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Various nursing documentation systems, charting methods, and communication techniques used in healthcare settings. It includes definitions and explanations of patient records, pie charting, soap format, pomr, progress notes, referral, variance report, and isbar. Additionally, it explains interviewing techniques, communication zones, proxemics, and therapeutic communication. These concepts are crucial for effective nurse-patient communication, care planning, and documentation.
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Cultural Assimilation - Correct Answer-process that occurs when a minority group, living as a part of the dominant group within a culture, loses the cultural characteristics that made it different Cultural Blindness - Correct Answer-the process of ignoring differences in people and proceeding as though the differences do not exist Cultutal Diversity - Correct Answer-diverse groups in society, with varying racial classifications and national origins, religious affiliations, languages, physical size, gender, sexual orientation, age, disability, socioeconomic status, occupational status, and geographic location. Cultural Imposition - Correct Answer-tendency of some to impose their beliefs, practices, and values on another culture because they believe that their ideas are superior to those of another person or group Culture - Correct Answer-sum total of human behavior or social characteristics particular to a specific group and passed from generation to generation or from one to another within a group Culture Competent Care - Correct Answer-care delivered with an awareness of the aspects of the patient's culture Cultural Conflict - Correct Answer-Situation that occurs when people become aware of cultural differences, feel threatened, and respond by ridiculing the beliefs and traditions of others to make themselves feel more secure about their own values Culture Shock - Correct Answer-Those feelings, usually negative, a person's experiences when placed in a different culture Ethnicity - Correct Answer-Sense of identification that a cultural group collectively has; the sharing of common and unique cultural and social beliefs and behavior patterns, including language and dialect, religious practices, literature, folklore, music, political interests, food preferences, and employment patterns Ethnocentrism - Correct Answer-Beliefs that one's own ideas, beliefs, and practices are best, superior, or most preferred to those of others; using one's cultural norms as the standard to evaluate others' beliefs
Linguistic Competence - Correct Answer-The ability of caregivers and organizations to understand and effectively respond to the linguistic needs of patients and their families in a health care encounter Personal Space - Correct Answer-External environment surrounding a person that is regarded as being part of that person Race - Correct Answer-(A human fabricated idea) Division of human beings based on distinct physical characteristics Stereotyping - Correct Answer-Assigning characteristics to a group of people without considering specific individuality Subculture - Correct Answer-A group of people with different interests or goals than the primary culture Transcultural Nursing - Correct Answer-Providing nursing care that is planned and implemented in a way that is sensitive to the needs of individuals, families, and groups representing the diverse cultural populations within our society Common Health Problems of Native Americans and Alaska Natives - Correct Answer- Heart Disease Cirrhosis of the Liver Diabetes mellitus Fetal alcohol syndrome Common Health Problems of African Americans - Correct Answer-Hypertension Stroke Sickle cell anemia Lactose intolerance Keloids Common Health Problems of Asians - Correct Answer-Hypertension Cancer of the Liver Lactose intolerance Thalassemia Common Health Problems of Hispanics - Correct Answer-Diabetes mellitus Lactose intolerance Common Health Problems of Whites - Correct Answer-Breast cancer Heart Disease Hypertension Diabetes mellitus Obesity
Health information exchange (HIE) - Correct Answer-an electronic system that allows physicians, nurses, pharmacists, and other health care providers, and patients to appropriately access and securely share the patient's vital medical information Incident/variance Report - Correct Answer-a report of any event that is not consistent with the routine operation of the health care agency that results in or has the potential to result in harm to a patient, employee, or visitor ISBARR communication - Correct Answer-a process for effective hand-off communication among health care professionals about a patient's condition, standing for Identity/Introduction, Situation, Background, Assessment, Recommendation, and Read back. Meaningful use - Correct Answer-the use of certified electronic health record technology to achieve health and efficiency goals, with a financial incentive from Medicare and Medicaid Narrative notes - Correct Answer-progress notes written by nurses in a source-oriented record Nursing informatics - Correct Answer-A specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Outcome and Assessment Information Set (OASIS) - Correct Answer-assessment instrument representing core items of comprehensive assessment for adult non maternity home healthcare patients that forms the basis for measuring Occurrence/variance charting - Correct Answer-When a patient fails to meet an expected outcome or a planned intervention is not implemented, including the unexpected event, the cause of the event, actions taken in response of the event and discharge planning when appropriate. Usually used for variances that affect quality, cost, or length of stay Patient record - Correct Answer-a compilation of a patient's health information; the patient record is the only permanent legal document that details the nurse's interactions with the patient Personal health record (PHR) - Correct Answer-information sheets that contain the individual's medical history, including diagnoses, symptoms, and medications PIE Charting - Correct Answer-documentation system that does not develop a separate care plan; the care plan is incorporated into the progress notes in which problems are identified by number, worked up using the problem (P), intervention (I), evaluation(E) format, and evaluated each shift
Problem-oriented medical record (POMR) - Correct Answer-documentation system organized according to the persons specific health problems; includes database,problem list, plan of care and progress notes Progress notes - Correct Answer-any of a variety of methods of notes that relate how a patient is progressing toward expected outcomes Read Back - Correct Answer-a process in which a nurse and other health care provider repeats a verbal order back to a physician to ensure that it was correctly heard or interpreted Referral - Correct Answer-The process of sending or guiding the patient to another source for assistance SOAP format - Correct Answer-method of charting narrative progress notes; organizes data according to subjective information (S), objective information (O), assessment (A), and plan (P) source-oriented record - Correct Answer-documentation system in which each healthcare group records data on its own separate form variance report - Correct Answer-documentation method in case management that records unexpected events, the cause for the event, actions taken in response to the event, and discharge planning when appropriate "P" in PIE Charting - Correct Answer-Problem "I" in PIE Charting - Correct Answer-Intervention "E" in PIE Charting - Correct Answer-Evaluation "S" in SOAP format - Correct Answer-Subjective Data "O" in SOAP format - Correct Answer-Objective Data "A" in SOAP format - Correct Answer-Assessment "P" in SOAP format - Correct Answer-Plan "I" in SOAPIER format - Correct Answer-Intervention "E" in SOAPIER format - Correct Answer-Evaluation "R" in SOAPIER format - Correct Answer-Response "I" in ISBAR - Correct Answer-Identity/Introduction
Channel - Correct Answer-term used in communication theory to denote the medium selected to convey the message' the channel may target any of the receiver's senses Cliche - Correct Answer-a stereotyped, trite, or pat answer. Don't use these with patients. Communication - Correct Answer-process of sharing information; process of generating and transmitting messages Empathy - Correct Answer-intellectually identifying with the way another person feels Feedback - Correct Answer-verbal and nonverbal evidence that the message is received and understood Group Dynamics - Correct Answer-study of a group's characteristics and ways of functioning Helping Relationship - Correct Answer-interaction that sets the climate of movement of the participants toward common goals Horizontal Violence - Correct Answer-Anger and aggressive behavior between nurses or nurse-to-nurse hostility. Incivility - Correct Answer-rude, intimidating, and undesirable behavior directed at another person Interpersonal Communication - Correct Answer-Communication that occurs simultaneously between two or more people with a goal to exchange messages; -2 or more people interact & exchange messages -Occurs between individuals Intrapersonal Communication - Correct Answer-communication techniques or self-talk to enhance positive interaction with the patient and family; -Self-talk -Occurs within the individual Interviewing Techniques - Correct Answer-communication skills specifically designed to gather and validate information Language - Correct Answer-prescribed way of using words; a means to express thoughts and feelings Message - Correct Answer-a term used in communication theory to denote the actual physical product of the source or encoder
Noise - Correct Answer-Factors that distort the quality of a message and interfere with the communication process Nonverbal Communication - Correct Answer-Exchange of information without the use of words Organizational Communication - Correct Answer-Process of communication that involves individuals and groups to achieve established goals Professionalism - Correct Answer-a way of being/commitment to secure the interests and welfare of those entrusted to one's care Rapport - Correct Answer-feeling of mutual trust experienced by people in a satisfactory relationship Receiver (decoder) - Correct Answer-term used in the communication theory that specifies the person or object to which the message is directed Semantics - Correct Answer-study of the meaning of words Small-group Communication - Correct Answer-communication that occurs when two or more nurses interact with two or more individuals, allowing the members to achieve a goal through communication; -Staff meeting; support group; nursing report -Organizational communication Social Media - Correct Answer-web-based technologies that allow users to create, share, and participate in dialogue in virtual communities and networks Source (encoder) - Correct Answer-term used in communication theory to specify the one who prepares and sends a message to the receiver Stimulus - Correct Answer-agent, act, or other influence capable of initiating a response by the nervous system Verbal Communication - Correct Answer-exchange of information using words The Communication Process - Correct Answer--Sender (encoder) -Message -Channel -Visual, Auditory, Kinesthetic (touch) -Receiver (decoder) -Feedback Factors Influencing Communication - Correct Answer-Developmental Stage Children versus adults
The Nursing Process (Therapeutic) - Correct Answer--Assessing -Diagnosing -Outcome Identification -Planning -Implementing -Evaluating -Documenting Communication Nurse-client relationship - Correct Answer-defined as the one-to-one interactive process b/w a client and a nurse that is directed at improving the client's health status or assisting in problem solving. -A helping-relationship (unequal sharing of info) Therapeutic Use of Self - Correct Answer-A process in which a nurse deliberately plans his/her actions AND approaches the relationship with a specific goal in mind before interacting with the client 4 Phases of the Helping Relationship - Correct Answer--Preparatory Phase -Orientation Phase [Introductory Phase] -Working Phase [Maintenance Phase] -Termination Phase [Concluding Phase] Phase of the Helping Relationship: Preparatory - Correct Answer--Before you meet the patient, review patient info/chart -Assess your own feelings/reactions to clients in the past Seek assistance from more experienced nurses, mentors, if concerned about carrying out the interaction/interview -Plan for a private, quiet setting; determine time needed -Modify the environment, if needed Phase of the Helping Relationship: Orientation - Correct Answer-(aka Introductory Phase) -Introduce yourself; explain purpose and content of interaction & establish Rapport -Observe patient's behavior; listen to patient's self-perceptions; validate perceptions as interaction/interview progresses -Inform patient how long the nurse-pt r/s will last -Start with non-threatening, specific questions; then open-ended questions -Establish a verbal contract & incorporate the goals of the interaction/interview Phase of the Helping Relationship: Working - Correct Answer-(aka Maintenance Phase) -Ask open-ended questions and stay on task -Allow patient to express feelings and watch for non-verbals for incongruence Phase of the Helping Relationship: Termination - Correct Answer-(aka Concluding Phase)
-Review goals/tasks attained -Summarize the highlights of the interview -Encourage the patient to express feelings (re: the ending of the nurse-pt relationship) -Use language concurrent with the patient's cultural background & local custom