Final Exam Study Guide PDF

Hello everyone, - - - - 1. a. b. c. d. e. f. 2. g. h. i. j. k. l. m. 3. n. o. 4. p. **ATI** Telehealth, or telemedicine, utilizes telecommunication technologies to facilitate client-to-provider communication. It employs social communication apps, videoconferen...

Hello everyone, - - - - 1. a. b. c. d. e. f. 2. g. h. i. j. k. l. m. 3. n. o. 4. p. **ATI** Telehealth, or telemedicine, utilizes telecommunication technologies to facilitate client-to-provider communication. It employs social communication apps, videoconferencing, and other media to assess, diagnose, treat, and prevent disease. Telehealth plays a pivotal role in promoting access to healthcare by eliminating the need to travel to healthcare providers\' offices. Importantly, it is a significant strategy in combating the nursing shortage and the growing demand for nursing care. The core competencies of telehealth, which encompass a fusion of clinical experience, communication skills, clinical knowledge, legal and ethical awareness, and a supportive attitude, are deeply ingrained in the nursing curriculum and standard nursing practice. These competencies, which are invaluable, must be continually strengthened and implemented throughout nursing education and practice, from novice to expert nurse. 5.  The phases of the medication administration process are: 1\. Medication prescribing - The healthcare provider evaluates the patient and prescribes the appropriate medication. 2\. Transcription - The medication order is transcribed accurately into the patient\'s medical record. 3\. Preparing and dispensing - The medication is prepared and dispensed by a pharmacist or nurse. 4\. Administering - The nurse administers the medication to the patient via the prescribed route and dosage. 5\. Monitoring and follow-up - The nurse monitors the patient for the desired therapeutic effects and any adverse reactions, documenting the outcome. Proper adherence to each phase is crucial for safe and effective medication administration to prevent medication errors. Pg 630 sherpath, video "Aspects of Safe Medication Administration" **ATI** TJC recognizes the impact of accurate medication administration and believes that medication reconciliation in the ambulatory care setting plays an important role in client safety. Medication reconciliation is a collaborative process between a nurse and client in which the nurse confirms and documents all of the client's current medications when the client is admitted to the health care institution. TJC's 2024 National Patient Safety Goals (NPSG) went into effect June 2024 and include NPSG 3: *Improve the safety of using medications*. This can be achieved in the practice setting by ensuring that client medications are reviewed at each clinical encounter with their health care provider. Nurses should reinforce for clients the importance of bringing a current list of medicines to each visit, including over the counter medications and supplements. During every transition of care to another health care provider, the nurse should communicate a client's current medications and report and record any allergy or sensitivity to medication. 6. q. 1\. Improved data accessibility and care coordination by integrating all patient information into one comprehensive record accessible to the healthcare team. 2\. Enhanced quality of care through clinical decision support tools, tracking of care processes, and ability to identify quality issues. 3\. Increased patient engagement by providing patients access to their health data and educational resources. 4\. Better care continuity by maintaining a longitudinal record across multiple care settings. 5\. Facilitation of evidence-based practice by enabling data analysis to link interventions with outcomes. 6\. Improved efficiency through streamlined documentation, order entry, and results reporting. 7\. Support for public health initiatives through data reporting and monitoring capabilities. 8\. Potential cost savings from reduced duplication of tests and improved care coordination. The key advantages allow EHRs to enhance patient safety, care quality, and organizational performance when properly implemented and utilized. Improved data accessibility and sharing across healthcare providers for better care coordination. Elimination of duplicate tests due to centralized patient information. Enhanced patient safety through computerized order entry, medication interaction checks, and clinical decision support tools. More legible documentation reducing errors from handwritten notes. Ability to generate reports for population health monitoring and quality improvement initiatives. Potential for cost savings by increasing practice efficiencies and reducing redundant care. Pg 392 sherpath **ATI INFO:** EHRs offer numerous advantages. For example, such electronic records allow providers to follow a client's care from one facility to another, with information, including a complete medical history, being available instantaneously. EHRs also enhance communication between providers. Moreover, with legible documentation, medical and prescription errors are reduced, and more reliable coding and billing can occur. While EHRs offer convenience and improvements over the paper chart documentation systems of the past, their most important goal is to improve client care and provide for better health outcomes. Heath care workers utilize information systems in the form of the electronic health record to obtain histories on their clients in real-time. The electronic health record is a real-time computerized form of a client's paper chart that can be shared among authorized providers; it includes the client's medical history, diagnosis, allergies, and diagnostic testing results. Service quality and customer service must also be factored in. Clinical quality depends on its clinical information systems and is considered an indispensable element of routine operations in today\'s hospitals. A robust clinical information system has the ability to shorten critical decision-making periods by providing accurate and reliable client information. The system will be expected to expediently process extensive amounts of client protected health information (PHI) and complex medical information. This decreases health care workers' response time to clients by allowing for more rapid diagnoses and comprehensive treatment plans, which enhances client satisfaction and ultimately hospital revenue. The concerns for loss of client information, redundancy in forms, and accurate timely medication reconciliation are just a few examples of how quality is improved with a robust system. With improvement in the quality of care that the system provides, client satisfaction, which greatly impacts the health of any health care system, is greatly improved. 7. r. 1\. High implementation and ongoing costs for hardware, software, training, and maintenance. 2\. Workflow disruptions and productivity loss during the transition from paper to electronic records. 3\. System interoperability issues when integrating data from different EHR platforms. 4\. User resistance and difficulties adapting to new technologies and processes. 5\. Concerns over privacy and data security breaches with electronic records. 6\. Need for extensive user training to ensure proper documentation and maximize EHR capabilities. 7\. Alert fatigue from excessive clinical decision support alerts and pop-ups. 8\. Potential for transcription errors when inputting data into structured EHR formats. Overcoming these challenges requires careful planning, training, optimized system design, and ongoing refinement to realize the full benefits of EHRs. High implementation and maintenance costs for healthcare organizations. Workflow disruptions and productivity loss during EHR transition from paper records. System interoperability issues between different EHR platforms. User training and resistance to change from clinicians. Concerns over data privacy, security breaches, and patient confidentiality. Alert fatigue from excessive clinical decision support alerts. Potential for documentation errors if data is inputted incorrectly. Time required for data entry detracting from patient interaction time. Pg. 392 sherpath **ATI** Although EHRs have proven to have great benefits, there can be legal ramifications if documentation is incomplete or inaccurate. Specifically, components of a medical record can be used as evidence in a court of law. Thus, nurses must follow the ANA's standards, which require documentation to be factual, accurate, complete, timely, organized, and compliant. In using EHRs, nurses must also be aware of state and federal regulations, the health care facility's policies, and their obligations to their profession to ensure documentation is accurate. 8. s. t. u. v. w. x. Pg 29 sherpath Remote patient monitoring (RPM) involves the use of digital technologies to collect and transmit patient health data from their home or other location to healthcare providers for monitoring and management of their condition. Key aspects of RPM include: \- Wearable or implantable biosensors that continuously track vital signs like heart rate, blood pressure, blood glucose levels, etc. \- Mobile apps and connected devices that allow patients to report symptoms, adherence to treatment plans, etc. \- Secure transmission of patient data to their care team via the internet or wireless networks. \- Analysis of the data by providers to monitor disease progression, adjust treatment plans, detect early warning signs, etc. \- Two-way communication between patients and providers for education, feedback, and virtual visits as needed. RPM enables more proactive and personalized care for patients with chronic conditions while reducing hospital admissions and allowing them to receive care in their home environment. It empowers patients to take an active role in self-management under professional guidance. **ATI:** ### **Electronic Monitoring Devices** Remote patient monitoring (RPM) is a form of telehealth medicine that assists in the tracking of client information and facilitates the rapid transfer of information to the health care provider. Electronic monitoring devices involve the use of mobile medical devices, sensors, and technology to collect client data and transmit the data to health care providers. The collection and transfer of information is accomplished through the use of wired or wireless devices, such as implantable defibrillators, sensors, blood pressure cuffs, pulse oximeters, and blood glucose meters Typical physiological data that can be collected include heart rhythm, vital signs, blood oxygen saturation level, and blood glucose level. Other types of monitoring devices include those that can detect motion or transmit real-time video. Wearable monitoring device sensors can be placed in clothes and elastic bands directly attached to a client's body. The devices can be used for real-time monitoring in detecting client falls, observing gait and activity, and assessing sleep patterns RPM can send information submitted by the user, store data in secure locations accessible to the health care providers, highlight abnormal data, and alert both health care providers and caregivers of unexpected readings by text message or email. Some devices also include the ability to link clients to their health records, provide educational resources and interactive self-care tools, and connect the client to their health care provider. Many RPM devices permit the client to produce patient-generated health data (PGHD), data that is generated, documented, or collected by the client or caregiver to maintain their health. PGHD includes client health history, bodily measurements, symptoms, and individual behavioral factors. Through the use of RPM, clients are better able to manage their health and be an active participant in their health care. 9. y. z. a. b. c. Pg. 373 sherpath video " Patient Education in Nursing Practice" **ATI** According to Healthy People 2030, health literacy is a very important foundational principle and goal. The Healthy People 2030 definitions of health literacy include personal and organizational health literacy. Organizational health literacy is the extent to which organizations equitably assist individuals with understanding, finding, and using information and services to make informed health-related decisions for themselves and others. Personal health literacy is defined as the extent to which an individual can obtain, process, and comprehend basic health information. Health literacy, the ability to read, write, and understand health-related information, significantly impacts client outcomes. - - 10. d. e. f. g. h. i. j. k. ATI INFO: clinical information system Computer systems that allow for instant retrieval of client information either directly or from data networks. A clinical information system is a computer system that allows for instant retrieval of client information either directly or from data networks. They are those processes used primarily by nurses, providers, and other members of the interprofessional team at the clinical point of care site. To enhance the quality of health services, health care organizations recognize the importance of information technology and user end satisfaction. Information technology is technology and physical devices used to create and store information, including electronic health records. Clinical information systems are comprised of those interface opportunities that take place at the point of clinical care. This can range from barcode scanning, documenting, and medication administration to arm band scanning by ancillary personnel for procedures such as venipuncture lab draws. Health care providers may also utilize order entry systems at the point of clinical care to ensure timely entry of medications, procedures, or treatments. 11. l. m. n. o. Pg.402, 403 sherpath **ATI** A clinical information system is a computer system that allows for instant retrieval of client information either directly or from data networks. They are those processes used primarily by nurses, providers, and other members of the interprofessional team at the clinical point of care site. To enhance the quality of health services, health care organizations recognize the importance of information technology and user end satisfaction 12. p. 1\. Improve quality, safety, and efficiency of care 2\. Engage patients and families 3\. Improve care coordination 4\. Promote public and population health 5\. Ensure privacy and security of patient data The goal was for healthcare providers to demonstrate \"meaningful use\" of certified EHR technology by meeting certain objectives within each of these pillars. This initiative aimed to leverage health IT to enhance patient care, increase transparency, and facilitate better health outcomes while safeguarding protected health information. Pg. 392 Sherpath **-ATI** 13. q. r. s. t. u. Pg. 180, 181 sherpath video" Patient Education in Nursing Practice" 14. v. 1\. Communication - It provides a means for the healthcare team to communicate patient information, assessments, interventions, and responses to treatment. This facilitates continuity of care. 2\. Quality Assurance - Thorough documentation demonstrates the quality of care provided and allows for evaluation against standards of practice. It supports quality improvement efforts. 3\. Legal Record - Documentation creates a legal record of the care delivered, protecting both patients and providers. It serves as evidence in case of litigation. 4\. Reimbursement - Accurate and complete documentation is required for appropriate reimbursement from insurance companies and government programs like Medicare/Medicaid. 5\. Research and Education - De-identified patient data from documentation can contribute to research studies and provide learning opportunities for students. Overall, meticulous documentation promotes patient safety, care coordination, professional accountability, and the advancement of evidence-based practices in healthcare. Pg.389 sherpath video" Documentation in the Electronic Health Record" **ATI INFO:** The functions/purpose of documentation can include charting vital signs and assessments, medication administration, and documenting completed treatments and procedures. While electronic documentation has enabled quick and easy creation and storage of vast amounts of client information, and mainstream hospitals and clinics in the United States have integrated electronic documentation systems in their clinical practices, health care workers report struggling to balance documentation and client care tasks. They often feel that the enormity of time spent on documentation compromises their time spent on direct client care. However, the importance of complete, accurate, and timely documentation cannot be understated. Nursing documentation not only provides evidence of care provided, it is a professional and legal necessity. Inaccurate or incomplete documentation can influence continuity and quality of client care which has fostered a need to improve nursing documentation. The need for improved nursing documentation involves meeting legal requirements, decreasing paperwork, and complying with professional standards. 15. w. [Patient Demographics:] Name, date of birth, contact information, insurance details. [Medical History:] Past illnesses, surgeries, medications, allergies, immunizations. [Clinical Notes:] Progress notes, consultation reports, discharge summaries from providers. [Diagnostic Data]: Laboratory test results, radiology reports, pathology findings. [Medication Lists:] Current and past prescribed medications, dosages, instructions. [Vital Signs]: Blood pressure, temperature, pulse, respiratory rate, etc. [Care Plans:] Diagnoses, goals, interventions, and evaluations for treatment. [Orders:] Prescriptions, referrals, procedures requested by providers. [Billing/Claims:] Charges, payments, insurance information for reimbursement. The integrated EHR allows access to this comprehensive patient data across healthcare settings to coordinate care. Pg 392 sherpath 16. +-----------------------------------+-----------------------------------+ | Pros of Electronic Health Records | Cons of EHRs: | | (EHRs): | | | | 1\. High upfront implementation | | 1\. Improved accessibility to | and maintenance costs | | patient data across healthcare | | | settings | 2\. Workflow disruptions during | | | transition from paper records | | 2\. Enhanced coordination and | | | continuity of care | 3\. Privacy and security | | | concerns over electronic data | | 3\. Reduction in medical errors | | | through computerized order | 4\. Excessive time spent on data | | entry | entry by clinicians | | | | | 4\. Better tracking of patient | 5\. Potential for transcription | | data over time | errors during data migration | | | | | 5\. Ability to generate reports | 6\. Overdependence on technology | | for quality improvement and | and system downtimes | | research | | | | 7\. Need for extensive training | | 6\. Increased legibility | and technical support | | compared to handwritten records | | | | | | 7\. Potential cost savings from | | | reduced paperwork and improved | | | efficiency | | +-----------------------------------+-----------------------------------+ While EHRs offer many benefits, their successful adoption requires addressing challenges related to costs, workflow integration, data integrity, and user acceptance. Pg. 392 Sherpath Pro's ATI: **Electronic Documentation** Electronic documentation is often used as a means of communication among health care providers. It offers many advantages, including the following. - - - - - While electronic documentation certainly offers many benefits, its use also requires that precautions be taken. The security and privacy of client data must always be protected. To address these needs, many EHRs contain security features such as password protection, firewalls, and encryption. Con's ATI: **Documentation During EHR Downtime** EHRs are widely used throughout the health care system, but occasionally these systems experience downtimes. A downtime event occurs when all of or part of the EHR's functions become unavailable; such events may be either planned or unexpected. EHR downtimes can be extremely disruptive to client care. Nurses must be aware of their facility's procedures for managing such events---and must recognize that documentation still needs to occur during downtime events. Health care providers must often switch to paper documentation during downtime. 17. x. **ATI INFO:** Several different systems can be used when documenting client information. The documentation system used within any health care facility depends on the specific needs and preference of that facility. Documentation methods include: - - - - - - ### **PIE Model** - - - A simplified approach to documentation, this model uses both flowsheets and progress notes. When using the PIE model for a progress note, the problem is defined using a nursing diagnosis. The PIE model focuses on the nursing process and includes an ongoing plan of care instead of the traditional plan of care. +-----------------------+-----------------------+-----------------------+ | DATE | TIME | NURSE\'S NOTE | +=======================+=======================+=======================+ | 5/1/2019 | 0900 | P\#1 Risk for | | | | impaired skin | | | | integrity secondary | | | | to prescription for | | | | complete bed rest. | +-----------------------+-----------------------+-----------------------+ | | | I\#1 Schedule for | | | | turning every 2 hours | | | | established. | | | | | | | | ---J. Doe, RN | +-----------------------+-----------------------+-----------------------+ | | 1500 | E\#1 No evidence of | | | | skin breakdown. | | | | Client tolerating | | | | turns well. | | | | | | | | ---J. Doe, RN | +-----------------------+-----------------------+-----------------------+ 18. y. **ATI INFO:** ------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------- **S: Subjective** **The subjective portion of SOAP documentation contains information from the client.\ **Client states "I noticed I'm a bit short of breath when I walked in the hallway."** This information can include the client's feelings or views. This information is collected from the client or sometimes a caregiver or family member.** ------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------- +-----------------------+-----------------------+-----------------------+ | **O: Objective** | **The clinical | **Temperature: 99.4° | | | impressions recorded | F (37.4° C); Heart | | | in this section are | rate 88/min; | | | based on what the | Respiration rate | | | nurse observes or | 20/min; Blood | | | measures. This | pressure 138/88 mmHg; | | | include vital signs | SpO2 93% on room air | | | and physical | while at rest.** | | | assessment | | | | findings.** | **Respirations | | | | unlabored at rest but | | | | becomes slightly | | | | dyspneic while | | | | speaking. Color is | | | | pale. Lung sounds | | | | diminished in the | | | | bases bilaterally. | | | | Frequent cough | | | | productive for thick | | | | green sputum.** | +-----------------------+-----------------------+-----------------------+ 19. z. ATI Focus charting documents a client's specific health care problem by focusing on the nursing diagnosis as well as changes in the client's condition, events, and concerns. The three items that must be documented when using the focused charting method are data, action, and response (**DAR**). Focus charting also includes immediate and future nursing actions. focus charting +-----------------------+-----------------------+-----------------------+ | DATE/TIME | FOCUS | PROGRESS NOTE | +=======================+=======================+=======================+ | 5/1/2019 | Pain | D: Client reports | | | | incisional pain at | | 0830 | | 8/10. | +-----------------------+-----------------------+-----------------------+ | | | A: Hydromorphone | | | | 0.5mg IV | | | | administered. | | | | | | | | ---J. Doe, RN | +-----------------------+-----------------------+-----------------------+ | 0945 | | R: Client pain has | | | | decreased to 3/10 | | | | which meets the | | | | client's pain goal. | | | | | | | | ---J. Doe, RN | +-----------------------+-----------------------+-----------------------+ 20. a. 1\. Narrative charting - Writing detailed notes in a free-flowing paragraph format to document patient care. 2\. Source-oriented charting - Documenting based on sources like progress notes, flow sheets, graphics, etc. 3\. Problem-oriented charting - Organizing notes around a patient\'s identified problems or needs. 4\. Focus charting - Documenting by exception, only noting new or changing patient data. 5\. PIE (Problem/Intervention/Evaluation) charting - Structuring notes around identified problems, nursing interventions, and evaluations. The materials state that healthcare agencies select a documentation system that aligns with their nursing philosophy and use it consistently throughout the organization. Pg.396 sherpath video "Documentation in the Electronic Health Record" 21. b. c. d. e. f. g. h. i. Thorough documentation demonstrating you met standards of care is vital evidence if legal issues arise. Pg.390,394,396 sherpath video "Documentation in the Electronic Health Record" 22. j. 23. k. \- Measuring blood pressure to evaluate cardiac output and vascular resistance \- Palpating peripheral pulses to assess arterial flow and heart function \- Inspecting for edema, skin color changes, and capillary refill time to detect circulatory issues \- Auscultating heart sounds to identify murmurs or abnormal rhythms \- Monitoring heart rate and rhythm for tachycardia, bradycardia or dysrhythmias \- Assessing respiratory rate and effort which impacts cardiac workload \- Noting any chest pain, shortness of breath or other cardiovascular symptoms A thorough cardiovascular assessment provides vital data on heart health, perfusion status, and potential cardiac or vascular disorders. Prompt recognition of abnormalities guides nursing interventions. Pg. 515, 887. sherpath , Video "Pulse" 24. l. Inspection: Observe abdomen for distension, visible peristalsis, surgical scars. Note bowel sounds. Auscultation: Listen for normal or abnormal bowel sounds in all abdominal quadrants. Palpation: Gently palpate for tenderness, masses, organomegaly, abnormal pulsations. Percussion: Percuss for tympany or dullness indicating gas patterns or fluid accumulation. History: Ask about diet, bowel habits, pain, nausea, vomiting, bleeding, medications. Diagnostic tests like endoscopy, imaging, labs may be needed for further evaluation. Thorough GI assessment helps identify issues like obstruction, inflammation, bleeding, or malabsorption. Pg. 1284 sherpath Video" Assessment of Abdomen" 25. m. n. o. p. *Hand-off* is a term that is used to describe the process of data and information exchange about a patient. - - q. 26. r. 27. s. 28. t. \- Establishing national standards for electronic health transactions and code sets. \- Requiring reasonable safeguards to protect the confidentiality, integrity, and availability of electronic protected health information (ePHI). \- Defining limits on the use and disclosure of individuals\' health records. \- Giving patients rights over their health information, including the right to access their records. \- Implementing civil and criminal penalties for HIPAA violations. HIPAA mandates that healthcare providers, health plans, and healthcare clearinghouses take measures to protect patient privacy and prevent unauthorized access or sharing of protected health information. Adhering to HIPAA regulations is crucial for maintaining patient confidentiality and trust in the healthcare system. Pg.318,392,393 sherpath **ATI:** Client health care information is both protected and sensitive under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA is a federal law enacted to safeguard clients' medical health information when it is being accessed or shared electronically without the clients' consent or knowledge. The purpose of HIPAA is to reduce fraud and deter inappropriate use of client health care information. There are several regulatory components that are covered under HIPAA. These components include the Privacy Rule, which defines the standards under which protected health information (PHI) in any form could be used and disclosed; the Security Rule, which establishes safeguards for electronic PHI; and the Breach Notification Rule, which mandates that clients are notified about a breach of their unsecured PHI. 29. u. Situation - Identify the patient and describe the current situation or concern. Background - Provide relevant background information, such as patient history, medications, and recent events. Assessment - Explain your assessment of the situation, including vital signs, symptoms, and potential issues. Recommendation - State your recommendation for the next steps or actions needed. Using the SBAR format ensures that critical information is communicated effectively during handoffs, consultations, or when escalating concerns. It promotes patient safety by facilitating accurate information transfer and shared understanding among the healthcare team. Pg. 351,398,426 sherpath B\) Integrating nursing science with information technology