study guide test review

 In this model different tasks are devided into functional categories, with one nurse assuming responsability for spacific tasks.

in this model the RN acts as a team leader, giving subordinates patient assignments.

an RN is responsible for all aspects of patient care for one, or more patients.

an RN selects a caseload of patients to care for over time, typically the RN selects these patients. (Like Bryson's RN at the NICU) 

The RN maintains responsability of a patient from addmition untill after discharge. -- the nurse continues to follow the patient after he/she returnes home. ((case managers don't alawys provide direct care.))

• Subjective: Patients verbal description of their health problems.
• Objective: Observations or measures of a patients health status.

• Assess      evaluates the patients condition
• Diagnose       Identifys the patients problems            contains a (R/T)
• Plan       sets goals of care and nd desired outcomes,            contains a "Patient will"
• Implementation       Preform the nusring ations identified in planning.            Contains a I, " the nurse will"
• Evaluate      Determinsr if the goals are met and outcomes achieved.

• a Clinical judgement about individual, family, or community responses to actual, or potential health problems, or life processes.
• EX. Fatigue Related to disease process.

• A report which is given anytime that anything unusual happens that (does or) could potentially harm a patient, visitor or employee.
• EX. patient found on floor on RT. side...

occures at the end of a shift. provides a transfer of revelant information form the Nurse going off shift to the one coming on shift.

Doccumentation made upon discharge of a patient. Covers care delivered and changes of patient status while in the hospital, patient status changes and reccomendations for continued care.

• Primary Prevention: True prevention, procedes desease or dysfunction and is applied to patients who are concidered phisically healthy.
• EX: Health promotions, Health education programs, immunizations, and phisical and nutritionalfitness activivties.
• Secondary Prevention: Is focused on people who are experienceing health problems or illness, and are at risk for worsening conditions Secondary Prevention activities are directed toward diagnosis and prompt intervention.
• EX. Screening techniques, and treating early stages of disease to limit dissability.
• Tertiary prevention: Occures when a defecet, or disability is perminant, irreversable, and stabalized. Involves minimizing the effects of long term disease.
• EX. rehabilitation.

• Direct care interventions are treatments performed through interactions with patients
• EX. Medications incertion of a intravenious catheter and counciling during a time of grief.
• Indirect Care Interventions: are treatmente preformed away from patient, but on their behalf.
• EX. Safety and infection control

• 1 - must write down the complete order, or enter it into the computer as it is being recieved.
• 2 - Must read the order back
• 3 - Must recieve confermation from th eperson who gave the order.

• Nerritive- tells a story
• PODR problem oriented medical record -
• Charting by acception- normal, normal, abnormal.

• 1- Basic       Trusts that experts have the right answer to everything
• 2- Complex      Begins to sepoate themselves from the authorities
• 3- Commitment      Anticipatesd the need to make choices without the assistance from others.

• Knowledge
• experiences
• competence
• attitudes
• standards

- more than just the absence of disease, its a state of being that people define in relation to their own values, personality, and values.

• the inner sensing or "gut feeling" that something is so.
• EX. you walk into a patient's room and, by looking at the patient's apperience without the benefit of a thorough assessment, sence that he, or she has worsened physically.

joint comission on acfredidtation fro hospitals and orginizations (created the JACHO do not use list..)

Health Insurance portability and accountability act.

Diagnosis- related groups. basis for establishing reembersement for patient care

• rates the alertness of a patient ( associate with eyes )
• Oriented times 1,2,3 ..
• 1-person
• 2-place
• 3-time.

• Assessment
• Diagnosis
• Planning
• Intervention
• Evaluation

American Nursing asociation

• North American Nuursing Diagnosis Association-
• developed a model for orginizing nursing diagnosis for documemtation. 

a serious offense that results in significant harm to another person or to society  in general.

an intentional threat toward another person that gives that person reasonable fear of harmful contact.

any intentional touching without concent or lawful justification

an unintentional tort.. (tort = civil wrongfull asct or omissions against a person, or person's propertywhich are resolved by awarding monetary damages to the individual whos rights have been violated.)

laws that limit liability and offer immunity to nurses who helps at the scene of an accident. HOWEVER if you perform a prosedure for which you have no training you WILL be liable for any injury resulting from that act.