front 1 Documentation | back 1 Must be clear, accurate, concise and accessible. There should be a clear understanding and picture of the client. This also allows the interprofessional team to communication. |
front 2 P.I.E | back 2 Problem Intervention Evaluation |
front 3 Subjective | back 3 What the client is describing |
front 4 Objective | back 4 What the health care provider sees, hears, touches, measure or smells |
front 5 Assessment | back 5 Combines subjective & objective info to arrive at the nursing diagnosis |
front 6 Plan | back 6 Details steps to treat clients and suggests the need for consultation, or additional testing to address the clients needs. |
front 7 Source oriented | back 7 A traditional format for documenting within a medical record. It can be divided into sections like history, physical, progress notes, nurses notes, lab reports, and diagnostic testing.F |
front 8 Focus Charting | back 8 focuses on health care problems and changes in condition, client events, and concerns |
front 9 D.A.R | back 9 Data, Action, Response |
front 10 Charting by exception | back 10 Documenting only unexpected or unusual findings |
front 11 Problem oriented medical records | back 11 Developing a database (client’s history, findings, diagnostics, and laboratory results). Identifying and numbering specific problems based on the client’s history. The date the problem is resolved is noted. Formulating a plan of action for each problem. Noting ongoing progress for each problem. |
front 12 F.A.C.T | back 12 Factual, Accurate, Complete, and Timely |
front 13 Error in documentation | back 13 Keep the OG document, draw an single line and write error with ur initials.Write the date & time. Do not obscure the original entry with a marker, pen, white out, etc.. |
front 14 Late charting entry | back 14 Identify the entry as "late entry", identify which even the late entry is for, make sure its signed & dated, no blank lines, and which event or previous note is referencing |
front 15 Electronic Health Records(EHR) | back 15 Allows comprehensive records a person's health history & communication for all health care providers. |
front 16 Electronic Documentation Guidelines | back 16 Dont use anyone else's login, use a strong password, log off completely when documentation is done, log off if ur leaving ur station, try to avoid info being seen by others. If an electronic signature is used, ensure your name is correct and professional credentials are noted. |
front 17 The Institute for Safe Medication Practices (ISMP) | back 17 preventing errors that occur within health care facilities |
front 18 Nursing Process | back 18 Help nurses make clinical judgment that are appropriate for clients |
front 19 Assessment | back 19 assess the objective and subjective data that pertains to the client |
front 20 Analysis | back 20 determine the clients problem |
front 21 planning | back 21 create a plan to address the clients problems |
front 22 implementation | back 22 taking action to provide care |
front 23 evaluation | back 23 the effectiveness of interventions provided and document the clients response |
front 24 Data collection for Lvn | back 24 collects subjective and objective data bout the client and report changes to the RN |
front 25 planning for Lvn | back 25 create a plan to address client problems under the supervision of the RN |
front 26 implementation for Lvn | back 26 collaborating with the RN to take action |
front 27 Evaluation for Lvn | back 27 Evaluate the effectiveness of the interventions provided, within the LVN scope of practice, and under the supervision of the RN. |
front 28 Steps | back 28 The steps usually go in order but at some point the process can go back and forth between the steps. Such as planning, implementation, and evaluation, to meet optimal results. |
front 29 Critical thinking | back 29 Its the skill of learning to analyze and interpret data to solve a problem. This includes questioning, analysis, synthesis, interpretation, inference, inductive and deductive reasoning, intuition, application, and creativity. |
front 30 Clinical reasoning | back 30 analyzing all the data and making a decision based on the analysis. |
front 31 Clinical Judgment | back 31 The visible or observed outcome of critical thinking and decision making that considers nursing knowledge, client situations, and prioritization of client problems and concerns, while utilizing evidence-based practice. |
front 32 Delegation | back 32 Nurses must remember that clinical reasoning and judgment cannot be delegated. |
front 33 Intervention | back 33 being able to intervene on high risk problems |
front 34 Priority setting | back 34 delivery of nursing care based on the importance or urgency of a clients needs |
front 35 Maslow's hierarchy of needs | back 35 Levels of the pyramid- from the top is Self-actualization, Esteem, social belonging, safety needs, physiological needs |
front 36 A.B.C.D.E | back 36 Airway, Breathing, Circulation, Disability, Exposure |
front 37 C.U.R.E | back 37 Critical, urgent, routine, and extra |
front 38 Critical | back 38 life-threatening situations |
front 39 Urgent | back 39 Situations in which the client could suffer harm of discomfort if there is a delay in addressing the client's needs. |
front 40 Routine | back 40 Routine tasks associated with client care. |
front 41 Extras | back 41 Tasks that are not essential to client care but promote comfort. |
front 42 Triage | back 42 Prioritizing what can be done quickly on a client |
front 43 Levels of Triage | back 43 level 1 as the most urgent category with clients experiencing a life-threatening illness and level 5 as the least urgent category with clients being stable and suffering from nonemergency ailments. |
front 44 Resource Allocation | back 44 the process of assigning a portion or amount of a service |
front 45 Client care coordination | back 45 nurses must be aware of their role on the health care team and how to mange time and organize client care activites |
front 46 Time management | back 46 nurse must know how to prioritize client care activities according to tome constaints |
front 47 S.M.A.R.T | back 47 Specific, Measurable, Attainable, Realistic, Timely |
front 48 S.B.A.R | back 48 Situation-Background-Assessment-Recommendation |
front 49 S.O.A.P | back 49 Subjective, Objective, Assessment, and Plan |
front 50 Measuring client acuity levels | back 50 helps ensure client assignments are consistent and fair. Acuity tools may vary by facility, but basically clients are ranked from stable to high risk based on the tasks involved in their care. |
front 51 I.D.E.A.L discharge planning | back 51 (I) Include the client and caregivers. (D) Discuss the 5 key areas: medications, home life, warning signs, test results, follow-up. (E) Educate the client: condition, discharge process, next steps. (A) Assess effectiveness of education.(L) Listen to the client’s goals and preferences. |
front 52 Delegation | back 52 one person assigning tasks to another |
front 53 5 rights of delegation | back 53 Right task, Right circumstance, Right person, Right directions and communication, Right supervision and evaluation |
front 54 Team nursing | back 54 Pairs two or more nurses together as a team to care for a group of clients. This helps with increased team work and sharing responsibilities |
front 55 Non compliance | back 55 failure to act in accordance with a plan |
front 56 Barriers to Interprofessional collaboration | back 56 Miscommunication, Distrust, Lack of respect among provider types, Different levels of perceived importance, Misunderstanding of each other’s roles |
front 57 Interprofessional Education Collaborative (IPEC) | back 57 Values and ethics for interprofessional practice, Roles and responsibilities, Interprofessional communication, Teams and teamwork |
front 58 The Chain of infection | back 58 A sequence of necessary pieces for an infection to occur, includes an infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host. |
front 59 Infectious agent | back 59 contains bacteria, fungi, virus, parasite, or prion. |
front 60 Reservoir | back 60 the habitat of the infectious agent and is where it lives, grows, and reproduces itself or replicates. |
front 61 Portal of entry | back 61 opening from the body, ( ears, nose, mouth) or can even be through skin |
front 62 Portal of Exit | back 62 when the infectious agent can leave the reservoir. |
front 63 Susceptible host | back 63 it's when the infectious agent to take hold and become a reservoir for infection |
front 64 3 Modes of Transmission | back 64 Contact -microorganisms move from an infected person to another person. Droplets-when airborne droplets from the respiratory tract of a client travel through the air and into the mucosa of a host Airborne-when small particulates move into the airspace of another person. |
front 65 Two types of Contact Transmission | back 65 Direct Contact, Indirect Contact |
front 66 Direct contact | back 66 when microorganisms are directly moved from the infected person to another person without having a contaminated object or person between the two. |
front 67 Indirect contact | back 67 when microorganisms are moved from the infected person to another person with a contaminated object or person between the two. |
front 68 Nonspecific immunity | back 68 when neutrophils(white blood cell) and macrophages and their work as phagocytes(obsorbing bacteria). |
front 69 Specific immunity | back 69 refers to the work of antibodies (also called immunoglobulins) and lymphocytes. Antibodies bind to infectious agents and call to the white blood cells and complement to destroy them. |
front 70 The Inflammatory response | back 70 Inflammatory pathways are activated, Inflammatory markers are released, Inflammatory cells are recruited |
front 71 Stages of infection | back 71
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front 72 Local infections | back 72 they are confined to one area of the body. Local infections can be treated with topical antibiotics and oral antibiotics. |
front 73 Systemic infections | back 73 it start as local infections and then spread to the bloodstream to infect the entire body. |
front 74 Hand hygiene | back 74 Cleaning the hands with handwashing, alcohol based hand sanitizer, using an antiseptic handwash or hand rub, and surgical hand antisepsis. |
front 75 Medical asepsis | back 75 the elimination of and absence of disease-causing microorganisms. |
front 76 Standard precautions | back 76 describing the infection prevention practices applied to all clients, whether or not they are known to have an infectious agent. Ex. ( masks, gloves, gowns, glasses, etc.) |
front 77 4 major H.A.I.S | back 77
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front 78 P.P.E | back 78 Personal Protective Equipment, knowing what is needed to care for clients and how to don and doff approprately |