Nursing Fundamentals: Vital Signs and Medication Administration

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Questions and Answers

What is the primary goal of a Clinical Decision Support System (CDSS)?

To improve nurse job satisfaction

To reduce hospital costs

To develop clinical databases

To generate tailored recommendations for individual patients (correct)

What is the main advantage of using a critical pathway design in a Nursing Clinical Information System (NCIS)?

Better documentation quality

Increased nurse job satisfaction

Reduced hospital costs

Interprofessional management of information (correct)

What is the primary focus of a nursing model design in a Nursing Clinical Information System (NCIS)?

Developing clinical databases

Reducing errors of omission

Improving nurse job satisfaction

Facilitating documentation of nursing process activities (correct)

What is the main function of the knowledge base within a Clinical Decision Support System (CDSS)?

To link information required for clinical decisions to generate tailored recommendations Signup and view all the answers

What is the primary focus of nursing informatics?

Integrating nursing science, computer science, and information science Signup and view all the answers

What is the main advantage of using a Nursing Clinical Information System (NCIS)?

Better information access and documentation quality Signup and view all the answers

What is the primary goal of informatics competencies for nursing graduates?

To be knowledgeable in the science and application of nursing informatics Signup and view all the answers

How many designs are typically used in a Nursing Clinical Information System (NCIS)?

Two Signup and view all the answers

What is the primary focus of the principle of beneficence in healthcare?

Acting in the best interest of the patient Signup and view all the answers

What is the term for the branch of ethics that focuses on healthcare?

Bioethics Signup and view all the answers

What is the primary goal of values clarification in ethical decision-making?

To distinguish between values, facts, and opinions Signup and view all the answers

What is the term for a deeply held personal belief about the worth of an idea, custom, or object?

Value Signup and view all the answers

What is the primary focus of the principle of autonomy in healthcare?

Freedom of external control Signup and view all the answers

What is the term for a set of guiding principles that all members of a profession accept?

Code of ethics Signup and view all the answers

What is the term for a situation where two opposing courses of action can both be justified by ethical principles?

Ethical dilemma Signup and view all the answers

What is the primary focus of the principle of nonmaleficence in healthcare?

Avoiding harm or hurt to patients Signup and view all the answers

What is the primary purpose of an acuity rating system?

To determine hours of care and number of staff required Signup and view all the answers

What is the basis of a patient's acuity level?

Type and number of nursing interventions required Signup and view all the answers

What is the range of a patient's acuity level classification?

1 to 5 Signup and view all the answers

What governs documentation in the Long-Term Health Care Setting?

Individual state regulations, The Joint Commission (TJC), and Centers for Medicare and Medicaid Services (CMS) Signup and view all the answers

What is the primary goal of health care information technology (HIT)?

To enhance quality and efficiency of care Signup and view all the answers

What are the two types of health care information systems?

Clinical and administrative Signup and view all the answers

What is an example of a clinical information system (CIS)?

Computerized provider order entry (CPOE) Signup and view all the answers

What is the function of computerized provider order entry (CPOE)?

To allow healthcare providers to directly enter standardized orders for patient care Signup and view all the answers

What is moral distress?

When taking a specific action while believing that action to be wrong Signup and view all the answers

What is the purpose of an ethics committee?

To address ethical issues and dilemmas Signup and view all the answers

What is the first step in processing an ethical problem?

Ask: Is this an ethical problem? Signup and view all the answers

What is the focus of deontology in ethics?

The act itself and its adherence to rules and principles Signup and view all the answers

What is the primary focus of utilitarianism?

The outcome of the action and the greatest good for the greatest number Signup and view all the answers

What is the focus of feminist ethics?

Natural caring for others and practical situations Signup and view all the answers

What is the focus of ethics of care?

Understanding relationships and personal narratives Signup and view all the answers

What is a common source of ethical problems in healthcare?

All of the above Signup and view all the answers

What is the main purpose of documenting patient assessment data?

To record patient physiological data and routine care Signup and view all the answers

What is the philosophy behind charting by exception?

That all standards for normal assessment findings are met unless otherwise documented Signup and view all the answers

What is the purpose of a discharge summary form?

To prepare patients for a safe and timely discharge Signup and view all the answers

How should the abbreviation 'unit' be written in nursing documentation?

unit Signup and view all the answers

What is the purpose of a care plan?

To identify and address a patient's specific health problems Signup and view all the answers

What is the main characteristic of a flow sheet in nursing documentation?

It is organized by body systems and navigated through the use of a computer mouse Signup and view all the answers

What should be included in a patient care summary?

All relevant information about the patient's care Signup and view all the answers

What is the purpose of progress notes in nursing documentation?

To monitor and record the progress made toward resolving a patient's problems Signup and view all the answers

Study Notes

Standards and Guidelines for Quality Nursing Documentation

Record entries and reports should be organized, concise, clear, and complete, containing essential information.
Use standardized abbreviations, such as "unit" instead of "unit of measurement", and avoid using decimal points after whole numbers.

Methods of Documentation

Documentation of patient assessment data includes:
- Flow sheets, which are organized by body systems and navigated using a computer mouse.
- Progress notes, which monitor and record patient progress toward resolving problems.
- Charting by exception, which assumes that all standards for normal assessment findings or routine care activities are met unless otherwise documented.

Common Record-Keeping Forms within the Electronic Health Record

Includes:
- Admission nursing history form
- Patient care summary
- Care plans
- Discharge summary forms

Acuity Rating Systems

Used to determine hours of care and number of staff required for a group of patients every shift or every 24 hours.
Patient acuity level is based on the type and number of nursing interventions required by the patient over a 24-hour period.

Documentation in the Long-Term Health Care Setting

Governed by individual state regulations, The Joint Commission, and Centers for Medicare and Medicaid Services (CMS).
Notes: Check for pain management.

Informatics and Information Management in Health Care

Health care information technology (HIT) enhances quality and efficiency of care by recording, monitoring, and delivering patient care.
Health care information system (HIS) consists of two types:
- Clinical information system (CIS)
- Administrative information system
Examples of CIS:
- Computerized provider order entry (CPOE)
- Nursing clinical information systems (NCIS)
NCIS designs:
- 1. Nursing model
- 1. Critical pathway
Advantages of NCIS:
- Better information access
- Better documentation quality
- Reduced errors of omission
- Reduced hospital costs
- Increased nurse job satisfaction
- Clinical database development

Clinical Decision Support Systems (CDSS)

Aids and supports clinical decision making by providing tailored recommendations for individual patients.

Nursing Informatics

Specialty area of practice that integrates nursing science, computer science, and information science.
Informatics competencies for nursing graduates require knowledge of nursing informatics science and application.

Ethics and Values

Basic Terms in Health Ethics

Morals: Judgment or behavior based on beliefs
Value: A deeply held personal belief about the worth of an idea, custom, object
Bioethics: Branch of ethics in healthcare
Autonomy: Freedom of external control
Beneficence: A positive action to help others
Nonmaleficence: Avoidance of harm or hurt
Justice: Fairness and distribution of resources
Fidelity: Faithfulness and keeping promises

Professional Nursing Code of Ethics

Code of ethics: Set of guiding principles that all members of a profession accept
Key principles:
- Advocacy
- Responsibility
- Accountability
- Confidentiality

Values

Value clarification: Resolving ethical conflicts by distinguishing among value, fact, and opinion
Clarifying values: Important for effective ethical discourse

Nursing Point of View

Types of ethical problems:
- Ethical dilemma
- Moral distress
Ethics committees
Processing an ethical problem:
- Step 1: Ask if it's an ethical problem
- Step 2: Gather relevant information
- Step 3: Identify ethical elements and examine values
- Step 4: Name the problem
- Step 5: Identify possible courses of action
- Step 6: Create and implement an action plan
- Step 7: Evaluate the action plan

Issues in Health Care Ethics

Social media: Can be a supportive source of information about patient care or professional nursing activities
Quality of life: Deeply personal
Care at the end of life: Frequent source of ethical problems
Access to health care: Not always available

Approaches to Ethics

Deontology: Defines actions as right or wrong based on adherence to rules and principles
Utilitarianism: Focuses on the greatest good for the greatest number of people
Casuistry: Case-based reasoning, focusing on the details of a situation
Feminist ethics: Natural caring for others is the basis for moral behavior, focusing on practical situations and relationships
Ethics of care: Focuses on understanding relationships, personal narratives, and context in which ethical problems arise.

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Description

This quiz covers the basics of nursing practice, including vital signs, pain assessment, and administration of medications and treatments. It also reviews proper recording and reporting techniques.