exam 1 nur 210(Graded A+ actual test)

abbreviations (**just know them-VERY IMPORTANT) - VOLUME: liter (L) milliliter (mL) 1 L = 1,000 mL 1 mL = 1 cc WEIGHT: kilogram (kg) 1 kg = 1,000 g gram (g) 1 g = 1,000 mg milligram (mg) 1 mg = 1,000 mcg microgram (mcg) HOUSEHOLD: 1 Tbsp = 15 mL 2.2 lbs = 1 kg tablespoon (Tbsp) 1 tsp = 5 mL 30 mL = 1 oz teaspoon (tsp) 3 tsp = 1 Tbsp 2 Tbsp = 1 oz fahrenheit / celsius - °F — °C °C = (°F - 32) / 1.8 °C — °F °F = °C x 1.8 + 32 exchange of information using words understood by the receiver in a way that conveys professional caring and respect. - verbal communication includes body language and facial expressions, tone of voice, and pace of conversation - examples include facing a patient at eye level and making eye contact - nonverbal communication **80% of communication is nonverballist and explain the 3 types of communication styles which type should us as nurses use? - passive communication - puts the rights of others before their own, tend to be apologetic, often do not speak up aggressive communication - advocate for their own rights, tells others their feelings don't matter assertive communication*** - conveys information that describes the facts and the sender's feelings without disrespecting the receiver's feelings (this communication is an effective way to solve problems with patients, coworkers, and other health care members) list some of the common barriers to communication - jargon (avoid using medical terminology) lack of attention noise light hearing and speech problems language differences differences in cultural beliefs the purposeful, interpersonal information-transmitting process through words and behaviors based on both parties' knowledge, attitudes, and skills, which leads to patient understanding and participation - therapeutic communication (vital element of nursing) communicating verbally and nonverbally, being interested in what the other person is saying while also actively verifying our understanding with the speaker - active listening powerful way to professionally communicate caring and empathy if done respectfully while being aware of patients cultural beliefs - touch therapeutic techniques are specific methods used to provide patients with support and information while focusing on their concerns. list some of these techniques. - active listening using silence acceptinggiving recognition offering self seeking clarification focusing list some examples of NONtherapeutic responses - asking personal questions giving personal opinions changing subject asking "why" questions approving or disapproving giving defensive responses arguing what is the act that provides standards for ensuring privacy of patient information that are enforceable by law (maintains patient confidentiality)? - the health insurance portability and accountability act (HIPAA) ISBARR - common format used to exchange patient information. - Introduction - your name, role, and agency from which you're calling Situation - patients name, reason for calling, vital signs, and status Background - info about patient such as admitting medical diagnosis, allergies, or lab results Assessment - abnormal findings Request/Recommendations - state what you would like the provider to do, such as prescribing medicine Repeat back - to confirm accuracy real-time, patient-centered record that makes information available instantly and securely to authorized users (can be found in patient rooms, on wheeled carts, in workstations, or on handheld devices) - electronic health record (EHR) history and physical, provider orders, medication records, treatment records, lab and diagnostic results, progress n types of documentation (**just know) - charting by exception (CBE) - list of normal findings - decreases time required to document care DAR (data, action, response) narrative notes - progress note that chronicles all the assessment findings and nursing activities for patient that occurred during shift SOAPIE - subjective, objective, assessment, plan, interventions, evaluation patient discharge summary minimum data set (MDS) - federally mandated assessment tool to track a patient's goal achievement, as well as optimizing the residents quality of care and quality of life - guides nursing care plan development services that a trained health professional is deemed competent to perform and permitted to undertake according to their terms of their license. - scope of practice authoritative statements of the actions and behaviors that all RNs, regardless of role, population, speciality, and setting, are expected to perform competently. - standards of practice (nurse practice act) (goal is to ensure safe, competent care for the public) levels of health care - PRIMARY - promotes wellness and prevents disease (physician offices, school nursing) SECONDARY - person has contracted an illness or injury and requires medical care (hospital, urgent care, clinics) TERTIARY - long term effects from chronic illnesses or conditions with purpose to restore a patients maximum function (home care, hospice centers, nursing units, rehabilitation units)name some of the members of the health care team. - dieticians, therapists, pharmacists, social workers negligence and malpractice - negligence is a general term that denotes conduct lacking in due care, carelessness, and a deviation from the standard of care that a reasonable person would use in a particular set of circumstances. malpractice is a more specific term that looks at a standard of care as well as the status of the caregiver. to be considered malpractice, 6 criteria have to be met - duty owed the patient, breach of duty (like failure to follow protocols), foreseeability, causation, injury, and damages "nursing practice is safe, effective, efficient, equitable, timely, and person-centered." - quality of practice "a lifelong problem-solving approach that integrates the best evidence from well-designed research studies and evidence-based theories." - evidence-based practice **means that nurses provide patient care based on research studies and clinical expertise founder of modern nursing practice; focused on clean environment, clean water, and good nutrition for wounded soldiers - florence nightingale regulations of nursing practice within that state and defines the scope of nursing practice - nurse practice act this allows a nurse to have one multistate nursing license with the ability to practice in their home state - the nurse licensure compact (NLC) the right of an individual to have personal, identifiable medical information kept private - patient confidentialitypersonal values, character, or conduct of individuals within communities and societies - morality protocol - a precise and detailed written plan for a regiment of therapy organization whose mission is to improve health care for the public by inspiring organizations to excel in providing safe, effective, and high quality health care - joint commission