Communication
Answerable for your action and care that is provided
Accountability
Delegation of toileting to which team member
CNAs, Clinical Technicians, Unlicensed Assistive Personnel (UAP)
Risk for infection related to open wound
Risk for nursing diagnosis
SMART Goal
Specific, measurable, attainable, realistic, timely
Direct care
Wound care, inserting a nasogastric tube, anything that is directly benefiting the patient
HIPPA
Health Insurance Portability & Accountability Act of 1996
Good Samaritan Laws
Laws that protects a person giving aid in an emergency situation if they stay in their scope of practice and do not abandon the patient
Assault
an intentional act that gives another person reasonable fear that they'll be physically harmed or offensively touched
Negligence
the failure to exercise the care toward others which a reasonable or prudent nurse would do in the same or similar circumstances
A patient is participating in the decision of which rehabilitation center to attend
Patient autonomy
Delegation of administrating medication to which team member?
LPN
Impaired skin integrity related to open wound as evidenced by open laceration (1cm/20cm) to left lower leg
Problem-focused nursing diagnosis
Patient will report decreased pain within 24 hours
Example of a short term goal
Indirect care
Handwashing, documenting, anything that benefits the patient but will not be seen immediately
Confidentiality
Restricting information access and disclosure, including means for protecting personal privacy information.
Informed consent
Consent that is obtained prior to a procedure by the provider and includes both the risks and benefits of that procedure
Battery
any willful and unlawful use of force or violence on the person of another
Malpractice
failure of professional duty or a failure to exercise an accepted degree of professional skill which results in injury, loss, or damage
Supporting a patients health, safety, and rights
Patient advocacy
Delegation of blood glucose checks to which team member
Clinical Technicians
Readiness for enhanced knowledge related to open wound as evidenced by patient asking questions about wound care
Health promotion nursing diagnosis
•Patient will enroll in/successfully complete outpatient addiction treatment program within the next 3-6 months
Long term goal
Concept map
A way to organize a patient's nursing diagnoses that has the medical diagnosis or the patient in the middle and the diagnoses around, connected to the middle
Privacy
The client's right to have control over their personal information and be free from being observed by others not involved in their care
Living will
A living will is a written, legal document that spells out medical treatments you would and would not want to be used to keep you alive
False Imprisonment
the act of restraint on another person which confines that person in a restricted area
What makes an act malpractice?
1.) Nurse owed duty to patient
2.) Nurse breached said duty of care
3.) Patient injured
4.) Nurses’ failure to carry out duty properly caused patient to be injured
A nurse is completing a care plan on a patient
Nurse autonomy
Define delegation
Transferring responsibility for performance of an activity or task while retaining accountability for the outcome
Problem + etiology + symptoms
Three parts of a problem focused nursing diagnosis
How do you know that your intervention has been effective?
You reassess the patient to see if the patient has achieved the goal set in the planning stage
A type of health insurance designed to bridge the gap between jobs.
COBRA Insurance
Healthcare proxy
a person who can make health care decisions for the patient if they are unable to communicate themselves
Invasion of privacy
infringement upon an individual's protected right to privacy through a variety of intrusive or unwanted actions
Valid reasons to refuse an assignment without it being patient abandonment
Knowledge/Skill Competency Issue
State Nurse Practice Act Issue
Health-care Provider Health threatened Issue
Still orienting to unit/organization Issue
Moral/Ethical/Religious Issues
Impairment of Nursing Judgement Issue
RN will assess all of their patients and administer medications for the shift
Responsibility
5 rights of delegation
Right task
Right circumstance
Right person
Right communication
Right supervision
Problem + Etiology
Three parts of a risk nursing diagnosis
Durable Power of Attorney
gives someone else legal authority to act on the patient's behalf