending to understand you. The nurse may need to use pictures and gestures to communicate. Ask the residents family, friends or other staff members who speaks the residents language for help. Be patient and calm.
What does being a good listener involve?: Give feedback as you listen (active).-Active listening requires full attention to what patient is saying. The nurse hears the message, interprets meaning, restates what the nurse believes the patient is communicating, and then gets patient feedback if message received was intended or not.
NAT-CEP: nurse aide training and competency evaluation program sets minimum requirements for nurses
values: personal beliefs about the worth of an object, an idea, a custom or an attitude
Malpractice: professional wrongdoing (negligence) that results in injury or damage
Positive Non Verbal Examples: Smiling in a friendly way, leaning forward to listen, and therapeutic touch during conversation.
what is law: laws prescribe how a person should act in society, they sanction acceptable and prohibit unacceptable behaviour, provides protection for all members of the health care system
what should a nurse do before performing a procedure on a patient: ? First one may introduce him/her self, check name band, explain to the patient, wash your hand and provide for privacy.
What is the proper way to answer the phone at work?: • Greet the caller - ie "Good Morning".Identify your facility - ie "Banner Hospital".Identify yourself and position - ie " Dr. Wealth"
how to avoid a lawsuit: provide compassionate, competent nursing care
Therapeutic communication consists of?: Therapeutic- An exchange of information that facilitates the formation of a positive nurse-patient relationship and activity usually involves the patient in all areas of the nursing process.eg active listening, silence, touch, conveying acceptance
rounds: staff movement from room to room to discuss each patient and plans of care
Define sentinel event.: A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, which require immediate investigation. For example, a patient that falls out of bed and breaks a hip or a medication error that results in a patient's death.
Ways to keep patients information safe: Do not give health information on the phone, unless you know you are speaking with an approve staff.Do not give any personal information to any visitor, no matter who they are.Turn computers off when not in use.
interstate compact: a written agreement between two or more states, that allows multiple state practice of nursing
civil litigation: lawsuit in a civil court, begins when the plantiff contacts an attorney
Malpractice insurance: insurance purchased by physicians and hospitals to cover the cost of being sued for malpractice
What are some causes of inappropriate behave?How should the nurse react?: causes:Disease affecting the brain, worsening of anger or frustration, medication or change in health, How the nurse react? nurses have responsibility to keep everyone safe and requires special techniques.
When is touching a patient appropriate?: During bedbath,Assisting on/off bedpan,Inserting catheter,With patient consent,During a difficult procedure,Small child that is frightened by hospital environment,Older adult patients frequently reach out for caretaker
What are some ways a nurse can have a good relationship with the patient and family?: One way to do this is to always respond immediately when a resident calls for help. This lets them know that you are taking great care of their loved ones and also this prevents injury.
discovery: a pretrial process allowing both sides to interview witnesses and look at documents before the trial
what is the hours of training for NA's: at least 75 hours
JCAHO: Joint Commission on the Accreditation of Healthcare Organization, they acredit healthcare facilities and monitors them to ensure that the facility is in compliance with all the applicable laws and regulations.
What are some effective ways to organize work?: Plan ahead - list your tasks, check if you have all of the supplies needed.Prioritize - Identify the most important tasks and do these first.Make a schedule - write out the hours of the day and fill in what you will do.Combine activities - work more efficiently when possible.Get help - don't be afraid to ask for help, speak up if you cannot complete assignment
what happens If non-verbal cues are not consistent with the verbal message: If non-verbal cues are not consistent with the verbal message, it will most likely be the non-verbal message that is received-It is okay to identify inconsistency.
root: its the main part of the word that gives it meaning.
value clarification: process of self evaluation that helps a person gain insight into individually held values
unethical behaviour: failing to perform the duties of a competent caring nurse, failure to report when a mistake is made, accepting gifts from patients
Why is accurate documentation so important?: This is important because documentation provides an up-to-date record of each residents status and care. Its a legal record of all residents care, and its also important for planning residents care.
battery: intentional touching of another person without informed consent
OBRA: Omnibus Budget Reconciliation Act, was passed in 1987 as a response to poor care and abuse in nursing homes
nonverbal communication: the way we communicate using body language such as gestures, body orientation, touching, personal distance, paralanguage, and facial expressions
Define criminal law (public): they protect society from harmful people or organisation, conduct in issue is offensive to society in general, conduct is detrimental to society as a whole, involves public offenses (robbery, murder, assault), laws purpose is to punish for the crime and deter and prevent furrther crimes
When should medical terminology not be used?: When speaking with residents and their families, instead use simple, non-medical terms.
types of abuse: physical, psychological (verbal), sexual, finiancial
advocate: one who will defend or plead a cause or issue on behalf of another, the nurse accepts the role of an advocate for the patient, a nurse advocate has a legal and ethical obligation to safeguard the patients interests
depositions: out of court statements made by a witness under oath
Define and give examples of angry behaviours: aggressive behavior is expressing thoughts and feeling in a way that humiliates or overpowers another person. Doesn't show respect for the needs or feelings of others. Assertive behavior is being confident when dealing with other people. Expressing feelings in a direct, honest, respectful way. Ask for help when it is unsafe to handle by self. Combative behavior is violent or hostile. Hitting, shoving, kicking, throwing things and insulting others.
laws: tell us what we must do, they also help protect the rights of all members of society
What is anxiety and what s/s might occur?: Anxiety is an uneasiness,often about a situation or condition. It can be a unpleasant feeling that come from the anticipation of something bad that could happen.It can cause physical symptoms. It is a vague emotional state
What are confusing or conflicting messages?: When a patients non-verbal cues are not consistent with the verbal message. For example, a patient saying they're feeling fine but seeing that they are obviously in pain (e.g. grunting, moaning, holding a body part, crying etc.)
code: when a group of specially trained staff provide advanced life support during a medical emergency
How does one overcome communication barriers: Avoid asking "Why?", it causes defensiveness,Do NOT give advice,Be a good listener,Give feedback as you listen (active),Therapeutic touch (culturally sensitive),Simple, non-medical terms,Do NOT change the subject during conversation,Sit near patient,Lean forward in your chair when speaking,Talk directly to person,Avoid gossip
culture: refers to accepted values, beliefs and behaviours that are shared by a particular group of people
interogatories: written questions that must be answered in writing
Define Ethnic stereotype: is a fixed concept of how all members of an ethnic group act or think.
What are some causes of anger and signs that occur?: Anger is a natural emotion.Cause by disease, fear, pain, grief, loneliness and loss of independence. Also be part of someone's personality.Signs: Yelling, throwing things, threatening, pacing -narrowed eye, clenched and raised fists
what are the 2 types of neglect: active (purposefully harming a person by not providing care), passive (unintentionally)
confidentiality: The nurse has a duty to protect information about a patient no matter how that information is received.
tracheostomy: a surgical operation that creates an opening into the trachea with a tube inserted to provide a passage for air
advance directives: written documents oral statements that allow people to decide what kind of medical care they wish to have if they are unable to make those decisions themselves
Transcultural nursing: understanding and intergrating this knowlegde into all aspects of nursing care
negligence: the commission (doing) of an act or the omission (not doing) of an act that a reasonable prudent person would have done in a similar situation that leads to harm to another person
legal liability: failure to provide care to the expertise, if a nurse doesnt know how to do a procedure, he/she should discuss it with the charge nurse, asing for direction
What is non verbal communication? Give Examples.: Non verbal communication is communicating without using words.Eye contact is also non verbal communication.Eye contact for at least 2-6 seconds during conversation helps involve the patient.
What is a MDS and when is it used?: Minimum data set (MDS) - part of the patient assessment instrument (PAI) that incorporates many of the same assessment factors as a functional assessment tool and requires input from nursing and social services within a specific time frame
How do you communicate with a stroke patient: Use yes/no questions,Agree on signals, shaking ,or nodding, Use pictures, gestures, or pointing,Keep a special call light within reach
what should a nurse do if she suspects abuse: She should follow the proper chain of command, explain the facts as clearly as possible, documentation of the incident; objective, accurate, and where, other pertinent facts.
How should a nurse deal with an angry person?: Nurse deal with angry person is by being pleasant and supportive.Dont argue and stay calm
RAP: Resident Assessment Protocols (RAPs) are part of this process, and provide the foundation upon which a resident's individual care plan is formulated. MDS assessment forms are completed for all residents in certified nursing homes, regardless of source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. In most cases, participants in the assessment process are licensed health care professionals, usually Registered Nurses, employed by the nursing home. MDS information is transmitted electronically by nursing homes to the MDS database in their respective states. MDS information from the state databases is captured into the national MDS database at Centers for Medicare and Medicaid Services (CMS).
what is the first step to providing holistic care: Accepting each person as an individual is the first step in providing holistic care to the patient
answer: a detailed response to the charges outlined in the complaint, usually prepared and filed by an attorney hired by the defendant, will either admit or deny any or all of the allegations made in the complaint
felony: A major crime such as robbery, murder, and arson
Convert the following to military time: 12:01 am=1201 am, 4:00 pm=1600 pm, 7:50pm=1950 pm, 10:53 pm=2253 pm
OBRA: The Omnibus Budget Reconciliation ACT. OBRA was written as a response to poor care and abuse in nursing home.
When is documentation done: documentation should be done immediately not at the end of a shift
Cultural competence: Nurse must be aware of personal cultural beiefs and practices. Understand that these beliefs put some limitations on the ability to care for those from other cultures
AHA: American Heart Association developed the patients bill of right in 1972
Ombudsman: assigned legal advocate for residents, work as a mediator to resolve conflicts
verdict: a decision, The decision of a trial jury or a judge that determines the guilt or innocence of a criminal defendant, or that determines the final outcome of a civil case.
what should the nurse do if a patient refuses to have vital signs taken: The nurse must report it to the doctor and also the nurse need to document it.
PSDA: it encourages people to make decisons about advance directives,federal law originally passed in 1990
Rights given to patient by the PSDA are: The right to participate in and direct health care decisions.The right to accept or refuse treatment .The right to prepare an advance directive.The information on policies that govern these rights. That is they are require to be given a facility policy on handling advance directives
assault: an intentional threat to cause bodily harm to another, does not have to include actual bodily contact
What is the nurses responsibilty with the patients chart?: To gather information and report it to the nurse.
How do you communicate with a hearing impaired patient: Get patients attention before speaking,Speak clearly in a normal voice,Lower pitch of voice,Do not eat or chew gum while speaking,Make sure light is on nurses face,Speak in better ear
ethical principles: the first fundamental principle is respect for people, autonomy(personal freedom of a choice), beneficence (doing what is good, nonmaleficence (doing no harm), justice (fairness)
euthanasia: the act of killing someone painlessly (especially someone suffering from an incurable illness)
What are communication barriers? Give examples.: Communication barriers can cause communication to be blocked or disrupted. It can be caused by:poor hearing,misinterpretation,resident speaks different language or residents difficult to understand
Patients right: quality of life, to expect a high level of wellness, services and activities, right to be fully informed at all times regarding rights and activities, right to participate in their own care
sentence: penalty decided based on the severity of the crime, the defendants past criminal record, and the applicable laws
What are good ways to communicate with a depressed person?: Be pleasant, respectful, and supportive. Sit down and listen to them, use body language that show interest,and empathy. Use your normal tone of voice,encourage social interaction with others.You may use touch but be aware of cultural differences.
domestic violence: Any physical or emotional abuse between household members
defense mechanism: unconscious behaviour used to release tension or help a person cope with stress e.g denial, displacement(transferring anger), projection, rationalization (making excuses), repression(blocking painful events), regression(going back to past behaviour)
informed consent doctrine: patients agreement to allow a particular kind of treatment based on full disclosure of the facts needed to to make an intelligent (informed) decision.
To ensure accurate communication: one needs to restate what the patient said back to them to make sure that the message was received the way the speaker intended to.
Nurse practice acts: define and limit the scope of nursing practice
Define Visual Impairment: Visual Impairment is when a patient has poor eye sight and is caused by diabetes or other illnesses, it effect all ages.Can be unilateral or bilateral.
PHI: Protected Health Information (name,address, phone number, SSN, medical records, email address etc)
what senses are used when making observation: touch;smeller;see.
combative: having or showing a ready disposition to fight
ethics: values that influences a perons behaviour, its an individuals feelings and beliefs about what is right or wrong, ethics tells us what we should do
What ways can a nurse ensure the resident's right is being met?: By giving them quality of life, to expect a high level of wellness, services and activities, right to be fully informed at all times regarding rights and services, and right to participate in their own care.
. What are good Techniques with working with an anxious patient?: You should always ask permission to touch them. Be calm and listen to them speak, speak slow and softly, greet them as you enter their rooms. You must avoid demanding behavior,reassure the patient that they are safe,and ask gentle questions to identify the cause for the anxiety.
CPR (Cardiopulmonary resuscitation): consists of the medical procedures used to restart a persons heart and breathing.
suffix: is found at the end of a word, a suffix by itself does not form a full word, when you add a prefix or a root, the suffix turns it into a working medical term.
what happens in a matriarchal society: Matriarchal society, women make decision about health care.
MDS: The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems
When should an incident report be filed?: What is concidered an incident is a problem or unexpected event during the course of care ; it is something that is not part of the normal routine.An error in care such as feeding the resident from the wrong meal tray.
Define Depression?: Depression is a mental illness that cause withdrawal, lack of energy, and loss of interest in activities.
durable power of attorney for health care: a person appointed as a proxy for health care decisions. The proxy is a spokesperson for the patient when he/she becomes incapable of making choices about treatment. goes into effect anytime the person is incompacitated and is not limited to terminal illness. the document can also specify some of the person's wishes
What is the best way to communicate with a combative patient?: Call for help or get someone . keep yourself and others safety distances, stay calm, Do not respond or be insulting, Follow the direction of the nurses, report the facts u know when anger passes, sit with the resident for a while to provide comfort
what are the guidelines for accurate documentation?: a) Keep all information in the chart accurate,b)Document immediately after care is given, record notes carefully, never record any note before it is done.
How should a phone be answered at a facility?: Smile when u answer the phone, identify yourself by first name and facility name, Ask how u may be of assistance,Take a message, thank
Does culture affect communication? How or how not?: Yes, all cultures are different and come with different values. Ways the communication may differ are sound of voice, eye contact, women in the culture, personal space, and use of touch.
3 steps of communication: sender, receiver, feedback
NINP: no information, no patient
what are OBRA requirements: NA's attend regular in-service education, that they pass a written test, that the state keep a current list of NA in a state registry, minimum staff requirements, complete assesment on every resident
complaint: statement by the plaintiff, written and filed in the appropriate court, states the facts involved in the legal issues raised and outlines the damages
involuntary seclusion: confinement or seperation from others into a seperate physical space
statutory law: its developed by federal, state and local government
living will: A document that indicates what medical intervention an individual wants if he or she becomes incapable of expressing those wishes.
Invasion of privacy: violating a person's right to be left alone or exposing information about that person without his or her consent. Example, releasing private facts (medical records, photograph) without the persons consent.
what are the two basic categories of law: criminal and civil
Ways to effective deal with angry behavior: call nurse, keep safe and remain safe.
code of ethics: used to help with employees with issues of right and wrong.
what are the 4 elements of malpractice: duty, breach, harm, proximate cause
false imprisonment: restraining a person against his or her will, either physically or with verbal threats.
Disorientation: confusion about person, place, or time. Occur due to dehydration, constipation,hypoxia or medication.
Subcultures: shares many characteristics with the primary culture but has characteristic patterns of behavior and ideals that distinguish it from the rest of a cultural group
verbal communication: the transmission of messages using words either written or spoken
mandated reporters: people required to report suspected abuse because they have regular contact with vulnerable populations
What are advance directive?: Is a written documents or oral states that allow people to decide what kind of medical care they wish to have if they are unable to make those decisions themselves.
honesty: is the human quality of communication and acting truthfully related to truth as a value.
defendant: the person alleged liable
what are the guidelines for accurate documentation?: If you make an error, draw one line through it. Write the correct information, put your initials and the date. Do not erase or use correcting fluid on what you have written
criminal trial: defendent is arrested for a crime against the people, peoples attorney and the defendents attorney presents their cases in court, the judge or jury then deliberates
Why is charting important: charting is a legal medical record that shows the happenings of ones shifts, if its not charted, it never happened
what are the guidelines for accurate documentation?: c)use black ink when documenting, write neatly,d)sign each note you make in the chart, sign your name and title, write it the way your state requires, use the correct date and time.e)use only facts not opinions, write exactly what has said or what you see, hear, smell or touch. The word "seems', "appears to be, look like" are not used in charting.
common law/case law: developed in response to specific legal questions brought before the court and usually follow precedent rullings on an issue
damages: compensation sought by the plaintiff
accountability: being responsible for ones own action
liability: legal responsibility, a nurse can be charged with civil or criminal liability depending on the prticular circumstances surrounding the case
How do you communicate with a visually impaired patient: Talk directly to resident,Use the face of an imaginary clock to explain positions of things in the room or on the meal tray,Do not move persons items or furniture without permission or knowledge,Tell resident when you are leaving the room,Explain any procedure you are doing
Active listening: a communication technique in which the listener repeats, rephrases and asks for clarification of statements made by the speaker
Ethnocentrism: believe that the beliefs and practices of their particular culture is the best.
prefix: prefix comes at the front of a word, it works with a word root to make a new term.
sentinel event: mistakes that have caused harm already but can be used to to avoid similar mistakes in the future
summons: a court order that notifies the defendant of the legal action
abbreviations: are used to communicate effectively in the medical field. They are also used to report information concisely and accurately. They help to give more complete information.
Patients rights: Quality of life, to expect a high level of wellness, services, and activities, right to be fully informed at all times regarding rights and services and right to participate in their own care.
define standards of care: they define acts that are permitted to be performed or prohibited from being performed, gives the direction to the practicing nurse, defining what should or should not be done for patients, failure to adhere these standards gives rise to legal liability
Abuse: purposely causing physical, mental, emotional pain or injury to someone
What are communication techniques for working with the hearing: Check hearing aides or devices.reduce noise in environment .get the patient's attention prior to speaking to them .do not shout .lower the pitch in your voice .do not eat or chew gum .make sure there is alight on nurse's face .keep hands away from face, speak in better ear .use short sentences .repeat what you have discussed using different words .be supportive .use notepads or pictures
objective data: factual information collected using the senses of sight, hearing, small, and touch ie - "Ms. Jones is scratching her foot." ,
When would an incident report be filled out? Why?: An incident report is a confidential written report documenting an incident in detail. The report must be completed as soon as possible, so that details are not forgotten, after an accident or injury to a patient, visitor, or employee
civil battery: unlawful touching of a person, also called technical battery, an intent to harm is not necessary, eg performing a procedure without a signed consent
How do HIPAA guidelines apply to computer charting?: When charting on the computer, be careful about who can see private or protected health information (PHI) on the computer screen. HIPAA was passed in 1996 to protect the privacy of health information.
misdemeanor: a crime or offense that is less serious than a felony; any minor misbehavior or misconduct
31. What is the first thing a nurse should do after getting a report?: After receiving start-of-shift report, the nurse should go and check on each of his/her patients.
Biomedical therapy: western cultures have almost universally used the biomedical method of treating illness and maintaining health. Used of mechanical interventions
subjective data: information collected form residents, family members, or friends; information may or may not be true but it is what person reported, also called symptoms .ie - "Ms. Jones says her foot is itchy."
fact: something that is undisputedly true.
Why was OBRA developed?: OBRA developed as a result of report of poor care and abuses in nursing homes.
fines for violating HIPAA: Fines and Prison times can be the penalty for violating HIPPA. FROM $100-$250,000.Prison sentences of up to ten years,
MDS: Minimum data sheet an assesment tool developed by the federal government
Negative Non Verbal Examples: Rolling eyes, tapping foot, crossing arms, and pointing at someone while speaking.
ETIQUETTE: the forms, manners, and ceremonies established as acceptable and appropriate by civilized society
code status: whether a patient has signed advance directive or not
plaintiff: an individual or group of people who bring a complaint against another party
Verbal Therapeutic Communication: Closed questioning - Focuses and seeks a particular answer (e.g. doing an assesment),Open-ended questions - Does not require a specific response and allows the patient to elaborate freely.Restating - Nurse repeats to the patient what the nurse understand to be the main point.
what is civil law (private): conduct violates a persons rights, conduct is detrimental to that individual, involves an offense that is against an individual, laws purpose is to make the aggrieved person whole again, to restore them to where they were
legal relationship: nurse-patient relationship, when the nurse assumes responsibility for the patients care

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