Exam (elaborations)
Foundations Test 2 Review (1).
Foundations Test 2 Review (1).
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Foundations Test 2 Reviewwhen documenting make sure to use - CORRECT ANSWER-standard terms
urine example: amber, yellow, cloudy, etc
WNL stands for - CORRECT ANSWER-within normal limits
document both subjective and objective because - CORRECT ANSWER-they don't match
Definition of informatics hierachy - CORRECT ANSWER-Wisdom - integrating to practice
Knowledge - interpreting, understanding & applying
Information - organizing & interpreting
Data - collection & organization
organized data term - CORRECT ANSWER-information
Classification system for nursing informatics - CORRECT ANSWER-Technical
Utility
Leadership
Benefits of standardized terminolgy - CORRECT ANSWER-- consistent documentation
- provides a common means of communication
- enables data from different geographic regions to be compared
- enables nurses to compare data across populations
handoff report best practice - CORRECT ANSWER-do at patient bedside
* patient can help fill in gaps if needed
( you can wake up to ask if they want to be involved )
handoff report is done when - CORRECT ANSWER-anytime transferring responbility
at shift time, at a break, etc
might do a mini one at rounds
SBAR communication - CORRECT ANSWER-Situation
Background
Assessment
Recommendation
Situation ( SBAR ) explained - CORRECT ANSWER-identify yourself the site/ unit calling from
patient by name & reason by report
concern you have
Background ( SBAR ) explained - CORRECT ANSWER-give the patient's reason for admission
explain significant medical history
Assessment ( SBAR ) explained - CORRECT ANSWER-Vital signs
contraction pattern
clinical impressions, concerns
Recommendation ( SBAR ) explained - CORRECT ANSWER-explain what you need - be specific
about request & time frame
, make suggestions
clarify expectations
Verbal & telephone orders - CORRECT ANSWER-will have to call the provider
write the order down and read back the order to the provider
incident reports - CORRECT ANSWER-unusual & unexpected incident occurs
factual, objective and nonjudgmental reporting
omission error - CORRECT ANSWER-missed dose, not documented
lack of clarity error - CORRECT ANSWER-patient care not validated
erroneous abbreviation error - CORRECT ANSWER-misinterpretation
late entry error - CORRECT ANSWER-inappropriate order of care
problem oriented documentation formats - CORRECT ANSWER-PIE - problem, intervention,
evaluation
APIE - assessment + pie
SOAP - subjective, objective, assessment, plan
DAR - data, action, response
sentinel event - CORRECT ANSWER-unexpected occurrence involving death harm or severe
temporary harm
Incident types - CORRECT ANSWER-med error, patient fall, equipment malfunction, staff injury
loss - CORRECT ANSWER-as absence of something or someone
doesn't have to be tangible - can be loss of job, body part, friendship, ability to do something
grief - CORRECT ANSWER-emotional response to a loss, the individualized & deeply personal
feelings and response
anticipatory grief - CORRECT ANSWER-reactions to an EXPECTED death
people tend to do much better because you can say goodbye, know it is coming
mourning - CORRECT ANSWER-outward social expression of loss
berevement - CORRECT ANSWER-both grief & mourning and can be described as inner feelings
& outward expressions
complicated grief - CORRECT ANSWER-when a person is not able to progress through the
normal stages of grieving
chronic grief - CORRECT ANSWER-can't process through within 6-12 months
delayed grief - CORRECT ANSWER-deal with it later, put it off
physical signs of something going on, not sleeping, headaches, etc
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