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Fundamentals of Nursing Final review
Terms in this set (22)
things that are observable through senses of hearing, sight, smell, touch, x-rays, medicals records, labs,
information that is known only by the patient and patient family members
What concerns should determine what pt to be seen as priority?
nursing interventions that are provided without consultation with anyone else, a physicians order is not required to perform them
interventions that require a healthcare provider's order before they can perform
Quality improvement program?
this practice requires that we review and evaluate our care and use the data to improve our processes (monitor improvement and compliance)
Why is Nursing documentation important?
protects us from legalities
documenting proves it was done
How to correct an documentation error?
mark a single horizontal line write "mistaken entry" and your initials just above the incorrect word
safeguarding pt's information- avoid discussing pt information in public places- avoid leaving charts open where they can be view
(HIPAA)The Health Insurance Portability and Accountability Act
protect health information(PHI) they network and process security measures in place and follow them to ensure compliance
What does it mean to be cultural literacy?
choosing to be aware of and familiarize oneself with aspects of cultural difference
is patient centered communication- to promote a greater understanding of pt's needs, concerns, feelings
What does it means to delegate safely?
That the person you are asking to do the task that it is within the person scope of practice- as the Nurse follow up to make sure the task was done
Hearing impaired how should you address them?
Always face the patient
Telephone order how to document after received?
T/O - R/B
Be able to identify what the philosophy of hospice is
a program designed to provide palliative care and emotional support to the terminally ill in home or a homelike setting so that quality of life is maintained and family members may be active participants in care.
Describe what happens to a patient that is actively dying.
decrease LOC- mottling-Fingers, earlobes, lips and nail beds may look bluish or light gray.
incontinence- restlessness- congestion- signs of dehydration- abnormal breathing patterns, urination decrease- urine may be concentrated- may develop fever- fluid and food intake decrease
Hoe to find Apical pulse
start at midclavicular line go down to the 5th intercostal space to locate pulse
How should Nursing goals be written?
measurable related to medical diagnosis may have subjective and objective data
Cardiac assessment what would the nurse see in this time of assessment if pt is experiencing right and left sided symptoms
SOB- coughing- irregular heart beat sounds "gallops"- increased heart rate- lungs crackling- experiencing cyanosis and feel cool- peripheral edema- weight gain- JVD
What would the Nurse include in an neurological assessment
Six cardinal gaze- PERRLA- (pupils, equal round reactive to light and accommodation)
capillary refill- check grip- LOC
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