FNP NR-506ANCC Non-Clinical Information,100% CORRECT

FNP NR-506ANCC Non-Clinical Information Level of Evidence Hierarchy: Ms. Reccee: 1. Meta-analysis 2. Systemic review 3. Randomized Controlled Trial (RCT) 4. Experiment 5. Cohort Study 6. Case Reports/Series 7. Expert Opinions/Editorials Types of Research • Meta-analysis • Systemic review • Randomized Controlled Trial (RCT) • Experiment (Classic Research) • Cross-Section • Longitudinal Design • Case Study (Report/ series) • Field study or Naturalistic study • Survey study • Cohort research Statute of Limitations: • The time limit of when a lawsuit can be filed or action against a nursing licensee for alleged violation can occur. Most states are 2-3 years. • A period of limitation for the bringing of certain kinds of legal action. Standards of Practice • Authoritative statements of the duties that all registered nurses, regardless of role, population, or specialty are expected to perform • It is developed by professional societies (ANA) and specialty organizations (AANP) Emancipated Minor • Can sign own legal documents • Legally married or divorce • Active duty in the armed forces • These are people under the age of 18 y/o but do not require an adult for consent. • Legal court document HITECH • Heath Information Technology or Economic and Clinical Health Act • Promotes adoption and meaningful use of health information technology • ACT approved in 2009 for the use of electronic health information. • Protection of PHI enacted in 2009. PHI must be encrypted prior to sending. • Patients must be informed if their PHI has been disclosed inappropriately even if the disclosure was accidental. • Providers will be offered financial incentives for demonstrating meaningful use of EHR until 2015 then penalties. • HITECH- signed by President Obama to transition to electronic health records. No more paper charting. The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act was signed into law with the explicit intention of accelerating the adoption and promoting the “meaningful use (MU)” of electronic health records (EHRs) by US physicians. Patient in EOL (end of life) stage ask of hospice: • The patient is already end stage so beneficence is not correct unless you are educating about smoking cessation or vaccination. This is to promote good. Utilitarianism is the greater good for a population of patients. Justice is to be fair. Which leaves us to autonomy. This is allowing the patient to make his own choice after giving him all the information to make a good informed decision. • AFTT (adult failure to thrive). This is a secondary diagnosis for hospice eligibility. So when you consult hospice for weight loss and not eating with no other major diagnoses, this is not a good referral. Hospice is no longer able to use this as a primary diagnosis. Prescriptive Authority • The majority of states require NPs to have a collaborative agreement with a physician in order to prescribe. • All states now allow NPs to prescribe certain controlled drugs, but with limitations DEA • Drug Enforcement Administration • NP must obtain prescriptive authority before getting a DEA number to prescribed controlled substances. • Allows advanced practice nurses to obtain registration numbers for prescribing controlled medication • Though DEA is federal, prescriptive authority is managed by the state board Certification • Generally a "voluntary" process and is done through a nongovernmental entity such as professional nursing association or specialty organization. • Many states mandate certification as a condition to obtain licensure Licensure • Legal requirement to practice as an NP • Obtained through a governmental entity, the SBON • Must meet minimal educational and clinical requirements in order to become licensed Incidence • Conveys information about the risk of contracting a disease • Measure of disease that allows us to determine a person's probability of being diagnosed with a disease during a given period of time. • Rate of new cases of the disease Prevalence • How widespread the disease is • Measure of disease that allows us to determine a person's likelihood of having a disease, number of alive cases with the disease What are the 4 ethical principles? (and define) • Beneficence (promoting well-being for pt. and society) • Nonmaleficence - "above all, do no harm" • Autonomy (person acts intentionally after being given informed consent) • Justice (equitable distribution of social benefits) Beneficence • To do good. The obligation to help the patient; to remove harm, prevent harm, and promote good • Acting in the patient's best interest • Compassionate patient care • The core principle in patient advocacy. • Encourage a patient to stop drinking and enroll in AA program. • Education on a new prescription about how to take the medication, health promotion, education, smoking cessation. Nonmaleficence • Obligation to do no harm; protecting a patient from harm • Your patient has asthma. She brown bags her medication on this visit and you notice a beta-blocker. You educate her that she is not a good candidate for these drugs • Example: Discussing risks vs. benefits of a treatment; working within SOP (standard operating procedures). Utilitarianism • The outcome of the action is what matters with utilitarianism. It also means to use a resource for the benefit of most (e.g., tax money). It may resemble justice, but it is not the same concept • The Women, Infants, and Children food (WIC) program is only for pregnant women and children. • Outcome of the action is what matter with utilitarianism. • It also means to use a resource for the benefit of most. • It may resemble justice, but it is not the same concept. • Example: WIC program is only for pregnant women and children. It is not open to adults and elderly males. The reason maybe that it would cost society more if women (and their fetuses), infants, and children are harmed by inadequate food intake (affects the brain growth). • Obligation to act in a way that is useful to or benefits the majority Justice • The quality of being fair and acting with a lack of bias • The fair and equitable distribution of societal resources • Example: Low income individuals do not pay some types of taxes to the government but still have equal access to the public services supported by taxes. Informed consent • Research subjects must be informed that they have the right to withdraw at any time without consequences or penalty • All information must be presented on what to expect, risks, benefits, alternatives, compensation, and confidentiality • Permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits. Durable Power of Attorney • A legal document that gives someone you choose the power to act in you place. Advance Directive • A written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should be the person be unable to communicate them to a doctor. Living Will • A written statement detailing a person's desire regarding their medical treatment in circumstances in which they are no longer able to express informed consent, especially an advance directive. CPOE • Computerized Provider Order Entry- electronic entry of medical practitioner instructions for the treatment of patients under his or her care EHR • Electronic health record; digital version of patient's chart; makes information available instantly and securely to authorized users Electronic Medical Record • Electronic version of the patient's chart; should remain confidential as the paper chart; providers should log out of patient identifying screens when away from the computer. ICD 10 • International Classification of Diseases • Used to indicate the diagnosis, including family history disorders. • Each disease is assigned an ICD-10 code. • Global health information standard for mortality and morbidity statistics. • Increasingly used in clinical care and research to define disease and study disease patterns, as well as manage health care, monitor outcomes and allocate resources. CPT • Current Procedural Terminology • List of descriptive identifying codes that are used to identify procedures and medical services. • It owned by the AMA. • Medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies, and accreditation organizations. CMS • Centers for Medicare and Medicaid Services • Agency under the U.S. Department of Health and Human Services Claims Based Policy • Policy that provides coverage when a claim is made against the policy, regardless of when the claim event took place. • A claims-made policy is most likely to be purchased when there is a delay between when claims are filed when they occur. • ONLY beneficial if a claim is made while your policy active. • You are covered when you have the policy for that period of time... ie you have the policy from . • If a claim is made while you have the policy you are good, but if a claim is made in 2019 and you do not have tail coverage then you're up the creek. Even if the incident occurred in . • Type of malpractice insurance that will cover claims only if the incident occurred when the NP paid the premium and only if the NP is still enrolled with the same insurance company at the time the claim is filed in court. Occurrence Based Policy • This includes tail coverage so it is more expensive. It will cover you even if you no longer have the policy. As long as you had the policy, if the claim is filed in the future.. ie... your insured from then you retire. A patient makes a claim in 2018 for something that happened in 2016. This means you are covered. • Type of malpractice policy is not affected by job changes or retirement. If a claim is filed against the NP in the future, it is covered at the time the incident occurred Tail Coverage • When you are retired and had claims based coverage. It will protect you if you have retired or changed providers against any claim made NPI • A number used to identify healthcare providers and is used for billing purposes. The Joint Commission • Has developed practice standards for which to measure quality. • Establishes performance standards for hospitals to follow for accreditation • Holds organizations accountable for sentinel events • Implements the Core Measures program The Centers for Medicare and Medicaid Services (CMS) • Responsible for administering several key federal health programs, such as Medicare and Medicaid. Third Party Payers • Medicare • Medicaid • Commercial Indemnity Insurers • Commercial management organizations (HMO) • Businesses or schools wanting health services for employees or students. Issues regarding Access to Care • Home health - Nurse/Therapy/HHA/MSW in the home - Cheaper Model than Hospital • Hospice - death diagnosis of the patient with 6 month survival with no additional treatment • Skilled nursing facilities - Nursing home with therapy room. Decrease of cost. • Private duty Nursing - $$$$$ - Nurse, Expensive Medicare • Federal health insurance program for people who are 65 and older, certain younger people with disabilities, and people with end stage renal disease. • Sets the standard of reimbursement and controlling cost • ie- aarp, blue cross Reimbursement rate for NP w/o incidence to • 85% of physician reimbursement for services provided in collaboration with a physician Medicare Part A • Medicare plan that you receive if you are 65 or older no matter the income, severely disabled, or have ESRD. • "Automatic" at 65 if person paid premiums • Covers persons with ESRD at any age • Will pay for certain "medically necessary" services: a. Inpatient hospitalization(including IP psych) b. Hospice associated with inpatient care c. Home health d. Skilled nursing facility • Will not pay for custodial care (nursing home, retirement home) Medicare Part B • Outpatient insurance • Supplemental medical insurance requiring recipients to pay a premium • Voluntary program with monthly premiums; must enroll during general enrollment period • Will pay for a. OP doctor visits b. Labs, EKG, Xray, CT c. Durable medical equipment - wheel chairs, walkers, etc d. 2nd opinions e. OP dialysis, self-dialysis equipment, organ transplant, surgeries f. Some health prevention services • Will not pay for: eyeglasses/exams, hearing aids, dentures/dental care, cosmetic surgery, OTC and most RX drugs Medicare Part C • Medicare Advantage • Cover IP (A) and OP (B) and some plans cover RX drugs • Administered by private health insurance companies approved by Medicare • "Choice" plan that includes for additional services: vision, dental. • Can keep Medicare Part A and pay for Medicare Part B. • Entitled to A, enrolled in B are eligible to receive all their health care services through one of the provider organizations (HMO,PPO) Medicare Part D • Prescription drug benefit; only those who are enrolled/eligible for A and B are eligible • Formulary for preferred drugs • D=Drug • Limited prescription drug coverage • Monthly premium required • Co-pay on each prescription is required • Medicaid • Authorized by social security act • Federal and state matching program • Provides health insurance coverage for low-income individuals and their families who meet the federal poverty level criteria • Covers children, pregnant women, adults, seniors, and individuals with disabilities • Pays for health care and RX drugs • Health care program that assists low-income families or individuals in paying for long- term medical and custodial care costs. • Joint program, funded primarily by the federal government and run at the state level, where coverage may vary. HIPAA • Health Insurance Portability and Accountability Act • Provides protections for the "use and disclosure of individuals' health information"-- called "protected health information" by organizations subject to the Privacy Rule, which are called "covered entities" • Health Insurance Portability and Accountability Act that was passed by Congress in 1996. • Must keep all information confidential, do NOT need consent for consultation with other providers. • Only healthcare providers that are active in the patients care can review any medical information. "Covered Entities" • All health care providers, health insurance companies, health care plans, laboratories, hospitals, SNFs, and 3rd party administrators who electronically transmit health information must follow HIPAA regulations HIPAA Requirements • Health providers are required to provide each pt a copy of their office's HIPAA policy (pt sign) • HIPAA form must be reviewed and signed annually • pt. has right to review medical files • Mental health provider has the right to refuse pts' requests to view their psychiatric and MH records • When pt. request to review records, health provider has up to 30 days to comply • Pts are allowed to correct errors in their medical records • Provider must keep identifying info (name, DOB, address, SS#) and any Dx/Dz or health concerns private except under certain conditions Balanced Budget Act • Broadened Medicare coverage of NP and clinical nurse specialist services • HIPAA required providers to have NPI to bill Medicare and Medicaid • NPs can be reimbursed directly by Medicare Part B, Medicaid, Tricare, and some health insurance plans • Medicare will reimburse NPs at 85% of the Medicare Physician Fee Schedule "Incident to" Billing • Way to bill Medicare for OP services rendered by a non-physician health provider and receive 100% physician fee • During 1st visit, the physician must evaluate the pt. (and write care plan); follow up visits with the NP can be billed as "incident to" so long as the same health care problems are being addressed • The physician's NPI number issued to bill for the service • The "incident to" billing is reimbursed at 100% of the physician rate Malpractice • Improper, illegal, or negligent professional activity or treatment Negligence • Failure to use reasonable care, resulting in damage or injury to another Veracity • Truth • Example: Patient recently diagnosed with advanced pancreatic cancer. Patient thinks that she has a very good chance of being cured. The oncologist explains to the patient her poor prognosis. The oncologist is being truthful and honest to the patient about her prognosis. Fidelity • Dedication and loyalty to one's patients. Keeping one's promise. • A woman with terminal breast cancer does not want the NP to reveal her poor prognosis to her mother. • The obligation to maintain trust in a relationship. • Dedication and loyalty to one's patients. Keeping one's promise. • Example: A woman with terminal breast cancer does not want the NP to reveal her poor prognosis to her mother. The patient explains to the NP that her mother is very anxious and she wants to wait until the next week before she tells her mother news. If the NP keeps the prognosis is confidence from the patient's mother, she is exercising the concept of fidelity. Autonomy • The obligation to ensure that mentally competent adult patients have the right to make their own health decisions and express treatment preferences. • Examples: An alert elderly female with periods of forgetfulness and who has breast cancer decides to have a mastectomy after discussing the treatment options with her oncologist. The woman's daughter tells the NP that she does not want her mother to have a mastectomy because she thinks her mother is too old and confused. The NP has the duty to respect the patient's decisions. This case is also a good example of the NP acting as the patient advocate. Paternalism • Making decisions for patient (or for others) because you "believe" that it is for their best interest. • The opinion (or desires) of the patient is minimized or ignored. • Patient is "powerless". • Example: 92-year-old male does not want to be on a ventilator if he codes. The son agrees and quietly tells the NP and physician that he wants this father to be aggressively treated with life support, if it is necessary. Tail insurance coverage • When an NP with claims-based malpractice insurance retires or changes to a new job, it is advisable to buy "tail" coverage insurance. The tail coverage insurance will cover the NP for malpractice claims that may be filed against him or her in the future. Health Risk Management • A systematic organizational process to identify risky practices to minimize adverse patient outcomes and corporate liability. • HAI (health care associated infection) Accountability • Being held responsible for your actions. Dignity • To treat with respect. • Example: Hospital gowns should be secured correctly so when patients get up to walk, their backs are not visible. Confidentiality • Ethical principle or legal right that a physician or other health professional will keep information private. Control group • Subjects in group that did not receive treatment Hypothesis • The proposed explanation for (or prediction of) a phenomenon. Median • The numerical value separating the higher half from the lower half. The middle value in a list of numbers. The numbers are sorted from the lowest to the highest value. Mode • Most common value in a list of numbers N • Symbol indicate total size of group n • Number of subjects in group Significance Level • Also known as the "α" or a "p-value." It is the probability that the study results are due to chance. The p-value is usually set at either p . 05 or p . 01. Null Hypothesis • There is no significant relation between the variables of the study. If the null hypothesis is rejected, it means that the results of the study are not due to chance. Budget Reconciliation Act of 1989 (HR • The first law allowing NPs to be reimbursed directly by Medicare. Only certified pediatric and family nurse practitioners were allowed as primary providers as long as they practiced in designated "rural" areas. Modifiable risk factors • Smoking • Blood pressure • Diabetes • Physical inactivity • Overweight • High cholesterol Non-modifiable risk factors • Age • Ethnic background • Family history • Gender Primary prevention (Vaccine and Education) • Prevent disease/injury • Nutritious diet, exercise, seatbelt, helmet • Gun safety • Immunizations, OSHA, EPA • Youth center, shelter • ASA prophylaxis for primary prevention of CVD and colon CA in adults age 50 to 59 yrs with 10% risk or higher Secondary Prevention (Blood and Touch {Screen}) • Early detection of a disease to minimize bodily damage • Screening tests (pap, mammo, CBC for anemia) • Screening for depression • Screening for STI • Screening for alcohol abuse • Testing for Hep C in person with risk factors Tertiary Prevention (Treat) • Prevention of disease progression, rehabilitation, support groups, education on equipment • AA, breast CA support group, HIV support group • Education for pts with preexisting dz (diabetes, HTN) • Cardiac rehab, PT, OT • Tx of person with Hep C • Tertiary prevention generally consists of the prevention of disease progression and attendant suffering after it is clinically obvious and a diagnosis established. This activity also includes the rehabilitation of disabling conditions. Examples include eliminating offending allergens from asthmatic patients; routine screening for and management of early renal, eye, and foot problems among diabetics; and preventing reoccurrence of heart attack with anticlotting medications and physical modalities to regain function among stroke patients Levels of Prevention: • P (Pupil), S (Screen), T (Treat) • Primary prevention (Vaccine and Education) • Secondary Prevention (Blood and Touch {Screen}) • Tertiary Prevention (Treatment and Post-Treatment {Rehab}) Reportable Communicable Diseases • Anthrax, botulism, west nile, encephalitis, chlamydia, chickenpox, diphtheria, gonorrhea, H.flu, Hep A, B, C, flu related infant deaths, Lyme disease, malaria, measles, meningitis, mumps, pertussis, polio, rabies, rocky mountain spotted fever, rubella, smallpox, syphilis, tetanus, TB, and more Relative Risk • Ratio of the probability of event occurring in exposed group to the probability of the of the event occurring in a non-exposed group Relative Risk Reduction • Measure of how much risk is reduced in the experimental group compared with the control group Therapeutic communication • Face-to-face process of interacting that focusses on advancing the physical and emotional well-being of a patient Root Cause Analysis • Process used in health care to identify the contributing factors that result in an error • "Structured facilitated team process to identify root causes of an event that resulted in an undesired outcome and develop corrective actions" • The gathered data are analyzed for root causes; the goal is to identify the system breakdowns that resulted in an inadvertent mistake and to propose at least one corrective action to reduce or eliminate each root cause • An approach designed to breakdown and analyze the cause of an adverse event. Consultation • To request another's opinion; could be specialist or colleague Collaboration • To work jointly Morbidity • Refers to illness or any departure from physical and/or mental health Mortality • Death Sentinel Events • An accident that results in death. • Sentinel Event (SE) • Patient safety event that results in any of the following: death, permanent harm, severe temporary harm with interventions required to sustain life. • Must perform RCA and improve. Infant Mortality • Refers to infant deaths per 100,000 live births; leading cause of death in an infant's 1st year is congenital malformations Transcultural Nursing Theory • Leininger -involves knowing and understanding different cultures with respect to nursing and health-illness caring practices, beliefs, and values with the goal to provide meaningful and efficacious nursing care services to people Family Systems Theory • Murray Bowen - suggests that individuals cannot be understood in isolation from one another, but rather as part of their family, as the family is an emotional unit • All parts of a system are interrelated and dependent on each other. If one part of the system is damaged or dysfunctional, the rest of the system is also affected. Health Belief Model • The psychological model that attempts to explain and predict health behaviors • Done by focusing on the attitudes and beliefs of individuals • A model that attempts to explain why people engage in health behavior( s). According to the HBM, a person is more likely to engage in healthier behavior if he or she feels threatened by the condition (perceived susceptibility), and believes that he or she can overcome the barriers (perceived barriers), will benefit, and can successfully perform the action (self-efficacy) (Irwin M. Rosenstock, Godfrey M. Hochbaum, S. Stephen Kegeles, and Howard Leventhal) Transitional Care Model • Designed to prevent health complications and re-hospitalizations of chronically ill, elderly hospital patients by providing them with comprehensive discharge planning and home follow up Stages of Change 1. Pre-contemplation- no intention on changing behavior 2. Contemplation- aware a problem exists but with no commitment to action 3. Preparation- intent on takin action to address the problem 4. Action- active modification of behavior 5. Maintenance- sustained change; new behavior replaces old 6. Relapse- fall back into old patterns of behavior Cultural Awareness • Foundation of communication and it involves the ability of standing back from ourselves and becoming aware of our cultural values, beliefs, and perceptions. Cultural Beliefs • Religion, culture, beliefs, and ethical customs can influence how patients understand health concepts, how they take care of their health, etc. Cultural Competence • Ability of providers and organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of patients. Hispanics • Strong matriarchal element • May consult folk healers (AKA - Santero, brujo, curandero, shaman, Babalawo) • "Susto" is a cultural illness (fright) • Mal ojo- the "evil eye"- folk illness usually of child/baby caused by an adult who stares with envy at the child; hex can be broken if the person staring at the child touches the child or to pass an egg over the child with prayers and then place the egg under the bed overnight • Families enjoy public affection • Extended family are treated like immediate family • Multi-generational may live in the same households are common • Some display distrust in physicians • Public affection is noted African American • This is a matriarchal (female is the head of household) and some patients may feel that their illness is caused by lack of faith or by sin. • Religious persons are important sources of emotional and tangible support. • Distrust in medical workers, especially doctors Native American • View illness as punishment by the spirits for wrongful actions • Healing is done by "shamans" using prayers, dance, fasting, smudging, and sometimes ingesting hallucinogenic plants • Native American medicine is used to treat Native American problems such as pain, disturbed family relationships, alcoholism and mental illness. While "White man" medicine is used to treat the "White Man" diseases such as DM, Cancer and cholelithiasis. • 50 yrs. of age and older qualifies an "elder". Jewish • Prefer clinicians of the same gender. Male may refuse to shake a female clinician’s hand. • Sabbath is from sundown Friday to sundown Saturday - may not even use electricity, drive cars, use anything electrical. • Keep kosher dietary laws. • Judaism has their Sabbath day on Saturday. They will not do anything on this day including seek medical attention. Jewish males prefer Male providers and may not shake a woman’s hand. Seventh day Adventist's Sabbath is also on Saturday but they are very strict about what they put in their body, no caffeine, drugs, alcohol, etc. Muslims prefer same sex providers but their Sabbath is not on Saturday. • Their sabbath is so strict that they cannot ride in cars, write on paper, do any business transactions (including paying copays for dr visit), shopping, turning things off and on that uses electricity but the fact that he asked for a Male provider is the key in deciphering between the two Muslims • Women must cover their head and hair; some wear a body cloak called the burka. • Females are not allowed to be alone with males who are not family members. • If a woman is seen by a male health provider, her husband or another male family member must be present in the room. • Female patient may refuse to undress (examine with gown on). • Male children are preferred. • Male is in charge of the household. • Qur'an forbids eating pork or blood or meat not slaughtered in the "halal" manner. • Modesty is paramount. • Arms, legs and head must be covered by women. • A hijab is the headscarf and the burqa or abaya is the full vail. Left hand is dirty and not used. Same gender provider preferred. • Women need male’s permission for visiting with clinician. Females may refuse to undress. The Qur'an forbids drinking alcohol, eating pork or eating meat not slaughtered in the "halal" manner. • Ramadan is observed by 30 days of fasting and cannot eat or drink during the day time. Children are not expected to fast until puberty. • Muslims don’t have a Sabbath it’s Ramadan • The word hijab describes the act of covering up generally but is often used to describe the headscarves worn by Muslim women. • The niqab is a veil for the face that leaves the area around the eyes clear. • The burka is the most concealing of all Islamic veils. It is a one-piece veil that covers the face and body, often leaving just a mesh screen to see through • The al-amira is a two-piece veil. It consists of a close fitting cap, • The shayla is a long, rectangular scarf popular in the Gulf region. • The khimar is a long, cape-like veil that hangs down to just above the waist. It covers the hair, neck and shoulders completely, but leaves the face clear • The chador, worn by many Iranian women when outside the house, is a full-body cloak. Vietnamese • May stop taking prescriptions when symptoms resolve or may think that only one visit is needed to cure an illness • Often save large quantities of left over prescription drugs • May fear blood tests and surgery bc of belief that blood loss worsens illness • May believe that Western medicine will put the body out of balance Chinese • Believe life energy (chi) imbalance or blockage is the cause of disease • Yin is the female and yang is the male • Believe acupuncture and cupping correct energy imbalance Asians (China, Vietnam, Cambodia, Korea, Japan) • Listening quietly without questioning is considered as a sign of respect. • Value college education and have high regarding for doctors. • Elderly are held in high esteem; opinion is highly respected. • Kinship ties are very important. • Vast array of herbal remedies are used. • Eye contact may be a sign of disrespect. • Influenced by Shinto - evil is caused by outside spirits (pleasing good spirits is important to health) Traditional Chinese Medicine • Life energy (chi or qi) imbalance or blockage is believed to be the cause disease. • Yin is female; yang is male. • Acupuncture and cupping correct energy imbalance. • Cupping will create large round reddened marks or bruises on back. • Coining is when a coin is rubbed vigorously on skin to create welts. • Cold illnesses (diarrhea) hot herbs and foods • Hot illnesses (hypertension) cold herbs and food • Use of color or texture of tongue to dx illness Buddhists • Meditation • Karma - good = happiness • Bad = pain in the future • Reincarnation • May be vegetarian • Come from Asia Filipinos • Amulets shield from witchcraft or as a good luck charm • Yin and yang subscribed • Gods will determines illness or punishment Caucasians • Low pain tolerance • Eye contact as communicating interest and honesty • Disease management/cure through medication • Males are viewed as the dominant force • Religious medals and rituals to prevent illness and heal • Expect a prescription when they leave the dr office Hindu • Spiritual purity is of prime importance and manifested in removing shoes indoors, sprinkling water around a plate of food to symbolize purification, regular bathing, and cleaning mouth and teeth prior to eating • food may be selected to enhance inner purity (no meat) Jehovah's Witnesses • Refuse to donate blood, store blood, or accept own blood but accept non blood plasma expanders and blood components without RBCs; if blood transfusion is needed to save the life of a child, parents may refuse (may require court order) • Believers do not celebrate civil holidays, birthdays, Christmas, Easter, and others Seventh Day Adventists • Are often vegetarian and abstain from tobacco, alcohol, and caffeinated beverages • Believe that the human body is a temple of God that deserves care • Observe the Sabbath (sundown Friday to sundown Saturday) as a holy day for rest from work/school and spiritual nurturing • If possible, avoid accessing unnecessary health services on the Sabbath Amish/Mennonites • Do not participate in Medicare, Social Security or go to war. • Community pays for health care. • Traditional roles for women. • Prefer large families with several children • Prefer giving birth (using midwives) and dying at home. • Folk practitioners and folk/alternative medicine is common. • If surgery or expensive test is needed, permission from church elders is required. • May speak German dialect. Avoid modern technology. • Closed communities have higher rates of some genetic diseases such as maple syrup urine disease, crigler-Najjar syndrome, ellis van creed syndrome and CF as well as certain metabolic disorders. Situational Leadership • Leader is flexible and can adjust his or her leadership style to fit the changing needs of an organization • Can establish rapport easily and bring out the best in people • Staff are engaged with the goals • Developed by Ken Blanchard and Paul Hersey. Transformational Leadership • Leader has the ability to communicate vision to staff members • May have charismatic personality , inspire staff • Good communication skills • Staff members usually have higher job satisfaction with this type of leader • Magnet designation • Establishes goals, provides direction then reward • Rewards good / punishes bad Laissez-Faire leadership • Leader engages in minimal supervision and direction of staff members • Prefers "hands off" approach • May not like to make decisions • Works well with experienced workers • New staff may become anxious. Authoritarian Leadership • Leader likes control and structure and prefers to give directions • May have many rules • Makes decisions without staff input • Gives directions. • Many rules • Motivated, independent and self-directed. Democratic Leadership • Leader may like to have more frequent meetings because he or she values staff members' input and feedback • Team shares in decision making process, which may be slow due to desire to include all • Leader values relationships and staff opinions Servant Leadership • Leader likes to work along with staff on the unit, treats staff as individuals • May assume many roles • Develops relationships with staff members and treats staff as individuals, which result in high job satisfaction for staff • This type of leader may not like to make decisions that can anger staff members Telehealth • A collection of means or methods for enhancing health care, public health, and health education delivery and support using telecommunications technologies • Requirement: NP to hold active licenses in each state where his/her patients are receiving care. The NPs scope of practice is determined by the state in which the patient receives care. Hospice • Care provided in the home or in a hospice house for terminally ill patients. • Requirements: under Medicare the patient must be deemed terminally ill by a provider in the next 6 months. • Need written order for hospice care. • Certifies that patient has a life expectancy of less than 6 months. • Patient gives consent to be admitted to a hospice program. • Patient agrees no to use life-sustaining equipment if a life. P-value • Represents the probability of error involved in accepting the observed results as a valid representative of the population. • Think of P-value as statistical significance of a hypothesis. Standard Deviation • The measure of the spread or dispersion of a set of data from the average. Confidence Interval • Measures the reliability of an estimate. With defined limits at each end, this specifies the probability of including the parameter being estimated. The Nurse Practice Act is enacted by: • State's legislature Primary Source • Where original research came from, seminal work Secondary Source • Secondary sources are created when the original data (primary data) are interpreted or analyzed by another person (not the original researcher). Level of Evidence Hierarchy: Ms. Reccee: 1. Meta-analysis 2. Systemic review 3. Randomized Controlled Trial (RCT) 4. Experiment 5. Cohort Study 6. Case Reports/Series 7. Expert Opinions/Editorials Randomized Controlled Trial • Best design to determine the benefits/risks of an intervention. Experimental Research • In experimental research, the researcher manipulates one or more variables and controls and measures any change in other variables. Cohort Study • Follows individuals with a particular condition over a period of time. • Best design to obtain valid information about the prognosis of a condition. • Study of a group of individuals with one or more common characteristics. Cross-Sectional Study • Best designs to evaluate a diagnostic test. • Describes and measures the interrelationships among the study's variables between two groups or more. Qualitative Research • Explores phenomena through descriptions or people and events. • Subjective data • Includes: case studies, field studies, participant observation, and ethnographic studies. • The researcher uses observation and detailed interviews to gather data. Qualitative research is inductive. Identifies phenomena and concepts. Asks broad questions. Non-Experimental Research • In non-experimental research the researcher cannot control, manipulate, or alter the predictor variable or subjects. • Relies on interpretation, observation, or interactions to arrive to a conclusion. • Includes: Descriptive and ex-post facto/correlational research. Quasi-Experimental • Similar to traditional experimental design but lacks the comparison group as well as randomization. • This is not randomized (controlled but not random). Patient-Centered Care • Patient-centered care is involving the patient and their families in all aspects of their care. • Care is provided in the manner the patient values, and decides. • Clinical decision making should be led by the patient's decision. Experimental • Random sampling is used to conduct experiment. Quantitative Research • Measurable • Systematic gathering of data. The study's data are measurable and numerical. Data are evaluated by using statistical methods. Quantitative research is deductive. Correlation Study • Describes and measures the interrelationships among the study's variables Systematic Review • Strongest level of evidence • Systematic Review: A document often written by a panel that provides a comprehensive review of all relevant studies on a particular clinical or health-related topic/question. Is created after reviewing and combining all the information from both published and unpublished studies (focusing on clinical trials of similar treatments) and then summarizing the findings. Once this is done you would do meta-analysis Randomized Controlled Trials • Second strongest level of evidence Cohort Studies • Third strongest level of evidence Case Reports • Fourth strongest level of evidence Expert Opinion • Fifth strongest level of evidence (lowest) Hierarchy of Evidence Descriptive Study • Describes and measures the characteristics of a group or a phenomenon. • Data are measurable, numerical, and evaluated by statistical testing. • No correlation are measured between variables. Longitudinal Study • A long-term study follows the same group of subjects (or subpopulation) over many years to observe and measure the same variables over time. • Observational study Prospective Studies • Studies that are done in the present (to the future) time frame. Retrospective • Studies done on events that have already occurred (e.g., chart reviews, recall of events). Another name for this study design is "Ex post facto." IRB • Protects the rights of the human subjects enrolled in the study. Inductive reasoning • Inductive reasoning is the process of developing a generalization after studying specific information. (s). Deductive reasoning • Deductive reasoning is figuring out a problem after evaluating some broad generalization(s) Experimental study • Considered the "gold standard" in research design. An important criterion is the use of random sampling to recruit research subjects. There is an intervention (or treatment) group and a control group. For example, a simple two-group experimental design will contain a control group and an intervention group that are "matched." Pretest (before intervention) and posttest data are measured. Meaningful Use • The final rule from the Centers for Medicare and Medicaid (CMS) Services state that eligible providers must use certified EHR technology product for at least 90-days in the payment year and for a full twelve months in subsequent years Teamwork and collaboration • Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care. EBP • Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care. Quality Improvement • Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems. Informatics • Use information and technology to communicate, manage knowledge, mitigate error, and support decision making Safety • Minimizes risk of harm to patients and providers through both system effectiveness and individual performance. Assent • Refers to minors not emancipated 18 y/o can choose to participated in study but parental consent is still needed. Vulnerable Populations • Infant and children 18 • Pregnant women / Fetus • Prisoners • At risk for suicide • Impaired decision-making & mental disabilities • Persons who are economically disadvantaged Variable • Constant being measured Independent Variable • Variable that is not affected by the other variables. • Variable that is manipulated. Dependent Variable • Variable that is the result of the manipulation of the interdependent variable. Case Study • Intensive and in-depth study of one person. Advocacy • Advocating for patients and their families. • Working to minimize the risk for the patient and the provider. Leadership • Collaboration and Consultation Collaboration • Action of working with someone to produce something. • NP and MD collaborate together. Consultation • When two people discuss and use expert knowledge for the patient's improvement. Conflict Resolution • Negotiation and Mediation Negotiation • Process where two or more people work to come to a resolution. Mediation • Process where a third person is involved to assist in resolving conflict. Specificity • Ability of the test to correctly identify those without the disease (negative;[-]). • Presence of nitrate by dipstick is very specific but not a sensitive test for bacteriuria. • Negatives test negative - they do not have the disease Sensitivity • Ability of test to correctly identify those with the disease (positive; [+]). • Sensitivity has the most T's (+ for positive, t for sensitivity). • Esterase detection by dipstick is very sensitive but not specific. • Positives test Positive - they have the disease Emancipated Minor • Minors active in the military or married. • These are people under the age of 18 y/o but do not require an adult for consent. Licensure • Legal right to practice as an NP. • This is granted by a state government. Certification • Process by which a nongovernmental agency validates, based on predetermined standards, an individual nurse's qualifications for practice in a defined functional or clinical area of nursing. Standards of Practice • Developed by the ANA, provides guidelines for nursing performance. • They are rules or definitions of what it means to provide competent care. State Nursing Practice Act • Laws that define responsibilities of the nurse and "scope of practice". • The range of activities and services as well as the qualifications for practice. • The acts are intended to protect patients from harm as a result of unsafe or incompetent practice, or unqualified nurses. • Actual law in place. Board of Nursing • Protects the public's health and welfare by assuring that safe and competent nursing care is provided by licensed nurses. • BON's achieve this mission by outlining the standards for safe nursing care and issuing licenses to practice nursing. • Responsible for enforcing the state's nurse practice act. • Formal governmental agency that has the statutory authority to regulate nursing practice. • Legal authority to license, monitor, and to discipline nurses. • Authorized to revoke a nurse's license (after formal hearing) HMO • Health Maintenance Organization • Plan provides coverage for providers in their network. • A PCP is chosen from the network and this provider will refer to you areas of need. PPO • Preferred Provider Organization • Selects own provider. • Does not require specific network or PCP referral for specialist. Incident to Billing • Are services supervised by certain non-physician practitioners such as PA, NP, CNS, nurse midwives, or clinical psychologist. • To qualify as "incident to" services must be part of your patient's normal course of treatment, during which a physician personally performed an initial service and remains active. • Bill under physician • Physician must be in the same building • 100% • Not allowed in the hospital setting Elements of Malpractice Lawsuits 1. A duty is owed (a legal duty exists) 2. The duty was breached (not following standard of care) 3. Breach caused an injury (proximate cause) 4. Damage occurred Scope and Standards of Practice • Document that contains "authoritative statements" that are used to evaluate and measure the nursing "quality of practice, service, or education". Consent vs Assent • A minor (who is not emancipated) as young as the age of 7 years up to age 17 years can give assent to participate in a research study, but cannot give consent legally. The parent or legal guardian must first consent to the minor's participation in the study. In addition, the researcher needs parental permission to speak with the minor in order to obtain assent (the child signs a separate assent form). Hippa Protected Information • Written information in the medical record • Conversations among health care providers • Patient information on the computer • Health information cannot be used/shared without written permission Patient Safety and Quality Improvement Act (PSQIA) • Establishes a voluntary reporting system to enhance the data available to assess and resolve patient safety and health care quality issues. • Patient safety work product includes information collected and created during the reporting and analysis of patient safety event. • Confidentiality provisions should serve to improve patient safety outcomes by creating an environment where providers may report and examine patient safety events w/o fear of increased liability risk. Confidentiality v/s Duty to Warn • Duty to warn supersedes the right to confidentiality if a patient’s condition may endanger others. • The duty to protect a patient from harming him/herself supersedes the right to confidentiality. Invasion of Privacy • If the information can be shown to have been accurate, given in good faith and the receiver had a valid reason for obtaining the information. • ie. Patient has HIV and is bleeding. You can tell the psych nurse who is going to be providing mental health care. Healthy People 2020 • Access to health care and improved health care • Continuance of 2000 • Goals: increased the quality and years of healthy life/ eliminate health disparities among Americans • Objectives r/t equal access, availability, cost, quality of care Report to the Police • Criminal acts and injury from a dangerous weapon Report to Department of Health • Gonorrhea • Chlamydia • Syphilis • Glasgow Coma Scale • HIV • TB • Report to animal control: Animal bites Report to Police via Social Services • Suspected or actual child or elder abuse Not legally required to report • Domestic Violence • This is a relationship that is consensual. However dysfunctional it may be. Collaborative Practice • True Partnership • Share common goals • Recognize/accept separate areas of responsibility and activity. Coding: ICD-10 "V-code" or Modifiers • Indicate reason for visit • CPT codes are comprised of 5 numeric digits. The first 3 numbers are always the same "992"...followed by the number assigned to the type of visit (e.g. New patient in an office (0), Established patient in an office (1), initial Hospital visit (2), and subsequent hospital visit (3)...then the last number on the CPT code is the encounter levels 1-5 (I.e. 1 =lowest level (problem-focused Hx, problem-focused exam, straightforward Medical decision making) and 5= highest level (comprehensive Hx, comprehensive exam, High Medical Decision making (MDM))). • Ex. 99201 = this is the code for a new patient in the office ("0") with a low level of encounter (problem-focused Hx, problem-focused exam, and straightforward MDM (1)). • Ex. 99215 = this is an established patient (1) with comprehensive Hx, comprehensive exam, and high MDM (5) Welcome to Medicare visits • The four components required for an assessment of functional ability and level of safety in the visit include the evaluation of hearing impairment, activities of daily living, fall risk and home safety Reliability • Determining the amount of random error; ensuring the tool is dependable, consistent, accurate and comparable Validity • The extent that the tool is measuring the construct that is being evaluated. • The variable measures what needs to be measured. Negligence • Failure to act as a reasonable and prudent person would have acted under similar circumstances Medicaid • Government health insurance program for low-income individuals. It is funded jointly by federal and state entities and is administered by state • Vary from state to state State Practice Act • Dictate the level of prescriptive authority allowed and provide prescriptive authority and numbers for non-narcotic medication Individualistic Culture • Emphasis is placed on personal responsibility • Independent living is valued Collectivistic Cultures • View themselves as a part of a larger group P Value • Represents the probability of error involved in accepting the observed results as a valid representative of the population • Level of significance T-test • Compares one variable between two groups Standard Deviation • Measure of the spread or dispersion of a set of data from the average (mean) Confidence Interval • Measures the reliability of an estimate. Specifies, with defined limits at each end, the probability of including the parameter being estimated Meta-Analysis • Data from multiple studies resulting in higher statistical power and single concussion. • Gold standard • A subset of systematic reviews; a method for systematically combining pertinent qualitative and quantitative study data from several selected studies to develop a single conclusion that has greater statistical power. This conclusion is statistically stronger than the analysis of any single study, due to increased numbers of subjects, greater diversity among subjects, or accumulated effects and results Experiment • Involves random subject selection, one placebo or control group, and one or more intervention groups. RCT is a type of experimental study. Randomized Controlled Trials (RCTs) • Randomly assigned double blind design (hidden from the patient, clinician and/or researchers. Experimental studies Cohort Study • Looks at a group - risk factors for a disease, death or any other condition. No intervention is done. Identify risk factors and associations. Can be from present to future (prospective study) Case Report • Detailed report of one person with a disease or an unusual condition that includes demo. Editorials • Based or not based on solid evidence. Weakest form Selection Bias • When a researcher places a person in one arm of the study because they believe, perhaps subconsciously, that the person will benefit the most from the new intervention and/or that they are likely to show the new intervention in its best light. Intimacy versus Isolation • Early adulthood • May be married • Friendships and relationships are enjoyed • Social isolation and lack of emotional commitment = failure Generativity versus Stagnation • Middle Age • Hold a job • May have a family • May become involved with social causes • Inability to hold down a job, self-centered and not contributing to society = failure Ego Integrity versus Despair • Ranging from older adult to frail elderly • Satisfaction with life accomplishments • Leave a legacy • Grandma sews a quilt for each grandchild • Many regrets about life who are at high risk for depression = failure Allowed to share health information • To ensure proper treatment • To pay for healthcare services • Persons identified by patient • To ensure quality care given • To protect the health of the public • To make required reports to the police Persons that do not have to follow HIPPA • Life insurers • Employers • Workers comp • Schools • Child protective services • Law enforcement • Municipal offices Pre-Contemplation • No intent to change behavior in the near future (6 months) • Resistant • Unmotivated • Avoid information, discussion or thought Contemplation • Intent to change in the next 6 months • Aware of benefits to change • Ambivalent to change • Procrastinator Relative Risk • Is the ratio of the probability of an event occurring (for example, developing a disease, being injured) in an exposed group to the probability of the event occurring in a comparison, non-exposed group Preparation • Intend to take steps to change within the next month • Transition rather than stable stage Action stage • Has made overt, perceptible lifestyle modifications for fewer than 6 months Maintenance • Working to prevent relapse • Highest levels of self-efficacy and are less frequently tempted to relapse Transitional Care Model • Prevent health complications and re-hospitalizations of chronically ill, elderly hospital patients by providing them with comprehensive discharge planning and home follow-up. Health Belief Model Look at the barriers, benefits, threats and self-efficacy. 6 constructs predict health behavior 1. Risk susceptibility 2. Risk severity 3. Benefits to action 4. Barriers to action 5. Self-efficacy 6. Cues to action Federal Health Insurance Program • Medicare • Administered by the CMS • Fee-for service program • Monthly payment deduction from SSC Family System Theory • All parts are integrated and need each other • Dysfunction affects the whole system • Others may overcompensate and take over • Increase stress someone else absorbs it and may become depressed or anxious • The father and a 14 yr old girl come in. During your assessment of the 14 yr old she tells you that her dad has been biting her head off more and stressed more. She reports that he is sleeping a lot more and she had to pick up more of the responsibilities around the home and help him to get up and moving in the mornings. She is angry and distress and feels overwhelmed. Transcultural Nursing - Leininger's Theory of Cultural Care • Specific pattern of behavior that distinguishes any society from others gives meaning to human expression of care • Sunrise model - care is influenced by many cultural features that shape one's world view. Kurt Lewin’s Theory of Change “Unfreezing” • Unfreezing is the process which involves finding a method of making it possible for people to let go of an old pattern that was counterproductive in some way. • Unfreezing is necessary to overcome the strains of individual resistance and group conformity. • Unfreezing can be achieved by the use of three methods. • First, increase the driving forces that direct behavior away from the existing situation or status quo. • Second, decrease the restraining forces that negatively affect the movement from the existing equilibrium. • Third, find a combination of the two methods listed above. “Moving to a new level or Changing” or Movement • This stage involves a process of change in thoughts, feeling, behavior, or all three, that is in some way more liberating or more productive. Refreezing” • Refreezing is establishing the change as a new habit, so that it now becomes the “standard operating procedure.” • Without this stage of refreezing, it is easy to go back to the old ways. Health Literacy • Degree to which individuals have the capacity to obtain, process, understand basic health information / services needed to make appropriate health decision. Belmont Report • Outlines the important ethical principles that should be followed when performing research involving human subjects Tuskegee Syphilis Experiment • Initiated informed consent - 600 AA that were positive for syphilis were not treated or informed. N • Total size sample Significance level • p • 0.5 or 0.1 Mean • average Median • Number in the middle when arranged from lowest to highest Mode • Most common value Range • Between the largest and smallest Total number of subjects in a group • n Quality Assurance • A process for evaluating the care of patients using established standards of care to ensure quality. Prospective Study • Studies done in the present to the future. Cross Sectional Study • Compares differences and similarities between two or more groups of people or phenomena and collects data at one point in time. Descriptive • Describe situation, experiences and phenomenon Ex post Facto • Examines relationship among variable Retrospective • Studies done on events that have already occurred Case Study • Investigation of a single person, group or phenomena. Bell curve • A normal curve Active Immunity • It is immunity to a disease developed either through vaccine or by infection Passive Immunity • Refers to immunity to a disease after receiving antibodies from another host Horizontal Transmission • Transmission of an infecting agent from one individual to another. Vertical Transmission • Transmission of an infecting agent from mother to infant. Epidemic • Rapid increase of a disease in a population that involves a large number of people Pandemic • Epidemic that occurs over a very large area. It involves a larger population Morbidity • To an illness or any departure from physical and/or mental health Mortality • Death Infant Mortality • Infant deaths for every 1,000 live births prior to the age of 1. The role of the NP • Developed in the early 1960s • Started in Peds First NP program • 1964, University of Colorado, Dr. Loretta Ford and Dr. Henry Silver The Role of the NP • Clinician • Consultant/collaborator • Educator • Researcher Consultative Relationship • Involves an informal process between two or more providers who exchange information about a patient occasionally. Elements of a Case for claim • A Duty is owed (legal duty exists), a duty was breached (not following standard of care), the breach caused an injury (proximate cause) and damage occurred. Budget Reconciliation Act of 1989 • The first law allowing NPs to be reimbursed directly by MCR. Balanced Budget Act 1997 • Broaden Medicare coverage of the NP, required NPI number for billing increased rate of reimbursement for NPS to 85%of the Medicare physician fee schedule State Nurse Practice Act • State legislature enacted • Differs from State to State • Education • Responsibilities • Scope of practice • Prescriptive authority • Disciplinary grounds • Use of titles • Within the state board of Nursing • Protects the public Standards of Advanced Practice • Delineated by ANA • Measures quality of practice, service or education • Both generic and specific standards exist • Developed by professional societies as well as specialty organizations. • Authoritative statements established by the profession for judging the quality of practice, service and education. Professional practice constantly changes as a result of a number of factors including technological advances, market and economic forces, and statutory and regulatory mandates. Scope of Practice • According to and delineated by individual state nurse practice acts • Guidelines for nurse practice varies state to state • Mandated by State Board of Nursing • Outlines the parameters of practice, identifies the boundaries for practice and usually is formatted as a list of tasks that are appropriate for an individual who is educationally prepared and clinically competent for that profession State Board of Nursing • Enforcing the state's nurse practice act. • Regulate nursing practice. • Legal authority to license, monitor and discipline nurses. • Different prescriptive authority from state to state • Called different titles from state to state State Practice Act • Licensure of the RN • Delineate what we can and cannot do • Prescriptive authority Credentials • Encompass required education, licensure and certification • Establish minimal levels of acceptable performance • Ensure that safe health care is provided by qualified individuals • Comes from non-governmental agency • Comply with federal and state laws • Voluntary Licensure • Establishes that a person is qualified to perform in a particular profession. • "Granting of authority to practice"