Patient interview

Orintation

working

termination

Standing order

Written by a physician and it lists specific actions to be taken by a nurse or other health care provider when access to a physician is not possible or when a care is common to a situation.

Five triage systems

Level 1- critical

level 2- emergent

level 3- urgent

level 4- nonurgent

level 5- fast tract

Focus assessment

Brief individualized physical exam conducted at the beginning of an acute care setting work shift

Comprehensive assessment

Includes thorough interview

health history

review of systems

extensive physical head to toe assessment

cranial nerves

Nurse educator

Ensures that patients receive sufficient info on which to base consent for care and related treatment

Change agent

Agent in a leadership role

Leader

Provides direction and purpose to others, builds a sense of commitment toward common goals. Communicates effectively, and assists with addressing challenges that arise

Manager

Manages all of the activities and treatments for patients

Professional identity in nursing

Sense of oneself that is influenced by characteristics, norms, and values of the nursing discipline and resulting in an individual thinking and feeling like a nurse

Delegator

The nurse delegates certain activities to other health care personal

Attributes and criteria

Doing

being

acting ethically

flourishing

changing identities

Being

Doing the right thing even when nobody is watching

Integrity

Following through with a pain meds

calling the MD when patient asks you to

checking the code cart by the prescribed time

giving meds within the 30 min window

Interrelated concepts

Clinical judgement

leadershio

ethics

communication

Deontology

Ethical theory that stresses the rightness or wrongness of an individual behaviors, duties and obligations

Beneficence

"Doing good"

Autonomy

Self determination

Utilitarianism

Maintains that behaviors are determined to be right or wrong solely on the basis of their consenquences

Reliability of POCT

Based on formal planning and systemic management to reduce errors and ensure the quality of patient testing

Recommend standards for POCT

Include routine assessment of the sampling practices, standarized evaluations of controls used in assessing the samples and review of the quality testing procesures

Scientific method

One approach to problem resolution. Is systemic, logical, and based on data collection and hypothesis testing

Nursing process

Requires critical thinking. Is based on assessments, diagnosis, planning, implementation and evaluation

Evaluation

Info including the reliability, credibility, and bias of the source is assessed

Analysis

Investigating plans of actions on the basis of examination of subjective and objective data

Inference

Making accurate conclusions that are based on sound reasoning

Critical decision making

Consistent use of the essential skills of critical thinking guides clinical decision making

Illogical thinking

Characterized by failure to follow rational, systematic processes when approaching an issue or problem

Bias

Inclination or tendency to favoritism or partiality

Leadership

Ability to influence and motivate others

SBAR

Charting technique

situation, background, assessment, and recommedation

nurse to physician interviews

Charting by exception

Documentation that records only abnormal or significant data

SOAPIE note

Subjective data, objective data, assessment, plan, intervention, evaluation

SOAP note

Subjective data, objective data, assessment, plan

Apie

Assessment, problem, intervention, evaluation

SOAPIER

Subjective data, objective data, assessment, plan, intervention, evaluation, revisions to plan

DAR note

Data, action, response

used to chart

Bureaucratic leader

Leader that assumes that followers are motivated by external forces

HIPPA

Federal standards for the protection of personal health information

Autocratic leader

Leader who exercises strong control over subordinates

Democratic leader

Leader that believes that employees are motivated by internal means and want to participate in decision making

Transformational leaders

Employ methods that inspire people to follow their lead

Laissez faire leader

Provides little or no direction to followers

Behavioral theories

Assume that leaders learn certain behaviors

Trait theories

Theories that assume that leaders are born with the personality traits necessary for leadership

Situational theories

Theory that leaders change their approach depending on the situation

Transactional leaders

Use reward and punishment to gain the cooperation of followers

Malpractice

Negligence committed by a person functioning in a professional role

negligence

Creating risk of harm to others by failing to do something

DNR-CC

Do not recuscitate, comfort care

Advanced directive

Living will- specifies treatment a person wants to receive when he or she is unconscious

durable power of attorney- legal document that allows a designated person to make legal decisions on behave of an individual

health care proxy- specifies the person who can make health care decisions for an individual

Euthanasia

Occurs when a person who willingly requests to die is injected with a lethal drug dosage by another individual

Assisted suicide

Occurs when a person causes his or her death with the assistance of medication or intravenous injection supplied by a physician or other health care provider

Clustering

Involves organizing patient assessment data into groupings with a similar underlying causes

Diagnosis label

Concise term or phrase that represents a pattern of related, clustered data. Taken from the official NANDA -I list

Components of nursing diagnoses

Diagnosis label

related factors

defining characteristics

Health promotions nursing diagnoses

Used in situations in which patients express interest in improving their health status. Through positive change in behavior

Veracity

Truthfulness

Nonmaleficence

First do no harm

Fidelity

Keeping promises or agreements made with others

Civility

Acting politely. Is essential in all intersections amoung faculty and nursing students

Code of ethics

Code of ethics- formalized statement that defines the values, morals, and standards guiding practice in a specific discipline or profession

Bioethics challenges in health care

Genetic testing

cloning and embryonic stem cell research

end of life care

Bioethics

Study of ethical and philosophical issues in biology and medicine

Sources of law impacting professional nursing

Constitutional, statutory, regulatory, and case law

Futile care

Care that is useless and prolongs the time until death rather than restoring life

Statutory law

Created legislative bodies such as the U.S congress and state legislature

Constitutional law

Derived from a formal written constitutional that defines the powers of government and that responsibilities of its elected or appointed officials

Case law

Historically referred to as common law because it originally was determined by customs or social mores that were common at that time

Regulatory law

Outlines how the requirements of statutory law will be met

Nurse practice act

Defines the nursing scope of practice in that state

Intentional torts

Wrong committed by individuals who deliberately seek to injure or hurt another person

Types of statutory law

Criminal, misdemeanor, felony, and civil law

Patient goals

All goals must be patient focused

realistic

measurement

Short term goals

Goals that are achievable within an immediate time frame of less than one week

Long term goals

Will take more time to achieve- weeks to months

Secondary data

Data obtained from reviewing a patients chart, medical records, results of labs, and diagnostic tests

Primary data

Data that comes directly from the patient

Researcher

Nurses concur research studies and apply research to practice

Referent

Event or thoughts initiating the communication

Sender

Person who initiates and encodes the communication

Receiver

Person who receives and decodes or interprets the communication

Message

Information that is being communicated

Channel

Method of communication

Feedback

Respons of the receiver

Encode

Translating their thoughts and feelings into communication with a receiver

Feedback

To avoid misinterpretation of a message, it is essential that the receiver provide feedback to the sender regarding conveyed meaning

Verbal communication

Spoke, written or electronic

most communication is nonverbal and provided in the form of body language such as gestures and eye contact

Nonverbal communication

Wordless transmission of information.

93% of communication is nonverbal. Body language constitutes 55% of all nonverbal communication and voice inflection accounts for 38%

Nonverbal communication

More accurate mode of conveying information

Proxemics

The study of the spatial requirements of humans and animals

Spaces

Intimate - 0-1.5 feet

personal -1.5 to 4 feet

social- 4-12 feet

public 12 feet or more

Personal space

Children demonstrate a need for greater personal space as they age.

english speaking people typically prefer at least 18 inches of distance between themselves and others when conversing

middle eastern people may be comfortable standing very close while communicating

Voice inflection

The second most significant form of nonverbal communication

Intrapersonal communication

Occurring internally

Positive self talks

Internal conversations that provides motivation and encoraugement. May be used to build self esteem and self confidence

Meditation

Mindful reflection or contemplation

Interpersonal communication

Takes place between two or more people

Interprofessional communication

Almost 70% of sentinel events were caused by communication breakdown and 50% of those cases occurred during patient handoff

professional role boundaries

limits and responsibilities of an individual in a given setting

4 phases of group development

forming

storming

norming

performance

5 areas of nurse -patient relationship

building trust

demonstrating empathy

establishing boundaries

recognizing and respecting culture influences

developing a comprehensive plan of care

helping relationship

the 5 steps of the nursing process are used in each phase of the helping relationships

nursing diagnoses for individual patients are identified during the orientation phase after assessment data are gathered and clustered

secondary date

with the patients permission relatives and friends may be considered secondary sources of subjective information

assertiveness

the ability to express ideas and concerns clearly while respecting the thoughts of others

therapeutic communication

the primary focus of therapeutic communication between a patient and nurse is the patient

social communication

most often occurs among individuals who know each other or who are getting to know each other informally.

SOLER

s- encourages the the listener to sit

o- reminds the nurse to maintain an open stance or posture

l- suggest the listener lean toward the speaker

e- to maintain eye contact without staring

r- reminds the nurse to relax

Uninterrupted sleep

Adults need 6-8 hours per night

Hospital sleep

Adults while in a hospital need at least 90 minutes of uninterrupted sleep

Ways to help your pt get their needed sleep

Cluster care

consult about medication regiment especially meds like diruretics- don't administer past 6 pm

Sleep disorders

20-30% of adults have some kind of sleep disorder

Stages of sleep

Stage 1- 3-10 minutes

stage 2- 10-20 minutes

stage 3 - 15-30 minutes

stage 4 - 15-30 minutes

REM sleep- memory is enhanced, cells regenerate, cerebral blood flow

cycle through about 6times/night

Sleep hygiene

Ritual to implement or promote sleep

drinking milk

brushing teeth

turning lights down

Not enough REM sleep

Increases agitation, and impulsiveness

Cortisol

Stress hormone

released early in the daytime

Melatonin

Hormone for sleep

induces sleep

Sleep study

Polysomnography

Multiple sleep latency test

During several 20 minute naps during the day

pt is suspected of having narcolepsy

Dyssomnia

Difficulty falling asleep

staying asleep

being excessively sleepy

Parasomnia

Disorders associated with abnormal sleep behaviors

Bruxism

Grinding teeth

Enuresis

Bed wetting

Somnambulism

Sleep walking

Other sleep disorders

Underlying medical or psychiatric problem

COPD-

pain

mentak health disorders

Insomnia

Difficulty with sleep

Hypersomia

Excessive day time sleeping

OSA

Obstructive sleep

apnea 10 seconds or greater without breathing

Sleep deprivation

Loss of good quality sleep

RLS

Restless leg syndrome

constantly needing to move legs

C-pap machine

Continuos positive airway pressure

Sodium

135-145 meq/l normal per textbook

Potassium

3.5-5.0 normal per textbook

Calcium

8.5-10.5

Magnesium

1.3-2.1

Phosphorus

1.76-2.6

Abnormal Na+ Levels

Behavior issues

Low sodium levels

Hyponatremia

Causes confusion, lethargy

High sodium levels

Hypernatremia

irritability, hallucinations

K+

Cardiac/ neuromuscular

Low Potassium

Weak, cardiac dysrhythmia

High potassium

Dysrhythmia

Hypervolemic

Too much volume

too much IV fluid

Hypovolemic

Too low volume

low BP, low heart rate

Fluid shifting

Good reason to keep electrolytes balanced

PH

7.35-7.45

Sa02

95-100

acid base balance

Respiratory- 1st thing to kick in with acid imbalance

renal - excretes hydrogen- doesn't kick in for 3 days

Kussmoulis

Deep shallow breathing

you exahule c02 when you breathe