Nursing fundamentals:
Chapter 2: Interprofessional team:
Provider: assesses, diagnoses and treats illnesses. Includes doctors, advanced practice
... [Show More] nurses for example nurse practitioners, and Physicians assistants.
Occupational therapist: helps patients regain their ability to perform ADL's activities of daily living.
Social worker: identifies and coordinates Community Resources and other patient needs necessary for discharge and Recovery.
Speech language pathologist: assist with patient issues related to speech, language, and swallowing.
Chapter 3: Nursing ethical principles:
Autonomy: patient has right to make his or her own decision, even if it is not his or her best interest.
Beneficence: do what is best for the patient do good.
Fidelity: keep your promises.
Justice: provide fairness and care and allocation of resources.
Nonmaleficence: Do no harm.
Veracity: tell the truth
Chapter 4: Legal Responsibilities Torts:
Unintentional torts:
Negligence: an example for getting to set bed alarm for patient at risk for Falls.
Malpractice: example medication error that harms patient.
Intentional torts:
Assault: example nurse threatens patient.
Battery: example nurse hits patient or administers medication against patients will.
False imprisonment: example nurse inappropriately restraints a patient or administers a chemical restraint such as a sedative.
Informed consent:
Provider responsibilities:
Communicate purpose of procedure, and complete description of procedure in the patient's primary language, use medical interpreter if needed.
Explain risks versus benefits.
Describe other options to treat the condition.
RN responsibilities:
Make sure provider gave the patient the above information.
Ensure patient is competent to give informed consent for example patient is an adult or emancipated minor, not impaired.
Have patient signed consent document.
Notify provider if patient has more questions or does not understand any information provided.
Advance directives & and mandatory reporting for RNs:
Advance directives:
Living will: communicates patient wishes regarding medical treatment if patient becomes incapacitated.
DPOA: patient designates Health Care proxy to make medical decisions for them if they become incapacitated.
Providers orders: prescription for DNR do not resuscitate and or AND allow natural death.
Mandatory reporting for RNs:
Suspicions of abuse for example child, elderly, domestic violence.
Communicable diseases to local and State Health Department mandated by state.
Chapter 5: Nursing documentation:
Objective data: what you see, hear, feel, smell. Do not include opinions or interpretations of data.
Subjective data: document as direct quotes, or clearly identify information as a statement by the patient.
Legal guidelines do not leave blank spaces and documentation. Do not use correction tape / fluid or scratch or blackout words. Include your name and title.
Incident reports: created when an accident or unusual events occur for example medication error, fall. Used for quality improvement at facility. Is not part of the patient's record and should not be referred to in the patient's medical record.
Telephone orders and information security:
Telephone orders: have second RN listen in on call, repeat prescription back, make sure provider signs prescription within 24 hours. [Show Less]