Final study guide-Nursing 169.docx

Final study guide: Chapter 26 Informatics and Documentation: Documentation: - Key communication strategy - Produces a written account of patient data, clinical intervention and patient responses - Available to all members of the healthcare team - Allows others to track a patient's...

Final study guide: Chapter 26 Informatics and Documentation: Documentation: - Key communication strategy - Produces a written account of patient data, clinical intervention and patient responses - Available to all members of the healthcare team - Allows others to track a patient's clinical course Purposes of the Health Care Record: - Facilitates interprofessional communication - Provides a legal record of care - Provides justification for financial billing and reimbursement of care - Supports the process of needed for quality and performance improvement - Serves as a resources for education and research Interprofessional Communication Within the Medical Record: - Legal documentation - Reimbursement -- hospital gets paid, no details , Diagnosis-related groups (DRG) - Auditing and monitoring- happens through leadership teams - Education- gather information on the computer, learn more about the pt. - Research Electronic health record (EHR): An individual's **lifetime** computerized record\ A close-up of a document Description automatically generated Electronic medical record (EMR): The record for an individual health care **visit** American Recovery and Reinvestment Act (ARRA): Health Information Technology for Economic and Clinical Health Act (HITECH) Maintaining privacy, confidentiality, and security of the health care record - Protected health information (PHI)- **log out/turn off** screen , hippa violations Privacy, confidentiality, and security mechanisms: Firewall & Password Handling and disposing of information: Guidelines for quality documentation:  Documentation of patient assessment data: Flow sheets, Progress notes, Charting by exception (CBE) is that all standards for normal assessment findings or for routine care activities are met unless otherwise documented.\ A close-up of a document Description automatically generated Health care providers write *narrative progress notes* in one of several formats or structured notes within the EHR. Notes either take the form of traditional narrative documentation or make use of precise formats such as (1) focus charting, incorporating data, action, and response (DAR); (2) SOAP notes, identifying interprofessional problems; or (3) notes with a specific nursing focus, identifying nursing problems or diagnoses (PIE).  Common Record-Keeping Forms within the Electronic Health Record (EHR): - Admission nursing history form - Patient care summary - Care plans - Discharge summary forms Documentation is Governed by : (audits the hospital and charting) - Individual state regulations - The Joint Commission (TJC) - Centers for Medicare and Medicaid Services (CMS) A close up of a text Description automatically generated Health care information technology (HIT): Used to enhance quality and efficiency of care Health care information system (HIS): Two types: a clinical information system and an administrative information system Clinical information system (CIS): Example: computerized provider order entry (CPOE)\~\ how MDs are inputting orders, its legible because its typed, nurses need to acknowledge the orders, time sensitive inputs.  \_\_\_\_ Nursing clinical information systems (**NCIS**) - Two designs: nursing model and critical pathway - Advantages: 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 ( confirmation is required along with critical thinking skills) \_\_ Final study guide: Chapter 22 Ethics Basic Terms in Health Ethics: - **Morals**- everyone is different refer to judgment about behavior, based on specific beliefs, and ethics refers to the study of the ideals of right and wrong behavior - **Value**- a deeply held personal belief about the worth a person holds for an idea, a custom, or an object - **Bioethics**- the study of ethical, social, and legal issues that arise in biomedicine and biomedical research. - **Autonomy**- patient autonomy, you acknowledge and protect a patient's independence - Beneficence- to act with beneficence implies that the best interests of the patient remain more important than self-interest. - **Nonmaleficence**- the will to do good but the equal commitment *to do no harm* or hurt - **Justice**- fairness and the distribution of resources - **Fidelity**- faithfulness or the agreement to keep promises A text on a page Description automatically generated Code of Ethics for Nursing: - **Advocacy**- the application of one's skills and knowledge for the benefit of another person. - **Responsibility**- willingness to respect one's professional obligations and to follow through. \~responsible for your actions, the care you provide, and the tasks that you delegate to others. This responsibility also means maintaining your competence and ask for help. - **Accountability**- answering for your own actions. (The Joint Commission) - **Confidentiality**- to respect patient privacy **Values**- A value is a deeply held belief about the worth of an idea, attitude, custom, or object that affects choices and behaviors. While values reflect cultural and social influences, they can change over time as individuals become part of different groups. To resolve [ethical conflicts], one needs to distinguish among value, *fact*, **versus** *opinion*.\ \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--\ Approaches to Ethics: 1. **Deontology**- a "duty" to do what's right simply because its right. Keep adherence to rules and principles such as fidelity to promises, truthfulness, and justice. No matter what. 2. **Utilitarianism**- focus on outcomes, what would be the greater good, best outcomes. 3. **Casuistry**- bending the policy to justify the preferred outcome using your own facts. 4. **Feminist ethics**- the *natural caring for others* is the basis for moral behavior, emotions; it places an emphasis on *caring* relationships and a strong sense of responsibility 5. **Ethics of care**- care-based ethics focuses on understanding *relationships*, personal narratives, and the context in which ethical problems arise. In the ethics of care, nurses participate in clinical *[ethics consultation]*, with **patient advocacy** being a top priority \-\-\-\-\-\-- Ethical problems: 1. Ethical dilemma- lying to people even if it's a white lie 2. Moral distress- force to take a specific action (lying to someone because your told to) while believing that action to be wrong Ethics committee - devoted to the teaching and processing of ethical issues and dilemmas. An ethics committee involves individuals from different disciplines and backgrounds. *Needs to be documented* Processing an ethical problem (7 steps): Ask, Gather, ID problem, Name problem, Possible Action, Take action, Evaluate the plan. \_\_\_\_\_\_\_\_\_\_\_\_\_\_ Final study guide: Chapter 25 Patient Education Patient education: goal of patient education is to help individuals, families, or communities **achieve optimal levels** of health. Education plan starts from day one. - Maintenance and promotion of health and illness prevention: adopt healthier behaviors - Restoration of health: regain or maintain their levels of health - Coping with impaired functions: learn to cope with permanent health alterations *\-\-\-\-\-\-\-\-\-\--* *Effective communication* involves feedback from the sender and receiver. An effective educator delivers instruction and then provides a mechanism (e.g., **teach-back**) for evaluating the success of a teaching plan by gaining **feedback** from the receiver \-\-\-\-- Domains of learning (3): The most effective learning takes place when all three of these domains are used 1. Cognitive learning: understanding ; has 6 levels of understanding (Bloom's taxonomy) 2. Affective learning: attitudes 3. Psychomotor learning: motor skills  A rainbow pyramid with text Description automatically generated A screenshot of a medical survey Description automatically generated **ACCESS** helps you to focus on cultural factors that influence patient education outcomes. A white sheet of paper with black text Description automatically generated 1. Denial or disbelief: avoids discussion 2. Anger: blames others 3. Bargaining: offers to live better life in exchange for promise of better health 4. Resolution: express emotions openly, realize that illness has created changes, ask question \*at this point they are ready to Learn\*. "is ready to be responsible for learning" 5. Acceptance: actively pursues information, and strives for independence Final study guide: Chapter 21 Managing Patient Care Nursing Team: (our leaders guide)\ A strong nursing team works together to achieve the best outcomes for patients. Effective team development requires: team building and training, trust, communication, and a workplace that facilitates collaboration\ \-\-\-\-\-\-\-\-\-- A hospital that is **Magnet** ® certified has a transformed culture with a practice environment that is  Typically, a **Magne**t hospital has clinical promotion systems and ***research*** and **evidence-base practice (EBP)** programs. The nurses have professional autonomy over their practice and control over the practice environment\ \-\-\-\-\-\-\-\-\-\-\-- An RN is the health care leader who assesses patient needs, identifies mutual outcomes, monitors patients for clinical changes, and directs care. The Institute for **Patient-and Family-Centered Care** identified four core concepts for patient-centered care:\ \ \ \-\-\-\-\-\-\-\-\-\-\-\-\--A close-up of a text Description automatically generated **Case management** coordinates and links health care services across all levels of care for patients and their families while streamlining costs and maintaining quality. Makes necessary arrangements \[Durable Medical Equipment (DME)\] \-\-\-\-\-- Decision making**:** 1. **Shared governance** is the typical [*decentralized* structure] used within health care organizations. Decentralization management approach allows decisions to be made at the staff level. 2. **Responsibility**: duties and activities that you are employed to perform. 3. **Autonomy**: you make independent decisions about patient care 4. **Authority**: legal ability to perform a task, assign task and follow up 5. **Accountability**: assume responsibility for the outcomes of the actions, clinical judgments, and omissions in providing patient care. 6. **Staff involvement**: all staff members actively participate in activities \-\-\-\-\-- Interprofessional **collaboration**: among nurses and health care providers (staff). Goal is delivery of quality, safe patient care and the creation of a positive work culture Interprofessional **rounding**: to encourage patient and family involvement in planning care. Helps with [coordination], and [communication] among the health care team..  \-\-- Head to Toe assessment leads to **prioritizing care**: (clinical judgments) A close-up of a text Description automatically generated Final study guide: Chapter 15 Critical Thinking and Clinical Judgment Clinical judgment **=** Observed outcome of critical thinking **+** decision making Clinical **decision making**: technicians or other assistive personnel (AP/CNA) cannot make or takes immediate action (they are not responsible)  A close-up of a text Description automatically generated  A white and black text on a white background Description automatically generated (on 11^th^ ed the table is 15.3 but, in the 10th, ed the same table above is called 15.4) \-\-\-- Reflection: like instant replay. It is not intuitive. It involves purposefully visualizing a situation and taking the time to honestly review everything you remember about it Final study guide: Chapter 24 Communication **Competent** communication maintains effective relationships within the entire sphere of professional practice and meets *legal, ethical*, and *clinical* standards of care. **Therapeutic** communication occurs within a healing relationship between a nurse and patient. In**tra**personal communication is a powerful form of communication that you use as a professional nurse. This level of communication is also called *self-talk*. **Interpersonal** communication is one-on-one interaction between a nurse and another person that occurs face to face or via text or other electronic format. Being able to relate to others Nurses who develop **critical thinking** skills and **clinical judgment** make the *best* communicators **Critical thinking** applied during any patient interaction helps to overcome perceptual *biases* or *stereotypes* that interfere with accurately perceiving and interpreting messages from others *Circular transactional model* includes several elements: the referent, sender and receiver, message, channels, context or environment in which the communication process occurs, feedback, and interpersonal variables. - Referent- Factor that motivates a person to communicate with another individual. Sender-Person who initiates interpersonal communication by conveying a message. - Receiver -Person to whom message is sent during the communication process. - Message -Information sent or expressed by sender in the communication process. - Channel -Method used in the teaching-learning process to present content: visual, auditory, taste, smell. In the communication process a method used to transmit a message: visual, auditory, touch. - Feedback is the message a receiver receives from the sender. Interpersonal variables are factors within both the sender and receiver that influence communication. Your own Perception Environment- effective communication with physical and emotional comfort and safety. Noise, temperature extremes, distractions, and lack of privacy or space create confusion, tension, and discomfort Verbal communication - Vocabulary- choice of words - Denotative and connotative meaning- denotative meaning: baseball has the same meaning for everyone who speaks English. **Connotative** meaning is the shade or interpretation of the meaning of a word influenced by the thoughts, feelings, or ideas that people have about the word. "Serious" can *vary in degree* depending on who hears it. - Pacing- Speak moderately slowly and enunciate clearly - Intonation- Tone of voice dramatically affects the meaning of a message - Clarity and Brevity- simple, brief, and direct - Timing and relevance- poor timing prevents it from being effective, keep patients up to date  Metacommunication: broad term that refers to all *factors* that influence communication. **Motivational interviewing** (MI) is a technique that encourages patients to share their thoughts, goals, beliefs, fears, and concerns Nurse-family relationships- in community and home care settings, require you to form caring relationships with *entire families* Nurse-health care team relationships- Effective communication with other members of the health care team affects patient outcomes, patient safety, and the work environment. SBAR technique for communicating critical information.\ SBAR: Situation, Background, Assessment, and Recommendation Lateral violence : *bullying* between colleagues sometimes occurs and includes behaviors such as withholding information, being hypercritical, raising blame or making put-downs, criticizing without solutions. A screenshot of a medical survey Description automatically generated **Therapeutic communication** techniques are specific responses that **encourage** the expression of feelings and ideas and convey acceptance and respect.  **Nontherapeutic** techniques **discourage** further expression of feelings and ideas and engender negative responses or behaviors in others. A white paper with black text Description automatically generated \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- - Sociocultural considerations - Culture influences thinking, feeling, behaving, and communicating. - Speech and language considerations Use appropriate interventions based on patient needs to adapt your communication techniques \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- - Through the patient's eyes - One form of evaluation is to determine a patient's perception of the success of the plan of care in facilitating communication. - Patient outcomes - If expected outcomes for the patient's plan of care are not met or if progress is unsatisfactory, you determine which factors influenced the outcomes and modify the plan of care.