Transitions Exam 3 questions well
answered already passed
Define Transitions of Care - correct answer ✔✔ Movement of patients between health care
practitioners, settings, and home as condition and care needs change
Ineffective transitions lead to... - correct answer ✔✔ Adverse events
Hospital readmission - biggest concern within 30 days
$$$$ - not getting reimbursement
Root causes of ineffective Transitions - correct answer ✔✔ *Communication breakdown*
-Breakdown in communication between providers, with patient and caregivers
-Culture of setting
-Inadequate time
-Lack of SBAR
*Patient Education Breakdowns*
-Patient education unclear, patient not involved, health literacy
-Confusing med regimens
-Conflicting recommendations
*Accountability Breakdowns*
-Accountability not taken
-Lack of resources
-Lack of coordination of transition
,Examples of causes of ineffective transitions - correct answer ✔✔ -Medical team busy,
discharge low priority, last minute tests delaying discharge
-Medication reconciliation with errors
-Hospital resources, standard forms, financial pressure to fill beds, resistance to change
-No primary care provider, insurance issues, payment for meds, late discharge
8 P's - Risk Factors for Readmission - correct answer ✔✔ *Problems with medications*
polypharmacy, medication reconciliation
Insulin, Anticoagulants, Narcotics, Digoxin
*Psychological*
Hx of psychiatric illness
*Principal Diagnosis*
Chronic diseases
Heart failure, kidney disease, diabetes, COPD
*Physical limitations*
Frailty, over 80, underweight
*Poor health literacy*
,*Poor social support*
No help after discharge
*Prior hospitalization*
Unplanned hospitalizations in the last 6 months is a risk factor
*Palliative care*
Poor prognosis, advanced illness, eligible for palliative care but they want full treatment
High risk medications - correct answer ✔✔ -Insulin
-Anticoagulants (Heparin, Lovenox)
-Narcotics
-Digoxin
-warfarin
Chronic Conditions - correct answer ✔✔ -Occurs in every age, socioeconomic level, culture
-Medical conditions or health problems long-term (3 months or longer)
-*Management only, don't resolve, can't be cured- comorbidities*
Managing involves more than treating medical problems
-Psychosocial - body image issues
-Finances
-Caregiver burnout
Requires *persistent adherence* to therapeutic regimens
, Chronic Illness Trajectory - correct answer ✔✔ 1. Pre-trajectory - at risk (genetic, behaviors)
2. Trajectory- onset of symptoms or disability
3. Stable- managed, reinforce positive behaviors
4. Unstable- exacerbation, complications, uncertainty
5. Acute: Sudden onset of severe sx or complications
6. Crisis phase- critical or life threatening
7. Comeback phase - recovery after acute period
8. Downward phase-worsening, can be arrested and restabilize
9. Dying- gradual or rapid decline despite efforts, failure of life-maintaining body functions
Nursing Process for Chronic Conditions - correct answer ✔✔ -Identify specific problems,
trajectory phase
-Establish, prioritize goals (Will be different depending on where the person is)
-Plan of action to achieve desired outcomes
Interventions focus:
-Regimens to control symptoms, avoid complications
-Psychosocial issues affect quality of life
-Stoplight tools
-Evaluate outcomes, reassess problems
Scope of Adherence - correct answer ✔✔ -non-adherence
-partial adherence: intentional (adjusting dose/frequency)
-partial adherence: non-intentional (forget/missing/neglects)
-total adherence
answered already passed
Define Transitions of Care - correct answer ✔✔ Movement of patients between health care
practitioners, settings, and home as condition and care needs change
Ineffective transitions lead to... - correct answer ✔✔ Adverse events
Hospital readmission - biggest concern within 30 days
$$$$ - not getting reimbursement
Root causes of ineffective Transitions - correct answer ✔✔ *Communication breakdown*
-Breakdown in communication between providers, with patient and caregivers
-Culture of setting
-Inadequate time
-Lack of SBAR
*Patient Education Breakdowns*
-Patient education unclear, patient not involved, health literacy
-Confusing med regimens
-Conflicting recommendations
*Accountability Breakdowns*
-Accountability not taken
-Lack of resources
-Lack of coordination of transition
,Examples of causes of ineffective transitions - correct answer ✔✔ -Medical team busy,
discharge low priority, last minute tests delaying discharge
-Medication reconciliation with errors
-Hospital resources, standard forms, financial pressure to fill beds, resistance to change
-No primary care provider, insurance issues, payment for meds, late discharge
8 P's - Risk Factors for Readmission - correct answer ✔✔ *Problems with medications*
polypharmacy, medication reconciliation
Insulin, Anticoagulants, Narcotics, Digoxin
*Psychological*
Hx of psychiatric illness
*Principal Diagnosis*
Chronic diseases
Heart failure, kidney disease, diabetes, COPD
*Physical limitations*
Frailty, over 80, underweight
*Poor health literacy*
,*Poor social support*
No help after discharge
*Prior hospitalization*
Unplanned hospitalizations in the last 6 months is a risk factor
*Palliative care*
Poor prognosis, advanced illness, eligible for palliative care but they want full treatment
High risk medications - correct answer ✔✔ -Insulin
-Anticoagulants (Heparin, Lovenox)
-Narcotics
-Digoxin
-warfarin
Chronic Conditions - correct answer ✔✔ -Occurs in every age, socioeconomic level, culture
-Medical conditions or health problems long-term (3 months or longer)
-*Management only, don't resolve, can't be cured- comorbidities*
Managing involves more than treating medical problems
-Psychosocial - body image issues
-Finances
-Caregiver burnout
Requires *persistent adherence* to therapeutic regimens
, Chronic Illness Trajectory - correct answer ✔✔ 1. Pre-trajectory - at risk (genetic, behaviors)
2. Trajectory- onset of symptoms or disability
3. Stable- managed, reinforce positive behaviors
4. Unstable- exacerbation, complications, uncertainty
5. Acute: Sudden onset of severe sx or complications
6. Crisis phase- critical or life threatening
7. Comeback phase - recovery after acute period
8. Downward phase-worsening, can be arrested and restabilize
9. Dying- gradual or rapid decline despite efforts, failure of life-maintaining body functions
Nursing Process for Chronic Conditions - correct answer ✔✔ -Identify specific problems,
trajectory phase
-Establish, prioritize goals (Will be different depending on where the person is)
-Plan of action to achieve desired outcomes
Interventions focus:
-Regimens to control symptoms, avoid complications
-Psychosocial issues affect quality of life
-Stoplight tools
-Evaluate outcomes, reassess problems
Scope of Adherence - correct answer ✔✔ -non-adherence
-partial adherence: intentional (adjusting dose/frequency)
-partial adherence: non-intentional (forget/missing/neglects)
-total adherence
