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Sara-Fundamentals 1A Unit 1

Tools

AB
Phases of the nursing processassessment, diagnosis (and outcomes), planning, implementation, evaluation
This is done in the assessment phase...gather information
This is done in the diagnosis phase...make educated judgment about health issues of the patient
This is done in the planning phase...prioritize information
This is done in the implementation phase...follow through with plan of judgment
This is done in the evaluation phase...determine if goals have been met
This is where the official patient problem statement is found,stated as a nursing diagnosisNANDA
This is the importance of using evidence based practice...more likely to result in desired outcome of the patient - also nursing care is more effective and dynamic
Levels of prevention and the type of health care that falls under each category.Primary (before person gets disease) Secondary (after disease occurs but before person notices anything is wrong-skin growth becomes cancer) Tertiary (person already has symptoms of disease-prevent pain from the disease)
Patients verbal description of problems (i.e. pain)...subjective data (what the subject tells you)
Observation or things that can be measured(i.e. BP, inspect wounds)...objective data
This is what is documented in an incident report...objective description of what happened and follow-up care
This is what is NOT documented in the medical record about an incident report...mentioning that an incident report has been filed
SBAR-what does it stand for and what is it used for?Situation, Background, Assessment, Recommendation - significant changes in patient's condition, communication strategy to improve patient safety
This is when discharge planning begins...Upon admission
This is what is done for discharge planning...discuss desirable outcomes, revise plan of care, involve patient and family (meds, diet, community resources, follow-up care)
These are the characteristics of a profession...-basic liberal foundation and extended education of its members -theoretic al body of knowledge lending to defined skills, abilities, and norms -provides specific service -has a code of ethics for practice
A goal should be SMART.. this means...Specific, Measurable, Attainable, Relevant/Realistic, Timeframe
HIPAA stands for...Health Insurance Portability and Accountability Act
Fire safety - PASS means...Pull Aim (at base of fire) Squeeze (handle) Sweep (from side to side)
Fire safety - RACE means...Rescue and Remove (patients) Activate Alarm, Confine (fire) Close (doors and windows-shut off O2) Extinguish (fire)
Steps of research process (PSCDU)...Problem identification, Study design, Conducting the study, Data analysis, Use of the findings
Caring as part of nursing practice means...central to nursing practice, from love to friendship, caring determines what matters to a person
QSEN stands for and means...Quality and Safety Education for Nurses) - involve family, teamwork and collaboration, evidence-based practice, quality improvement, safety, informatics


Martinsburg, WV

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