Healthcare Ethics and Documentation Quiz

Personal Ethical Principles

• These help guide our actions and ensure professional conduct
• They influence how we treat patients and make decisions regarding their care

Cultural Care

• Understanding and respecting a patient's beliefs and practices is crucial for effective healthcare.

Nonmaleficence

• Means "do no harm" and underlies every medical decision
• This ethical principle ensures we prioritize the patient's safety and well-being above all else.

Chief Complaint

• This is the main reason the patient seeks medical attention
• It should be concise and stated in the patient's own words.

Identifying Spiritual Needs

• Patients have diverse beliefs and practices, which heavily influence their health experiences.

Purpose of Documentation

• Accurate and detailed documentation is crucial for patient care.
• It facilitates effective communication between healthcare providers, improves patient safety, and ensures continuity of care.

Communicating with Non-English Speaking Clients

• Utilize interpreters or translation services to ensure effective communication.
• Use simple language and demonstrate respect by avoiding jargon or slang.

Closed-Ended vs Open-Ended Questions

• Closed-ended questions elicit a specific response, often 'yes' or 'no.'
• Open-ended questions encourage detailed responses and allow patients to express their experiences freely.

Asking for Examples

• Encourage patients to provide specific examples to gain deeper insights and understand their experiences fully.

Aggravating Factors

• These are factors that worsen a patient's symptoms.
• Identifying these helps determine potential triggers or causes of their condition.

When to Use Close-Ended Questions

• Use when asking for objective information, such as time of onset or presence of specific symptoms.

Therapeutic Communication

• This uses specific techniques to build rapport, understand the patient's perspective, and facilitate effective communication for optimal care.

Objective Data

• This is measurable and observable data gathered through physical examinations, laboratory tests, and diagnostic procedures.

Subjective Data

• These are the patient's personal experiences, perceptions, feelings, and sensations.

Questions about Alcohol and Drugs

• Pose these questions in a non-judgmental and straightforward manner to assess potential substance use and dependence.

Interviewing Rules

• Establish a trusting relationship and respect the patient's privacy.
• Utilize open-ended questions to encourage detailed responses.
• Ask questions to gain a comprehensive understanding of the patient's medical history, current health, and lifestyle.

Health History

• A thorough health history provides important context for understanding the current health issue.
• It includes past illnesses, surgeries, medications, and allergies.

Importance of Family History

• This sheds light on potential genetic predispositions to certain diseases
• It helps to understand the family's health history and identify relevant risk factors.

Comprehensive Assessment

• This involves a thorough evaluation of the patient's overall health status.
• Includes a detailed history, physical examination, and relevant laboratory or diagnostic tests.

Focused Assessment

• This focuses on a specific health concern or complaint, providing detailed information about the specific issue.

First Step During Physical Examination

• Start by inspecting the patient's general appearance and observing their overall demeanor.

Cyanosis

• This refers to a bluish discoloration of the skin, indicating a lack of oxygen in the blood.

Infection Control

• Adhering to strict infection control protocols is essential to protect both patients and healthcare workers.

Head-to-Toe Assessments

• This is a systematic approach to physical assessment, examining each body system in a specific order.

Physical Assessment Components

• These include inspection, palpation, percussion, and auscultation, allowing for thorough evaluation of various body systems.

Korotkoff Sounds

• These are the sounds heard during blood pressure readings, reflecting the flow of blood through the arteries.

General Survey

• This assesses the patient's overall appearance, behavior, and vital signs.
• Provides valuable information about their overall health status.

Verifying Irregular Pulse

• Count the pulse for a full minute to assess its regularity and rhythm.

Pulse Oximeter Placement

• Place the sensor on a fingertip, earlobe, or toe to accurately measure oxygen saturation levels.

Tachypnea

• This refers to an abnormally rapid breathing rate, often a sign of underlying respiratory distress.

FACES Pain Scale

• This scale uses faces to communicate pain levels, particularly useful for children or individuals who cannot effectively describe their pain.

Jaundice

• This is a yellowish discoloration of the skin and whites of the eyes, often indicating liver dysfunction.

Pulse Point Order

• Check the radial pulse, then the brachial pulse, then the carotid pulse if necessary.

Hypotension

• This means low blood pressure, a potential sign of underlying medical conditions.

Pain in Awake and Alert Patient

• Assess pain using a standardized pain scale and record the patient's description of the pain's location, intensity, quality, onset, duration, and aggravating and relieving factors.

BP Wrong Size Cuff

• Using a cuff that is too small can result in a falsely high reading.
• Using a cuff that is too large can result in a falsely low reading.

Diastolic / Systolic

• Systolic blood pressure represents the pressure in the arteries when the heart contracts.
• Diastolic blood pressure represents the pressure in the arteries when the heart relaxes between beats.

Normal Heart Rate/ Vital Signs

• Normal heart rate for adults falls between 60 and 100 beats per minute.
• Normal blood pressure is less than 120/80 mmHg.
• Normal respiratory rate for adults is between 12 and 20 breaths per minute.

OLD CART

• This mnemonic helps to structure a thorough pain assessment:
  • Onset: When did the pain start?
  • Location: Where is the pain located?
  • Duration: How long does the pain last?
  • Characteristics: How would you describe the pain (sharp, stabbing, dull, aching)?
  • Aggravating factors: What makes the pain worse?
  • Relieving factors: What makes the pain better?
  • Treatment: What have you done to treat the pain?

Level of Consciousness (LOC)

• This refers to a person's awareness of their surroundings, including their ability to respond appropriately to stimuli.

Aphasia

• This is a communication disorder that affects a person's ability to speak, write, or understand language.

Safety/ Mental Status Exam

• This assesses a patient's cognitive function and ability to make safe decisions.

Asking about Abuse

• Approach this topic with sensitivity and discretion, using direct questions to assess potential abuse.

Comatose

• This refers to a state of deep unconsciousness, characterized by an inability to respond to stimuli.

Normal Skin Turgor

• This refers to the elasticity of the skin, observed when the skin is gently pinched and then released.
• Normal skin turgor should return to its original position promptly.

Pruritus

• This refers to itching, a common symptom of many skin conditions.

Vesicles

• These are small, fluid-filled blisters, often a sign of skin infections or allergic reactions.

How to Best Assess Skin

• Use good lighting to visualize the skin's color, texture, and any lesions.
• Gently palpate the skin to assess its temperature, texture, and moisture.

Normal Nail Assessment Findings

• Normal nails should be smooth, pink, and slightly curved.
• The nail bed should be firmly attached to the nail.

Stage I Pressure Ulcer

• This is the earliest stage of a pressure ulcer.
• It's characterized by nonblanchable redness of intact skin, usually over a bony prominence.

Eschar

• This is a thick, leathery scab that forms over a wound or pressure ulcer.
• It may need to be removed to allow for proper healing and assessment.

Test your knowledge on key ethical principles in healthcare, including personal ethics, cultural care, and nonmaleficence. This quiz also covers the importance of accurate documentation and identifying spiritual needs of patients. Understand how these factors impact patient care and professional conduct.