ATI: Management of Care
Study online at quizlet.com/_22mrrr
1.
preventive
levels of health care: educating and
equipping clients to reduce and control risk
factors for disease
20.
EPO (exclusive provider
organizations)
private financing: clients choose
from a list of providers within a
contracted organization
2.
primary
levels of health care: emphasizes health
promotion such as prenatal and well-baby
care, nutrition counseling, disease control
21.
long term care insurance
private financing: providers for
long-term care expenses
Medicare does not cover
3.
secondary
levels of health care: diagnosis and treatment
of acute illness and injury
22.
hospital or specific
facility
usual settings for secondary and
tertiary health care
4.
tertiary
levels of health care: provision of specialized
and highly technical care
23.
QSEN (quality and safety
education for nurses)
5.
restorative
levels of health care: intermediate follow-up
for restoring health
6.
continuing
levels of health care: addresses long term or
chronic health care needs
7.
preventive
health care
examples: immunization, stress
management, seat belt use
organization that assists nursing
programs i preparing nurses to
provide safe, high-quality care:
includes 6 competencies; safety,
patient-centered care, evidence
based practice, informatics,
quality improvement,
teamwork/collaboration
24.
8.
primary
health care
examples: Office/clinical visits, schedules
school or work centered screenings
list the 6 competencies outlined
by QSEN
9.
secondary
health care
Care in hospital settings, diagnostic centers,
emergent care centers
safety, patient-centered
care, EBP, informatics,
quality improvement,
teamwork/collaboration
25.
safety
10.
tertiary
health care
examples: ICU, oncology centers, burn
centers
11.
restorative
health care
examples: home health care, rehab, skilled
nursing facilities
QSEN: minimization of risk factors
that could cause injury or harm
while promoting high quality
care and maintaining a secure
environment for clients, self, and
others
12.
continuing
health care
examples: end-of-life care, palliative care,
hospice, adult day care, in-home respite care
26.
patient centered care
13.
joint
commission
components of health care system: sets
quality standards for accreditation of health
care facilities
14.
state licensing
boards
components of health care system: ensure
that health care providers and agencies
comply with state regulations
QSEN: the provision of caring
and compassionate, culturally
sensitive care that addresses
clients' physiological,
psychological , sociological,
spiritual and cultural needs,
preferences, and values
27.
EBP
15.
utilization
review
committees
components of health care system: monitor
for appropriate diagnosis and treatment of
hospitalized clients
QSEN: the use of current
knowledge from research and
other credible sources on which
to base clinical judgement and
client care
16.
medicare
health care financing: program for clients 65
and older and for those with permanent
disabilities
28.
informatics
17.
medicaid
health care financing: program for clients
with low income
18.
MCO
(managed
care
organization)
private financing: primary care providers
oversee comprehensive care for enrolled
clients and focus on prevention and health
promotion
QSEN: the use of information
technology as communication
and information-gathering tool
that supports clinical decision
making and scientifically based
nursing practice
29.
quality improvement
PPO
(Preferred
provider
organizations)
private financing: clients choose from a list of
contracted providers. using non contracted
providers increases out-of-pocket cost
QSEN: care-related and
organizational processes that
involve the development and
implementation of a plan to
improve health care services and
better met clients' needs
19.
30.
teamwork/collaboration
QSEN: the delivery of client care
in partnership with
multidisciplinary members of the
health care team to achieve
continuity of care and positive
client outcomes
31.
spiritual support staff
interprofessional personnel:
provides spiritual care (pastors,
rabbis, priests)
32.
dietitian
interprofessional personnel:
assesses, plans for, and educates
regarding nutrition needs.
Designs special diets, supervises
meal preparation
33.
34.
lab technician
OT
interprofessional personnel:
obtains specimens of body fluids
and performs diagnostic tests
interprofessional personnel:
assesses and plans for th clients
to regain ADLs, especially motor
skills of the upper extremities
35.
lab technician
interprofessional personnel: who
should you refer?
provider needs to see clients CBC
results immediately
36.
OT
interprofessional personnel: who
should you refer?
client has difficulties using an
eating utensil with her dominant
hand following a stroke
37.
38.
pharmacist
PT
interprofessional personnel:
providers and monitors
medications, supervises
pharmacy technicians in states
that allow this practice
interprofessional personnel:
assesses and plans for clients to
increase musculoskeletal
function, especially of the lower
extremities, to maintain mobility
39.
provider
interprofessional personnel:
assesses, diagnoses, and treats
disease and injury. includes MDs,
doctors of osteopathy, APRNs,
PAs
40.
radiological technician
interprofessional personnel:
positions clients and performs xrays and the imaging procedures
for providers to review for
diagnosis of disorders of various
body parts
41.
respiratory
therapist
interprofessional personnel: evaluates
respiratory status and provides respiratory
treatments including oxygen therapy, chest
physiotherapy, inhalation therapy, and
mechanical ventilation
42.
social
worker
interprofessional personnel: works with clients
and families by coordinating inpatient and
community resources to meet psychosocial and
environmental needs that are necessary for
discharge and recovery
43.
speech
language
pathologist
interprofessional personnel: evaluates and
makes recommendations regarding the impact
of disorders or injuries on speech, language,
and swallowing. teaches techniques and
exercises to improve function
44.
RN
nursing personnel: perform assessments,
establish nursing diagnoses, goals, and
interventions; conduct ongoing client
evaluations
45.
LPN
nursing personnel: collaborate within the
nursing process, coordinate plan of care,
consult with other team members, recognize the
need for referrals to assist with actual or
potential problems, possess technical
knowledge and skills
46.
CBS
(clinical
nurse
specialist)
APRN: typically specializes in a practice setting or
a clinical field
47.
NP
APRN: collaborates with one or more providers
to deliver nonemergency primary health care in
a variety of settings
48.
CRNA
APRN: administers anesthesia and providers
care during procedures under the supervision
of an anesthesiologist
49.
CNM
APRN: collaborates with one or more providers
to deliver care to maternal-newborn clients and
their families
50.
social
worker
interprofessional personnel: who should you
refer?
a nurse is caring for an older adult client who
lives alone and is to be discharges in 3 day. He
states it is difficult to prepare adequate
nutritious meals at home for one person
51.
ethics
the study of conduct and character
52.
morals
the values and beliefs that guide decision
making and behavior
53.
ethnical
theory
examines principles, ideas, systems, and
philosophies that affect judgments about what
is right and wrong and good and band
examples: utilitarianism, deontology
54.
autonomy
ethical principles: the right to make one's
own personal decisions, even when those
decision might not be in that person's own
best interest
55.
beneficence
ethical principles: positive actions to help
others
56.
fidelity
ethical principles: agreement to keep
promises
57.
justice
ethical principles: fairness in care de;livery
and use of resources
58.
nonmaleficence
ethical principles: avoidance of harm or
injury
59.
autonomy,
beneficence,
fidelity, justice,
nonmaleficence
5 ethical principles that pertain to the
treatment of clients
ethical
dilemmas
problems that involve more than one
choice and stem from the different values
and beliefs of the decision makers
ex. review of scientific data is not enough to
solve the problem, involves a conflict
between 2 moral imperatives, answer has a
profound effect on situation and client
60.
71.
malpractice
tort: ex. nurse administers large dose of
medication due to a calculation error. the
client has a cardiac arrest and dies
72.
breach of
confidentiality,
defamation of
character
quasi-intensional torts (2)
73.
assault,
battery, false
imprisonment
intentional torts (3)
74.
assault
intentional torts: the conduct of one person
makes another person fearful and
apprehensive (ex. threatening to place an
NG tube in someone that refuses to eat)
75.
battery
intentional torts: intentional and wrongful
physical contact with a person that involves
an injury or offensive contact (ex. nurse
restrains a client and administers an
injection against her wishes)
76.
malpractice
what is professional negligence
77.
professional
negligence
the failure of a person who has professional
training to act in a reasonable and prudent
manner ( ex. failure to follow
professional/facility standards of care, use
of equipment in responsible/knowledgable
maker, communicating effectively with
clients, document care nurses provided)
78.
five elements
to prove
negligence
1. duty to provide care as defined by a
standard
2. breech of duty by failure to meet
standard
3. foreseeability of harm
4. breech of duty has potential to cause
harm
5. harm occurs
61.
advocacy,
responsibility,
accountability,
confidentiality
basic principles of ethics
62.
advocacy
basic principles of ethics: support of clients'
heart, safety, and personal rights
63.
responsibility
basic principles of ethics: willingness to
respect obligations and follow through on
promises
64.
accountability
basic principles of ethics: ability to answer
for one's own actions
65.
confidentiality
basic principles of ethics: protection of
privacy without diminishing access to highquality care
79.
informed
consent
legal process by which a client has given
written permission for a procedure or
treatment
66.
bioethics
addresses dilemmas that arise form
advancing science and technology such as
stem-cell research, organ transplantation,
gender reassignment, reproductive
technologies (in vitro, surrogate)`
80.
nursing role for informed consent
67.
tort law
example of a civil law that relates to the
provision of nursing care
68.
civil laws
laws that protect individual rights
witness clients
signature on
informed
consent form
(ensure client
got all info and
understands all
info)
81.
negligence,
malpractice
unintentional torts (2)
invasive
procedures,
surgery
when must a client provide written consent
69.
70.
negligence
tort: ex. use fails to implement safety
measure for a client at risk for falls
82.
implied
consent
consent: client adheres to the instructions
the nurse provides
83.
standards of care
define and direct the level of care
nurses should give, implicate nurses
who did not follow these standards in
malpractice lawsuits
84.
report to manager
what should the nurse do if the
suspect a coworker of behavior that
jeopardizes client care or could
indicate a substance use disorder
85.
advance directives
purpose is to communicate a client's
wishes regarding end-of-life care
should the client become unable to do
so
86.
living will, power of
attorney, providers
orders
3 types of advance directives
87.
living will
advance directives: legal document
that expresses that client's wishes
regarding medical treatment in the
event he client becomes incapacitates
and is facing end-of-life issues
power of attorney
advance directives: document in
which clients designate a health care
proxy to make health care decisions
for them if they are unable to do so.
the proxy can be any competent
adult the client chooses
providers orders
unless a provider writes DNR or AND
prescription in the clients medical
record, the nurse initiates CPR when
the client has no pulse or respirations.
the provider consults the client and
family prior to administering DNR or
AND
88.
89.
90.
91.
92.
provide info,
document client's
status, ensure
reflection on client's
current decisions,
inform members of
health care team
nursing role in advance directives
abuse,
communicable
disease
2 situations that have mandatory
reporting
local or state health
department
who do nurses report communicable
disease to
93.
mandatory
reports of
communicable
disease
purpose: ensure appropriate medical
treatment of disease (Tb), monitor for
common-source outbreaks (food
borne, hep A), plan and evaluate for
control/prevention plans
(immunizations), identify outbreaks
and epidemics, determine public
health priorities based on trends
94.
assessment, meds,
treatments,
education
information to document
95.
factual (subjective
and objective),
accurate,
complete/current,
organized
4 qualities of documentation
96.
factual
documentation: subjective (direct
quote or summary of info from client)
and objective (data collected from the
senses) no derogatory words or
opinions
97.
begin entry with
date and time,
legible, no
correction fluid,
sign
legal guidelines for documentation
98.
flow chart
documentation formats: shows trends
in vitals, blood glucose levels, pain
levels, and other frequent assessments
99.
narrative
documentation formats: records
information as a sequence of events in
a story-like manner
100.
charting by
exception
documentation formats: uses
standardized forms that identify norms
and allows selective documentation of
deviations from this enorms
101.
problem-oriented
documentation formats: consists of a
database, problem list, care plan, and
process notes
102.
SOAP, PIE, DAR
3 examples of problem-orientated
documentation
103.
subjective,
objective,
assessment, plan
what does SOAP stand for
104.
problem,
intervention,
evaluation
what does PIE stand for
105.
data, action,
response
what does DAR stand for
significant objective
information, logical
sequence, no opinion, recent
changes in
meds/treatments/procedures
components of an effective
change-of-shift report
107.
med name, dosage, time,
route
telephone/verbal
prescription: what should
you repeat back
108.
within 24 hours
telephone/verbal
prescription: when must
the provider sign
109.
transfer reports
reports that should include
demographic information,
medical diagnosis,
providers, overview of
health status, recent
progress, any alternations
that may become urgent
situations, directives, most
recent vitals, meds,
allergies, diets, activity,
special equipment,
advance directives
106.
110.
false
T/F
a nurse can refer to an
incident report in the
client's medical record
111.
other RNs, LPNS, AP
who can an RN delegate to
112.
nursing process, client
education, tasks that require
nursing judgement
what CAN'T an RN delegate
113.
monitor findings, reinforce
client teaching from standard
care plan, trach care,
suctioning, checking NG tube
patency, administering
enteral feedings, inserting
catheter, administerings
meds (except IV in some
states)
7 tasks an RN can delegate
to an LPN
114.
ADLs, specimen collection,
I/O, vitals
3 tasks an RN can delegate
to an AP
115.
right task, right
circumstance, right person,
right direction, right
evaluation
5 rights of delegation
right task
5 rights of delegation:
receptive, requires little
supervision, relatively
noninvasive
116.
117.
right
circumstance
5 rights of delegation: workload of team
member, assess and match the complexity
of care demands to the skill level of the
team member
118.
right person
5 rights of delegation: task is within scope
of member's practice, team member has
necessary training, review performance of
the team member
119.
right direction
5 rights of delegation: data,
method/timeline for reporting, specific
tasks to perform, expected results and
expectations for follow-up
120.
right evaluation
5 rights of delegation: provider
supervision, provider clear directions,
monitor performance, provide feedback,
intervene if necessary, evaluate client
outcome status, evaluate client care tasks
121.
assessment
ADPIE: data collection through
observation, interviews with client/family,
medicals history, comprehensive/focused
physical exam, diagnostic and laboratory
reports, collaboration
122.
nursing history
ADPIE: when do nurses collect subjective
data (client's feelings, perceptions, and
descriptions of health status
123.
diagnosis
(analysis/data
collection)
ADPIE: nurses use clinical thinking skills to
identify client's health status or problems,
interpret or monitor the collected
database, reach an appropriate nursing
judgment about health status and coping
mechanisms and provide direction for
nursing care
124.
comprehensive,
ongoing,
discharge
ADPIE: 3 types of planning
125.
comprehensive
planning
ADPIE: initial plan for care of clients based
on comprehensive assessments they have
completed (ex. do this upon admission to
health care facility)
126.
ongoing
planning
ADPIE: planning done throughout the
provision of care; while obtaining new
information and evaluating responses to
care, they modify and individualize the
initial plan of care
127.
discharge
ADPIE: planning that is a process of
anticipation and planning for a client's
needs after discharge
128.
upon admission
when should you start the discharge plan
129.
plan
ADPIE: nurses set priorities, determine
client outmodes, select specific nursing
interventions
130.
implementation
ADPIE: nurses base the care they provide
on assessment data, analysis and the
plan of care to select and perform
appropriate therapeutic interventions
141.
experience
critical thinking: understanding of clinical
situations, recognizes/analyzes cues for
relevance, incorporates experience into
intuition
131.
evaluation
ADPIE: step that determines whether or
not to modify the plan of care; did the
client meet the planned outcomes, where
the interventions appropriate and
effective, should i modify the outcomes or
interventions?
142.
competence
critical thinking: scientific methods, problem
solving, decision making, diagnostic
reasoning/inference, clinical decision
making, nursing process
143.
confidence
critical thinking; attitudes: feels sure of
abilities
144.
independence
critical thinking; attitudes: analyzes ideas for
logical reasoning
145.
fairness
critical thinking; attitudes: is objective and
nonjudgemental
146.
responsibility
critical thinking; attitudes: adheres to
standards of practice
147.
risk taking
critical thinking: precise, clear language
demonstrating focused thinking and
communicating unambiguous messages
and expectations to clients and other
health care team members
critical thinking; attitudes: takes calculated
changes in finding better solutions to
problems
148.
discipline
critical thinking; attitudes: develops a
systematic approach to thinking
149.
critical thinking: inner sensing that facts
do not currently support something,
should spark the nurse to search the
data to confirm or disprove the feeling
perseverance
critical thinking; attitudes: continues to work
at a problem until there is a resolution
150.
integrity
critical thinking; attitudes: practices
truthfully and ethically
132.
reflection,
language,
intuition
3 distinct levels of critical thinking
133.
reflection
critical thinking: purposefully thinking
back or recalling a situation to discover its
meaning and gain insight into the event:
why did I say or do this, did the original
plan of care achieve optimal outcomes?
134.
135.
language
intuition
136.
basic, complex,
commitment
3 levels of critical thinking
151.
humility
critical thinking; attitudes: acknowledges
weaknesses
137.
basic
critical thinking: a nurse trusts the
experts and thinks concretely based on
the rules; results from limited nursing
knowledge and experience, as well as
inadequate critical thinking process
152.
health history
admission process: current illness, current
meds, prior illness, chronic disease, surgery,
previous hospitalization, other relevant data
153.
vitals, height,
weight,
allergies,
meds
admission process: baseline data
154.
psychosocial
admission process: alcohol, tobaccos, drug,
caffeine use, history of mental illness, history
of abuse, history of homelessness, home
situation, significantothers
155.
nutrition
admission process: current diet, any
chewing or swallowing problems, recent
weight gain/loss
156.
safety
assessments
admission process: history of falls, sensory
deficits (vision, hearing), use of assistive
devices
157.
indications
for transfer or
discharge
indications for transfer or discharge
change in level of care, another setting
required for appropriate care, facility does
not offer necessary care, client no longer
needs inpatient care and is ready to return
home
138.
complex
critical thinking: nurse begins to express
autonomy by analyzing and examining
data to determine the best alternative;
results from an increase in nursing
knowledge, experience, intuition, and
more flexible attitudes
139.
commitment
critical thinking: nurse expects to make
choices without help from others and
fully assumes the responsibility of those
choices
140.
knowledge,
experience,
competence,
attitudes,
standards
5 components of critical thinking
158.
long term care
exception to beginning discharge plan upon admission
159.
discharge
planning
assess if client can return to previous residence, determine if client will need assistance at home, assess residence to
determine if client will need equipment/adaptations, make a referral to social worker for community resources,
communicate health status to community service provider
160.
standards for
discharge
education
identify safety concerns at homes, review s/s of potential complications, provide # for provider, provide name and #
for community resource,s dietary guidelines, amount/frequency of therapies, how to take meds and why
adherence is important
161.
transfer
documentation
documentation: medical diagnosis and care provides, demographic info, overview of health status/plan of clare, any
alterations that precipitate immediate concern, notification of any assessments or care essential in next few hours,
recent vitals/meds, allergies, diet/activity orders, special equipment, advance directives, family involvement
162.
discharge
documentation
documentation: type of discharge, date/time, who went with client, transportation, where client went, summary of
client's condition at discharge, description of unresolved difficulties and procedure for follow up, disposition of
valuables/meds, discharge instructions
163.
discharge
instructions
instructions for procedures at home, precautions to take when performing procedures/taking meds, s/s of
complications to report, names/numbers of health care providers and community resources, plan for follow up
care/therapy
