Assessment - Answers gathering information
Why do we assess? - Answers to create a plan of care for patient
Initial Assessment - Answers done on admission to establish a complete data base for problem
identification and care planning
Focused Assessment - Answers completed as often as necessary depending on pts status, focusing on
specific problems
Emergency Assessment - Answers focus on life threatening issue first, then may go back and
complete rest of the assessment
Characteristics of data: - Answers -complete
-factual and accurate
-relevant
Diagnosis - Answers identifying pt problem
Data Interpretation & Analysis - Answers -recognizing patterns
- identify strengths and problems
Formulations & Validating Nursing Diagnosis - Answers writing nursing diagnosis, actual, potential
and possible nursing diagnosis
Actual Problem - Answers a problem that is present (ex. pain,nausea,skin break down)
Potential Problem - Answers a problem that might happen in the future (ex.risk for falls, risk for skin
breakdown)
Diagnosis example include... - Answers -due to
-associated with
NANDA - Answers North American Nursing Diagnosis Association
What did NANDA do? - Answers developed to differentiate nursing diagnosis from medical diagnosis
Planning - Answers setting goals and deciding how to achieve them
What are types of goals? - Answers -cognitive and psychomotor
-short term and long term
Planning steps - Answers 1. set client centered goals
2. prioritize goals
3. outline expected outcomes
Plan statements always start with... - Answers "the client will"
Writing a plan should include... - Answers SMART criteria
SMART - Answers -specific
-measurable
-achievable
-realistic
-timely
Types of nursing interventions - Answers -nurse initiated (independant)
-physician initiated (dependant)
-collaborative
Components of Therapeutic Relationship - Answers -power,empathy,respect,trust,professional
intimacy
Client-Centered Care - Answers -right to know
-right to choose
-right to participate
-right to have an opinion
Maintaining Boundaries - Answers -do not get involved with clients personal relationship
-do not disclose info
-beware of co-relationships
-ensure its all about the client
-abstain from financial involvement
Giving Gifts - Answers -may be acceptable as a part of therapeutic plan
-may be given from group of nurse/institution
-do not expect a gift in return
Receiving Gifts - Answers -if its initiated by the pt
-if they're not expecting anything in return
, -if client is mentally competent
Appropriateness of Gift - Answers -dont solicit gift
-ensure cx and pt know they will be treated the same as everyone else
Co-existing Relationships - Answers should be limited, usually only when nobody else is available
Personal Care - Answers -not acting as a paid professional
-providing compotent care
Paid Employee - Answers -must have impute from client
-maintain objectivity
-ensure youre comfortable
Intimate Partner Care - Answers Can only provide when nobody else is available
Warning signs that you may be crossing boundaries - Answers · Spending extra time with one client
beyond therapeutic need
· Changing client assignments to give care to one specific client
· Feeling other members of the team don't understand a specific client as well as you do
· Spending time off duty with client
· Ignoring policies of the agency when working with a specific client
· Keeping secrets with a client apart from the health care team
· Giving a client your phone number unless it is required as a part of the nursing role
· Client only wanting to talk to one nurse
Client abuse - Answers -disrespect
-emotional
-physical
-sexual
-financial
-neglect
How to protect client from abuse - Answers -report
-intervene when necessary
-do not get involved with pt outside work
-monitor behaviour
Abuse - Answers physical or emotional harm to someone
CNO - Answers Chief Nursing Officer
CNO - Confidentiality and Privacy - Answers nurses have ethical and legal responsibilities to maintain
the confidentiality and privacy of client health information obtained while providing client
CNO - Consent - Answers nurses have ethical and legal obligations for obtaining consent
RHPA - Answers Regulated Health Professions Act
What does RHPA do? - Answers ts out consistent rules and processes for governance, registration,
complaints and discipline, and regulation and by-law making authority
how do nurses break the law? - Answers -crime & torts
-false imprisonment
-negligence
-libel & slander
Libel - Answers written or printed material tending to injure a persons reputation unjustly
Slander - Answers -speaking or utterance of false info that damages another's reputation, social
media, group chats
- be aware of what you write and say
Crimes & Torts - Answers unintentional & intentional
Why do so many people breach confidentiality and privacy? - Answers -GOSSIP
Provincial Laws - Answers -good samaritan status
-PHIPA
-health care consent act
-substitute decisions act
-mental health act
Good Samaritan Drug Overdose Act - Answers -response to national health crisis of opioid overdose
and deaths
-provides some legal protection for people who experience or witness an overdose
PHIPA - Answers Personal Health Information Protection Act, 2004