A
VI
TU
IS
M
O
ATI PN Fundamentals
A
N
Nursing Content Mastery
JP
Series Review Module 2024
Latest Version GRADE A+!!
,Caring for a Client Who Has Dysphagia
when feeding tell them to tilt their chin to their chest
- Provide oral care prior to eating
- Refer these patients to a speech therapist
- Dietary modifications are based on specific swallowing limitations
- Allow adequate time for eating, use adaptive eating devices, and encourage small
A
bites
- Pills should be taken with 8 ounces of fluid to prevent med staying in the esophagus
VI
- Avoid thin liquids and sticky foods
TU
Maintaining Client Confidentiality
-information should be accessed only on a need-to-need basis
-perform appropriate log-out
-conversations about patients should be held in private conference rooms
IS
-information about the patient could only be discussed with other employees that are
working directly with the patient
-PHI (protected health information)
M
Identifying Appropriate Documentation for a Client's Health Record
-must check the first and last name, date of birth
O
-all entries in the medical record must be permanent, accurate, complete and legible
Document assessments, medication administration, treatments and responses, client
A
education
N
Subjective data from patient - use quotation marks identifying that it's the client's
statement
JP
Client Advocacy Relating to Refusal of a Procedure
Competent adults have the right to refuse treatment or procedure
- Determine the reason
- Provide information regarding the risk of refusal
- Notify HCP
- Document refusal & actions taken
,Client must sign document stating they understand the risks involved with refusal of
treatment
Demonstrating Advocacy
-support and defend clients health, wellness, safety, wishes and personal rights
including privacy
A
Nurses demonstrate client advocacy by safeguarding clients from harm and by
representing clients' needs to other healthcare professionals.
VI
Understanding Ethical Principals
-advocacy, responsibility, accountability, confidentiality
TU
-autonomy: the right to make one's own personal decisions even when those decisions
might not be in that person's own interest.
-beneficence: action that promotes good from others, without any self-interest.
-fidelity: fulfillment of promises.
IS
-justice: fairness in care delivery and use of resources.
-nonmaleficence: a commitment to do no harm.
-veracity: a commitment to tell the truth.
M
Evaluating Patient's Understanding of Advance Directives
-the communication of a client's wishes regarding end-of-life care should the client
O
become unable to speak for themselves.
- Living Will - client's decisions written in advance.
A
- Durable Power of Attorney - designating another to make decisions.
N
Only a doctor can prescribe a DNR.
PSDA (Patient Self Determination Act) requires all patients upon admission to be asked
JP
if they have advanced directives.
If patient doesn't have advanced directives, nurse should give patient written information
regarding their rights related to health care and advance directives
Health care representative should be around during filling out of AD.
, Providing Information About Advance Directives
-legal documents that allow you to spell out your decisions about end of life ahead of
time
-providing written information about advanced directives
-document clients ADs
-ensure the ADs reflect the client's current decisions
-inform all members of the health care team of the clients ADs
A
Reinforcing Teaching About Informed Consent
-it is a legal process by which a client or the client's legally appointed designee has
VI
given written permission for a procedure or treatment
-if patient expresses that they do not understand the procedure, do not proceed.
TU
Identifying a Client Who Can Give Informed Consent
-the patient is able to sign the form themselves, they must be capable of understanding
the information from the health care professional who will perform the surgical
IS
procedure
• Actions to Take for a Client who is Attempting to Leave Before Being
M
Discharged
-Have them sign against medical advice form (AMA)
O
-Inform them about the consequences they may have if they are not being treated for
their illness
-Inform the health care provider
A
-Do not stop them.
N
• Legal Documentation Guidelines
-documentation has to have exactly what happened to the patient in case there are
JP
legal actions taken later on
-the quality and accuracy of nursing notes are extremely important
-nurses must ensure the information recorded in the chart is clear, concise, complete
and accurate
-Begin each entry with date and time
-legible
-no correction fluid or black out errors (use facility's procedure for error correction)
VI
TU
IS
M
O
ATI PN Fundamentals
A
N
Nursing Content Mastery
JP
Series Review Module 2024
Latest Version GRADE A+!!
,Caring for a Client Who Has Dysphagia
when feeding tell them to tilt their chin to their chest
- Provide oral care prior to eating
- Refer these patients to a speech therapist
- Dietary modifications are based on specific swallowing limitations
- Allow adequate time for eating, use adaptive eating devices, and encourage small
A
bites
- Pills should be taken with 8 ounces of fluid to prevent med staying in the esophagus
VI
- Avoid thin liquids and sticky foods
TU
Maintaining Client Confidentiality
-information should be accessed only on a need-to-need basis
-perform appropriate log-out
-conversations about patients should be held in private conference rooms
IS
-information about the patient could only be discussed with other employees that are
working directly with the patient
-PHI (protected health information)
M
Identifying Appropriate Documentation for a Client's Health Record
-must check the first and last name, date of birth
O
-all entries in the medical record must be permanent, accurate, complete and legible
Document assessments, medication administration, treatments and responses, client
A
education
N
Subjective data from patient - use quotation marks identifying that it's the client's
statement
JP
Client Advocacy Relating to Refusal of a Procedure
Competent adults have the right to refuse treatment or procedure
- Determine the reason
- Provide information regarding the risk of refusal
- Notify HCP
- Document refusal & actions taken
,Client must sign document stating they understand the risks involved with refusal of
treatment
Demonstrating Advocacy
-support and defend clients health, wellness, safety, wishes and personal rights
including privacy
A
Nurses demonstrate client advocacy by safeguarding clients from harm and by
representing clients' needs to other healthcare professionals.
VI
Understanding Ethical Principals
-advocacy, responsibility, accountability, confidentiality
TU
-autonomy: the right to make one's own personal decisions even when those decisions
might not be in that person's own interest.
-beneficence: action that promotes good from others, without any self-interest.
-fidelity: fulfillment of promises.
IS
-justice: fairness in care delivery and use of resources.
-nonmaleficence: a commitment to do no harm.
-veracity: a commitment to tell the truth.
M
Evaluating Patient's Understanding of Advance Directives
-the communication of a client's wishes regarding end-of-life care should the client
O
become unable to speak for themselves.
- Living Will - client's decisions written in advance.
A
- Durable Power of Attorney - designating another to make decisions.
N
Only a doctor can prescribe a DNR.
PSDA (Patient Self Determination Act) requires all patients upon admission to be asked
JP
if they have advanced directives.
If patient doesn't have advanced directives, nurse should give patient written information
regarding their rights related to health care and advance directives
Health care representative should be around during filling out of AD.
, Providing Information About Advance Directives
-legal documents that allow you to spell out your decisions about end of life ahead of
time
-providing written information about advanced directives
-document clients ADs
-ensure the ADs reflect the client's current decisions
-inform all members of the health care team of the clients ADs
A
Reinforcing Teaching About Informed Consent
-it is a legal process by which a client or the client's legally appointed designee has
VI
given written permission for a procedure or treatment
-if patient expresses that they do not understand the procedure, do not proceed.
TU
Identifying a Client Who Can Give Informed Consent
-the patient is able to sign the form themselves, they must be capable of understanding
the information from the health care professional who will perform the surgical
IS
procedure
• Actions to Take for a Client who is Attempting to Leave Before Being
M
Discharged
-Have them sign against medical advice form (AMA)
O
-Inform them about the consequences they may have if they are not being treated for
their illness
-Inform the health care provider
A
-Do not stop them.
N
• Legal Documentation Guidelines
-documentation has to have exactly what happened to the patient in case there are
JP
legal actions taken later on
-the quality and accuracy of nursing notes are extremely important
-nurses must ensure the information recorded in the chart is clear, concise, complete
and accurate
-Begin each entry with date and time
-legible
-no correction fluid or black out errors (use facility's procedure for error correction)
