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What is the best proof of compliance with teaching standards?
To document in the client's record who was taught, what was taught, the teaching method, and the evidencde of learning.
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What does "style of learning" refer to?
How a person prefers to acquire knowledge.
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cognitive domain
- a style of processing information by listening or reading facts and descriptions.
- (auditory or visual)
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affective domain
a style of processing that appeals to a person's feelings, beliefs, or values
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psychmotor domain
- a style of processing that focuses on learning by doing.
- (kinesthetic)
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4 progressive stages of learning
- 1. recognition (of what's being taught)
- 2. recall (or description of information to others)
- 3. explanation (or application of info)
- 4. independent use of new learning
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pedogogy
science of teaching children or those with cognitive ability comparable to children
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androgogy
the principle of teaching adult learners
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gerogogy
the techniques that enhance learning among older adults
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functionally illiterate
possess minimal literacy skills
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what does formal teaching require?
a plan
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what is informal teaching?
teaching that is unplanned and occurs spontaneously at the bedside.
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what are medical records?
written collections of information about a person's health, the care provided by health practicioners, and the client's progress.
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can you use white out on charts?
NO
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what is a medical record?
a written, chronological account of a person's illness or injury and the care provided from onset to discharge
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why do health care workers share information?
to prevent duplication of care and reduce the chance of error and omission
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why does the medical profession promote quality assurance?
to maintain a high level of care and insure compliance with standards of care
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how can we make our charting "legally defensible"?
by using correct grammar and spelling and by recording facts, not subjective interpretations
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SOURCE-ORIENTED RECORD
a type of record where the information is organized according to the source of documented information.
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problem - oriented record
organized according to the clients health problems. (contains the data base, the problem list, the plan of care, and progress notes)
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NARRATIVE CHARTING
style of documentation that is generally used in source oriented records that involves writing information about the client and client care in chronological order
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soap charting
- s = subjective data
- 0 = objective data
- a = analysis of the data (assesment)
- p = plan for care
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focus charting
follows the dar model where d = data, a = action, r = response
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charting by excepition
documentation method where only abnormal assesment findings or care that deviates from the standard is charted
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what is the disadvantage of computerized charting?
password aka hacking
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why was hipaa inacted?
to protect the rights of us citezens to retain their health insurance when changing their emploment
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where should the light boxes for examining x rays or other diagnostics scans on which the client's name appears?
private areas
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what do abbreviations do?
shorten the time required for the task
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when documenting, nurses must only use what abbreviaions?
those abbreviatinions on the agency approved list
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what is the nursing card x?
quick reference for current information about the client and his or her care
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what is the change of shift report?
a discussion between nursing spokesperson from the shift that is ending and personel coming on duty
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what is the single most important method for identifying the client?
the identification bracelet
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making the client feel welcome is one of the most important steps in what?
admissions
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what is the best thing to do to safe gaurd the clients valuables and clothing?
give to family members to take home
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what are the first 2 things that a nurse does when helping the client undress?
- provide privacy
- have the client sit on the edge of bed that has already been lowered
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discharge - when does the discharge process begin?
at admission
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knock knock
who's there?
YO MOMMA
OH HE SAID YO MOMMA
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what device do the nurses use to perform oral suction?
yankeur tip or tonsil tip
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What rate should the nasal canula be set at?
2-3 L
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Where does internal respiration take place?
At the cellular level
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How does the nurse physically asses oxygenation?
- 1. observing the breathing pattern and effort
- 2. checking chest symmetry
- 3. auscultating lung sounds
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Common signs of inadequate oxygenation
- RESTLESSNESS
- sitting up to breath
- CONFUSSION
- rapid shallow breathing
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What is incentive spirometry?
Deep breathing for inhalation; calibrated device
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What is the rate of a simple mask?
5-8 L
Gives us approx. 35-50% oxygenation
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Partial rebreather
6-10 L
oxygenation is approx. 35-60%
disadvantage: requires monitoring to verify that the bag remains inflated at all times
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Non-rebreather
6-10L
oxygenation is approx. 60-90%
Disadvantage: creates a risk for oxygen toxicity
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Venturi Mask
mixes a precise amount of oxygen and atmosphearic air which ensures that the mask delivers exactly the amount of prescribed oxygen, humidification can be added
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CPAP
- Continous
- Positive
- Air
- Pressure
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Oxygen toxicity
more than 50% for longer than 48hrs
- Can be caused by:
- Partial rebreather, rebreather, face tent, trach shit (T piece)
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S&S of oxygen toxicity (8)
- 1. Non-productive caugh
- 2. Substernal chest pain
- 3. Nasal stuffiness
- 4. Nausea and vomiting
- 5. Fatigue
- 6. Headache
- 7. Sore throat
- 8. Hypoventilation
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Nursing NANDA's for breathing (4)
Innefective breathing pattern
Impaired gas exchange
Anxiety
Risk for injury related to oxygen hazards
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