Summary

This study guide covers various modules related to nursing, including palliative care, disease prevention levels, and responsibilities of nursing professionals. It also details the nursing process, crucial documentation guidelines, and addresses issues such as employee passwords, security, and prescriptions.

Full Transcript

Module 1 – The Caring Profession of Nursing What is the purpose of palliative care? Specialized medical care for people living with a serious illness. This type of care is focused on providing relief from the symptoms and stress of the illness. The goal is to improve quality o...

Module 1 – The Caring Profession of Nursing What is the purpose of palliative care? Specialized medical care for people living with a serious illness. This type of care is focused on providing relief from the symptoms and stress of the illness. The goal is to improve quality of life for both the patient and the family. What are the 3 levels of disease prevention? Primary - Prevents illnesses and diseases from developing ○ Examples Vaccinations Counseling Secondary - Disease is detected and treated early, often before symptoms occur ○ Examples Mammogram DEXA scan Colonoscopy Tertiary - Management of a chronic disease to prevent complications or further damage ○ Examples Managing blood sugars, skin integrity and feet exams of a diabetic patient. Stroke patient taking aspirin to prevent another stroke from happening. Physical Therapy for injuries. What is the responsibility of the state board of nursing? evaluate license applications, issue licenses, renew licenses, and take disciplinary action in response to professional misconduct. What is the purpose of the Nurse Practice Act? Regulate and protect the public from practitioners who are a risk to the health, safety, and welfare of the citizens within its state board jurisdiction. This protection principle is accomplished by assessing competence at initial licensure and throughout the career of the nurse. What is the American Nurses’ Association and what is their role in nursing practice? ANA exists to advance the nursing profession by: Fostering high standards of nursing practice; Promoting a safe and ethical work environment; Bolstering the health and wellness of nurses What is the responsibility of The Joint Commission? The Joint Commission is an independent, nonprofit organization that aims to improve healthcare for the public by evaluating and accrediting healthcare organizations and programs. It accredits and certifies more than 22,000 healthcare organizations and programs, including hospitals, behavioral health, home health care, and nursing care centers. Describe social determinants of health. (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Ex: Physiological stressors, safety, transportation, health literacy, Give examples within of the levels of Maslow’s Hierarchy of Needs: o Physiological – Most basic needs; Ex. Food, water, shelter, etc. o Safety – Job and financial security, physical and emotional health, law and order in society, safety from physical danger o Love and belonging - Love, intimacy, friendship, trust, feeling of belonging, connecting with others o Self-esteem - Confidence, competence, respect, status, recognition, attention, reputation, achievement, dignity, etc. o Self-actualization - Personal growth and reaching the fullest potential. These needs are specific to each person; Ex: being a great parent, an accomplished athlete, an excellent student, etc. Module 2 – Clinical Judgment Applying the Nursing Process: What occurs during each step? o Assessment: Collecting and organizing relevant data; Includes subjective and objective information; Check body systems from head to toe. o Diagnosis: Identifying the causative factors that are impacting the patient; (NANDA book) o Planning: Identifying measurable goals in collaboration with the patient to resolve the nursing diagnosis. o Implementation: Implementing actions to attain defined goals. o Evaluation: Reassessing whether the identified goals have been achieved; Returned demonstration (teach-back method) Give examples of subjective and objective findings Subjective: o Stress o Abdomen hurting o Pain o Difficulty sleeping o Frequent headaches Objective: o BP 132/89 o Patient diaphoretic o Rash o Cough o Temp 101.1 o Swelling in lower extremities Module 3 – Documentation Employee passwords/security Receiving a prescription by telephone. What does the nurse need to remember? o Repeat the prescription back to the provider. o Question any unclear parts of the order. o Document in the MAR portion of the patient’s chart. o Obtain the provider’s signature on the order ASAP Legal Guidelines for Documentation-Documentation Errors o List important guidelines to follow when documenting. ▪ Document subjectively ▪ Follow the Joint Commission’s list of abbreviations per the Joint Commission’s guidelines ▪ Record only facts, no opinions or heresay ▪ Communicate effectively and efficiently o What should the nurse do to correct an error when documenting? ▪ Strike out the error, write error beside the strikeout and initial. HIPAA (Health Insurance Portability Accountability Act) o What is it? List guidelines to follow to protect the patient under HIPPA. ▪ Never share a password. ▪ Only access medical records for patients you are currently treating. ▪ Don’t gossip about patient status with other staff members ▪ Always logout of the computer when leaving a work station What is the proper channel to access your own medical records? ○ Requesting them directly from the providers office or medical records department. What is an incident report and why do we use them in healthcare? ○ A record of an unexpected event that involves a patient, family member, or employee. These reports can include things like falls or administering the wrong dose of medication. ○ Incident reports should not be documented directly in the patient’s chart. Describe the components of an SBAR report: o S (Situation) - Clearly and briefly describe the current situation. o B (Background) - Provide clear, relevant background information on the patient. o A (Assessment) - State your professional conclusion, based on the situation and background. o R (Recommendation) - Tell the person with whom you’re communicating what you need from him or her, in a clear and relevant way. Module 4 - Teaching/Learning Best environment for teaching: Well-lit room, no distractions, reduce noise by shutting door. Avoid medical terminology. Utilize the healthcare facility interpreter. Understanding of different types of learning styles. Module 5 – Therapeutic Communication Barriers to Effective Communication. List barriers. o Giving advice o Devaluing o Language o Environmental o Psychological o Competing demands o Lack of privacy o Noise Guidelines to Effective Therapeutic Communication. List techniques. o Open-ended questions o Offering self o Active listening o Do not ask “Why” questions. o Accepting Identify some effects of low health literacy o Leads to a decrease in the use of preventative services o Higher use of emergency medical services Identify barriers to effective communication o Loud noises o Pain o Culture o Language o Time constraints o Medication o Lack of preparedness o Conflict Module 6 – Safety Priority Action When Responding to a Fire o Rescue o Alert o Contain o Evacuate Identifying Fall Risks for A Client: List possible fall risks for the patient. o Hospital Environment: ▪ Dim lighting ▪ Loose cords ▪ Slippery surfaces ▪ Inappropriate bed height ▪ Out of reach items o Home Environment: ▪ Rugs ▪ Stairs ▪ Out of reach items ▪ Clutter What interventions would you implement for a confused client trying to get out of bed? o Keep a nightlight on o Move patient to a room closer to nurses station o Obtain periodic assessments o Consider the use of restraints List guidelines for proper use of restraints o Tie the restraints to a part of the bed that moves with the client o Remove every 2 hours to allow patient to move and exercise arms o Put eyes on the patient every 30 mins; Check skin integrity How often do restraints need to be documented? Every 2 hours How often does an order need to be placed for the use of restraints? Every 24 hours Module 7 – Spirituality, Culture, Diversity What is the correct action when speaking with a member of a culture who considers it rude to make eye contact? Continue speaking despite the lack of eye contact How does the nurse ensure accurate communication with a client who does not use English as their primary language? Utilize the use of the healthcare facility's interpreter. Define the following: Acculturation - Assimilation to a different culture. Ethnocentrism - Evaluation of other cultures based on the preconceptions of one's own culture. Ethnicity - Belonging to a population group made up of people who share a common cultural background or descent. Culture - The customs, arts, social institutions, and achievements of a particular nation, people, or other social group. Spirituality - Recognition of a feeling or sense or belief that there is something greater than myself, something more to being human than sensory experience, and that the greater whole of which we are part is cosmic or divine in nature. What culture opposes blood products? Jehova’s Witness Module 8 – Legal and Ethical Informed Consent What is it? What is the nurse’s role? ○ Legal and ethical obligation that protects the patient by ensuring they understand their condition and treatment options, and have had a chance to ask questions. ○ Nurses must witness the signature declaring informed consent by the patient and that they understand the risks associated with the surgery. Define the following and give an example of each: o Assault – An intentional tort and a violation of civil law, is the threat to touch a person without consent (Ex: nurse threatens older adult “if you don’t take this pill, I’ll pinch you when no one is looking”) o Veracity - Conformity and/or devotion to the truth; accuracy. o Beneficence - The act of doing good, being kind or helping others. o Autonomy - Respecting the client's right to make their own decisions about their healthcare. o Confidentiality - The state of keeping or being kept a secret. o Malpractice - Improper, illegal, or negligent professional activity or treatment, especially by a medical practitioner. o Battery - Unlawful application of physical force to another person, or the actual act of physically hurting someone. o Abuse - Improper usage or treatment of a person or thing, often to unfairly or improperly gain benefit. o Negligence - Failure to take proper care in doing something. o False imprisonment - When someone confines or detains another person without their consent. o Libel - The publication or written statement of false statements that damage someone's reputation; Aka defamation. o Slander - The act of saying an untrue, negative statement about someone. o Justice - the concept that individuals are to be treated in a manner that is equitable and fair. Describe health disparities among vulnerable populations: o Less likely to use preventative care o Food insecurity o Access to healthcare What is a sentinel event? Event that results in death, permanent harm, or severe temporary harm to a patient.

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