RN Shared "Week 12/13" - 27 Picmonics
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Week 12/13
Documentation Guidelines
- Factual
- Objective Information
- Subjective Information from Patient
- Objective Supports Subjective
- Accurate
- Avoid Unnecessary Words and Details
- Exact Measurements
- Current
- Assessments
- Document ASAP
- Treatment and Response
- Change in Status
- Admission, Transfer, Discharge or Death
- Organized
- Document in a Logical Order
- Ensure Information Recorded is Complete
4 mins
Tort Law
- Tort Law
- Tort
- Intentional Tort
- Assault
- False Imprisonment
- Battery
- Unintentional Tort
- Negligence
- Malpractice
- Legal Issues
- Documentation
3 mins
6 Rights of Medication Administration
- Right Patient
- Right Medication
- Right Dose
- Right Time
- Right Route
- Right Documentation
- Nursing Considerations
- Three Checks
- Check for Allergies
- Assess the Patient
- Education
2 mins
Negligence and Malpractice
- Failure to Provide Acceptable Care
- Anyone Can be Liable
- Did Not Carry Out Duty and Patient Was Injured
- Must Be a Professional
- Not Following Standard of Care
- Failure to Communicate
- Failure to Document
- Failure to Assess and Monitor Patient
- Improper Delegation
3 mins
Reports
- Reporting
- Shared Communication
- ISBAR
- ISBAR
- Identify
- Situation
- Background
- Assessment
- Recommendation
- Types of Reports
- Change-of-Shift/Handoff Reports
- Telephone/Telemedicine Reports
- Transfer and Discharge Reports
2 mins
Level of Consciousness: Descriptive guide for Glasgow Coma Scale
- Conscious
- Confused
- Delirious
- Somnolent
- Obtunded
- Stuporous
- Comatose
3 mins
Advanced Directives
- Advance Care Planning
- Process of Planning for Future Care
- Living Will
- Instructions about Healthcare
- Life-Sustaining Treatments
- Level of Comfort Care
- Artificial Nutrition and Hydration
- Durable Power of Attorney for Healthcare
- Appointed Person to Make Decisions
- Do Not Resuscitate (DNR)
- No CPR
- Allow Natural Death (AND)
- Physician Order for Life-Sustaining Treatment (POLST)
- Medical Order
3 mins
Health Insurance Portability and Accountability Act (HIPAA)
- Protected Health Information
- Confidentiality
- HIPAA Patient Rights
- See and Copy Health Records
- Update and Correct Health Record
- Use and Disclosure of Protected Health Information
- How to Receive Health Information
- Permitted Disclosure of Personal Health Information (PHI) Without Patient Authorization
- Public Health Activities
- Law Enforcement
- Deceased People
3 mins
Suicide Assessment
- SAD PERSONS Scale
- Verbal Cues
- Direct (Overt) Statements
- Indirect (Covert) Statements
- Behavioral Cues
- Giving Away Prized Possessions
- Sudden Improvement in Mood
- Putting Personal Affairs in Order
- Lethality of Plan
- Detail of Plan
- Availability of Means
- Proposed Method
- Suicide Precautions
- Safe Environment
- One-on-One Monitoring
- No Suicide Contract
2 mins
Glasgow Coma Scale
- LOC Assessment
- Score of 3 to 15
- 8 or Less = Coma
- Eye Opening
- Verbal Response
- Motor Response
1 min
Informed Consent
- Key Elements
- Names and Qualifications of People Involved
- Explanation of the Procedure
- Information on Harm that Can Result
- Alternative Therapies
- Right to Refuse
- Nurses and Consent
- Nurses May Witness Consent
- Student Nurses Do Not Witness Consent
- Emergency
- Consent from Legally Authorized Person
- Life Saving Procedure Without Consent
- Special Considerations
- Deaf, Illiterate, Speaks a Foreign Language
4 mins
Assessment
- Health History
- Objective Data
- Subjective Data
- TEST-TAKING STRATEGY: KEY WORDS
- Identify
- Determine
- Obtain Information
- CONSIDERATIONS
- Assessment Always Done Before Treatments
3 mins
Implementation
- Types of Nursing Interventions
- Direct Care Interventions
- Indirect Care Interventions
- A Community (Public Health) Intervention
- Implementing the Care Plan
- Partnership with the Patient/Family
- Performing the Nursing Action
- Documenting Nursing Care
- Delegating Nursing Care
- TEST-TAKING STRATEGY: KEY WORDS
- Intervene
- Priority Action
3 mins
Planning
- Nursing Care Plan
- Tailored to Patient
- Short-and-Long-Term Goals
- SMART GOALS
- Specific
- Measurable
- Attainable
- Realistic
- Time-Oriented
2 mins
Diagnosis
- A COMPARISON
- Medical Diagnosis
- Nursing Diagnosis
- Collaborative Problem
- Data Interpretation and Analysis
- Significant Data
- Patterns or Clusters
- Parts of Nursing Diagnosis Statement
- Problem
- Etiology
- Defining Characteristics
- TEST-TAKING STRATEGY: KEY WORDS
- Maslow’s Pyramid
- Patient’s Concerns
2 mins
How to Write a NANDA Nursing Diagnosis
- Nursing Diagnosis
- Nursing Diagnosis Components
- Problem Statement
- Etiology
- Defining Characteristics or Risk factors
- 4 Types of Nursing Diagnoses
- Problem-Focused
- Risk
- Health Promotion
- Syndrome
- Steps For Writing a Problem-Focused Diagnosis
- (Problem-Focused Diagnosis) related to________(Related Factors) as evidenced by _____________ (Defining Characteristics).
- Steps For Writing a Risk Diagnosis
- Risk for_____as evidenced by_____(Risk Factors).
3 mins
Tuberculosis Skin Mantoux Test (PPD)
- Delayed Hypersensitivity (Cell Mediated Response)
- Intradermal Injection
- Read 48-72 hours
- Positive Results
- ≥ 5 mm Induration
- Immunosuppressed
- ≥ 10 mm Induration
- High Risk Patients
- ≥ 15 mm Induration
- Considerations
- Chest X-Ray
3 mins
Pyelogram
- Indications
- Visualizes Urinary Tract
- Diagnose Urinary Disorders
- Considerations
- Bowel Prep (Enema)
- IV Contrast Media
- X-Ray (Radiopaque)
- Increase Fluid Intake
- Contraindications
- Iodine Allergy
- Decreased Renal Function
2 mins
Magnetic Resonance Imaging (MRI)
- Procedure
- Internal Body Images
- Detects Variations of Soft Tissues
- Considerations
- No Metal Objects
- No Pacemakers
- Contrast is Non-Iodine
- Safe During Pregnancy
- Long Procedure
- Antianxiety Medications
2 mins
Oral Glucose Tolerance Test (OGTT)
- Used for Diabetes Screening
- Fasting State
- Samples Drawn
- Baseline
- Normal < 100 mg/dL
- 30 and 60 Minutes
- Normal < 200 mg/dL
- 120 Minutes
- Normal < 140 mg/dL
2 mins
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