ATI: Management of Care

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1.

preventive

levels of health care: educating and

equipping clients to reduce and control risk
factors for disease

20.

EPO (exclusive provider

organizations)

private financing: clients choose

from a list of providers within a
contracted organization

2.

primary

levels of health care: emphasizes health

promotion such as prenatal and well-baby
care, nutrition counseling, disease control

21.

long term care insurance

private financing: providers for

long-term care expenses
Medicare does not cover

3.

secondary

levels of health care: diagnosis and treatment

of acute illness and injury

22.

hospital or specific
facility

usual settings for secondary and

tertiary health care

4.

tertiary

levels of health care: provision of specialized

and highly technical care

23.

QSEN (quality and safety

education for nurses)

5.

restorative

levels of health care: intermediate follow-up

for restoring health

6.

continuing

levels of health care: addresses long term or

chronic health care needs

7.

preventive
health care

examples: immunization, stress

management, seat belt use

organization that assists nursing

programs i preparing nurses to
provide safe, high-quality care:
includes 6 competencies; safety,
patient-centered care, evidence
based practice, informatics,
quality improvement,
teamwork/collaboration

24.

8.

primary
health care

examples: Office/clinical visits, schedules

school or work centered screenings

list the 6 competencies outlined

by QSEN

9.

secondary
health care

Care in hospital settings, diagnostic centers,

emergent care centers

safety, patient-centered
care, EBP, informatics,
quality improvement,
teamwork/collaboration

25.

safety

10.

tertiary
health care

examples: ICU, oncology centers, burn

centers

11.

restorative
health care

examples: home health care, rehab, skilled

nursing facilities

QSEN: minimization of risk factors

that could cause injury or harm
while promoting high quality
care and maintaining a secure
environment for clients, self, and
others

12.

continuing
health care

examples: end-of-life care, palliative care,

hospice, adult day care, in-home respite care

26.

patient centered care

13.

joint
commission

components of health care system: sets

quality standards for accreditation of health
care facilities

14.

state licensing
boards

components of health care system: ensure

that health care providers and agencies
comply with state regulations

QSEN: the provision of caring

and compassionate, culturally
sensitive care that addresses
clients' physiological,
psychological , sociological,
spiritual and cultural needs,
preferences, and values

27.

EBP

15.

utilization
review
committees

components of health care system: monitor

for appropriate diagnosis and treatment of
hospitalized clients

QSEN: the use of current

knowledge from research and
other credible sources on which
to base clinical judgement and
client care

16.

medicare

health care financing: program for clients 65

and older and for those with permanent
disabilities

28.

informatics

17.

medicaid

health care financing: program for clients

with low income

18.

MCO
(managed
care
organization)

private financing: primary care providers

oversee comprehensive care for enrolled
clients and focus on prevention and health
promotion

QSEN: the use of information

technology as communication
and information-gathering tool
that supports clinical decision
making and scientifically based
nursing practice

29.

quality improvement

PPO
(Preferred
provider
organizations)

private financing: clients choose from a list of

contracted providers. using non contracted
providers increases out-of-pocket cost

QSEN: care-related and

organizational processes that
involve the development and
implementation of a plan to
improve health care services and
better met clients' needs

19.

30.

teamwork/collaboration

QSEN: the delivery of client care

in partnership with
multidisciplinary members of the
health care team to achieve
continuity of care and positive
client outcomes

31.

spiritual support staff

interprofessional personnel:
provides spiritual care (pastors,
rabbis, priests)

32.

dietitian

interprofessional personnel:
assesses, plans for, and educates
regarding nutrition needs.
Designs special diets, supervises
meal preparation

33.

34.

lab technician

OT

interprofessional personnel:
obtains specimens of body fluids
and performs diagnostic tests
interprofessional personnel:
assesses and plans for th clients
to regain ADLs, especially motor
skills of the upper extremities

35.

lab technician

interprofessional personnel: who

should you refer?
provider needs to see clients CBC
results immediately

36.

OT

interprofessional personnel: who

should you refer?
client has difficulties using an
eating utensil with her dominant
hand following a stroke

37.

38.

pharmacist

PT

interprofessional personnel:
providers and monitors
medications, supervises
pharmacy technicians in states
that allow this practice
interprofessional personnel:
assesses and plans for clients to
increase musculoskeletal
function, especially of the lower
extremities, to maintain mobility

39.

provider

interprofessional personnel:
assesses, diagnoses, and treats
disease and injury. includes MDs,
doctors of osteopathy, APRNs,
PAs

40.

radiological technician

interprofessional personnel:
positions clients and performs xrays and the imaging procedures
for providers to review for
diagnosis of disorders of various
body parts

41.

respiratory
therapist

interprofessional personnel: evaluates

respiratory status and provides respiratory
treatments including oxygen therapy, chest
physiotherapy, inhalation therapy, and
mechanical ventilation

42.

social
worker

interprofessional personnel: works with clients

and families by coordinating inpatient and
community resources to meet psychosocial and
environmental needs that are necessary for
discharge and recovery

43.

speech
language
pathologist

interprofessional personnel: evaluates and

makes recommendations regarding the impact
of disorders or injuries on speech, language,
and swallowing. teaches techniques and
exercises to improve function

44.

RN

nursing personnel: perform assessments,

establish nursing diagnoses, goals, and
interventions; conduct ongoing client
evaluations

45.

LPN

nursing personnel: collaborate within the

nursing process, coordinate plan of care,
consult with other team members, recognize the
need for referrals to assist with actual or
potential problems, possess technical
knowledge and skills

46.

CBS
(clinical
nurse
specialist)

APRN: typically specializes in a practice setting or

a clinical field

47.

NP

APRN: collaborates with one or more providers

to deliver nonemergency primary health care in
a variety of settings

48.

CRNA

APRN: administers anesthesia and providers

care during procedures under the supervision
of an anesthesiologist

49.

CNM

APRN: collaborates with one or more providers

to deliver care to maternal-newborn clients and
their families

50.

social
worker

interprofessional personnel: who should you

refer?
a nurse is caring for an older adult client who
lives alone and is to be discharges in 3 day. He
states it is difficult to prepare adequate
nutritious meals at home for one person

51.

ethics

the study of conduct and character

52.

morals

the values and beliefs that guide decision

making and behavior

53.

ethnical
theory

examines principles, ideas, systems, and

philosophies that affect judgments about what
is right and wrong and good and band
examples: utilitarianism, deontology

54.

autonomy

ethical principles: the right to make one's

own personal decisions, even when those
decision might not be in that person's own
best interest

55.

beneficence

ethical principles: positive actions to help

others

56.

fidelity

ethical principles: agreement to keep

promises

57.

justice

ethical principles: fairness in care de;livery

and use of resources

58.

nonmaleficence

ethical principles: avoidance of harm or

injury

59.

autonomy,
beneficence,
fidelity, justice,
nonmaleficence

5 ethical principles that pertain to the

treatment of clients

ethical
dilemmas

problems that involve more than one

choice and stem from the different values
and beliefs of the decision makers
ex. review of scientific data is not enough to
solve the problem, involves a conflict
between 2 moral imperatives, answer has a
profound effect on situation and client

60.

71.

malpractice

tort: ex. nurse administers large dose of

medication due to a calculation error. the
client has a cardiac arrest and dies

72.

breach of
confidentiality,
defamation of
character

quasi-intensional torts (2)

73.

assault,
battery, false
imprisonment

intentional torts (3)

74.

assault

intentional torts: the conduct of one person

makes another person fearful and
apprehensive (ex. threatening to place an
NG tube in someone that refuses to eat)

75.

battery

intentional torts: intentional and wrongful

physical contact with a person that involves
an injury or offensive contact (ex. nurse
restrains a client and administers an
injection against her wishes)

76.

malpractice

what is professional negligence

77.

professional
negligence

the failure of a person who has professional

training to act in a reasonable and prudent
manner ( ex. failure to follow
professional/facility standards of care, use
of equipment in responsible/knowledgable
maker, communicating effectively with
clients, document care nurses provided)

78.

five elements
to prove
negligence

1. duty to provide care as defined by a

standard
2. breech of duty by failure to meet
standard
3. foreseeability of harm
4. breech of duty has potential to cause
harm
5. harm occurs

61.

advocacy,
responsibility,
accountability,
confidentiality

basic principles of ethics

62.

advocacy

basic principles of ethics: support of clients'

heart, safety, and personal rights

63.

responsibility

basic principles of ethics: willingness to

respect obligations and follow through on
promises

64.

accountability

basic principles of ethics: ability to answer

for one's own actions

65.

confidentiality

basic principles of ethics: protection of

privacy without diminishing access to highquality care

79.

informed
consent

legal process by which a client has given

written permission for a procedure or
treatment

66.

bioethics

addresses dilemmas that arise form

advancing science and technology such as
stem-cell research, organ transplantation,
gender reassignment, reproductive
technologies (in vitro, surrogate)`

80.

nursing role for informed consent

67.

tort law

example of a civil law that relates to the

provision of nursing care

68.

civil laws

laws that protect individual rights

witness clients
signature on
informed
consent form
(ensure client
got all info and
understands all
info)

81.

negligence,
malpractice

unintentional torts (2)

invasive
procedures,
surgery

when must a client provide written consent

69.

70.

negligence

tort: ex. use fails to implement safety

measure for a client at risk for falls

82.

implied
consent

consent: client adheres to the instructions

the nurse provides

83.

standards of care

define and direct the level of care

nurses should give, implicate nurses
who did not follow these standards in
malpractice lawsuits

84.

report to manager

what should the nurse do if the

suspect a coworker of behavior that
jeopardizes client care or could
indicate a substance use disorder

85.

advance directives

purpose is to communicate a client's

wishes regarding end-of-life care
should the client become unable to do
so

86.

living will, power of

attorney, providers
orders

3 types of advance directives

87.

living will

advance directives: legal document

that expresses that client's wishes
regarding medical treatment in the
event he client becomes incapacitates
and is facing end-of-life issues

power of attorney

advance directives: document in

which clients designate a health care
proxy to make health care decisions
for them if they are unable to do so.
the proxy can be any competent
adult the client chooses

providers orders

unless a provider writes DNR or AND

prescription in the clients medical
record, the nurse initiates CPR when
the client has no pulse or respirations.
the provider consults the client and
family prior to administering DNR or
AND

88.

89.

90.

91.

92.

provide info,
document client's
status, ensure
reflection on client's
current decisions,
inform members of
health care team

nursing role in advance directives

abuse,
communicable
disease

2 situations that have mandatory

reporting

local or state health

department

who do nurses report communicable

disease to

93.

mandatory
reports of
communicable
disease

purpose: ensure appropriate medical

treatment of disease (Tb), monitor for
common-source outbreaks (food
borne, hep A), plan and evaluate for
control/prevention plans
(immunizations), identify outbreaks
and epidemics, determine public
health priorities based on trends

94.

assessment, meds,
treatments,
education

information to document

95.

factual (subjective
and objective),
accurate,
complete/current,
organized

4 qualities of documentation

96.

factual

documentation: subjective (direct

quote or summary of info from client)
and objective (data collected from the
senses) no derogatory words or
opinions

97.

begin entry with

date and time,
legible, no
correction fluid,
sign

legal guidelines for documentation

98.

flow chart

documentation formats: shows trends

in vitals, blood glucose levels, pain
levels, and other frequent assessments

99.

narrative

documentation formats: records

information as a sequence of events in
a story-like manner

100.

charting by
exception

documentation formats: uses

standardized forms that identify norms
and allows selective documentation of
deviations from this enorms

101.

problem-oriented

documentation formats: consists of a

database, problem list, care plan, and
process notes

102.

SOAP, PIE, DAR

3 examples of problem-orientated
documentation

103.

subjective,
objective,
assessment, plan

what does SOAP stand for

104.

problem,
intervention,
evaluation

what does PIE stand for

105.

data, action,
response

what does DAR stand for

significant objective
information, logical
sequence, no opinion, recent
changes in
meds/treatments/procedures

components of an effective
change-of-shift report

107.

med name, dosage, time,

route

telephone/verbal
prescription: what should
you repeat back

108.

within 24 hours

telephone/verbal
prescription: when must
the provider sign

109.

transfer reports

reports that should include

demographic information,
medical diagnosis,
providers, overview of
health status, recent
progress, any alternations
that may become urgent
situations, directives, most
recent vitals, meds,
allergies, diets, activity,
special equipment,
advance directives

106.

110.

false

T/F
a nurse can refer to an
incident report in the
client's medical record

111.

other RNs, LPNS, AP

who can an RN delegate to

112.

nursing process, client

education, tasks that require
nursing judgement

what CAN'T an RN delegate

113.

monitor findings, reinforce

client teaching from standard
care plan, trach care,
suctioning, checking NG tube
patency, administering
enteral feedings, inserting
catheter, administerings
meds (except IV in some
states)

7 tasks an RN can delegate

to an LPN

114.

ADLs, specimen collection,

I/O, vitals

3 tasks an RN can delegate

to an AP

115.

right task, right

circumstance, right person,
right direction, right
evaluation

5 rights of delegation

right task

5 rights of delegation:
receptive, requires little
supervision, relatively
noninvasive

116.

117.

right
circumstance

5 rights of delegation: workload of team

member, assess and match the complexity
of care demands to the skill level of the
team member

118.

right person

5 rights of delegation: task is within scope

of member's practice, team member has
necessary training, review performance of
the team member

119.

right direction

5 rights of delegation: data,

method/timeline for reporting, specific
tasks to perform, expected results and
expectations for follow-up

120.

right evaluation

5 rights of delegation: provider

supervision, provider clear directions,
monitor performance, provide feedback,
intervene if necessary, evaluate client
outcome status, evaluate client care tasks

121.

assessment

ADPIE: data collection through

observation, interviews with client/family,
medicals history, comprehensive/focused
physical exam, diagnostic and laboratory
reports, collaboration

122.

nursing history

ADPIE: when do nurses collect subjective

data (client's feelings, perceptions, and
descriptions of health status

123.

diagnosis
(analysis/data
collection)

ADPIE: nurses use clinical thinking skills to

identify client's health status or problems,
interpret or monitor the collected
database, reach an appropriate nursing
judgment about health status and coping
mechanisms and provide direction for
nursing care

124.

comprehensive,
ongoing,
discharge

ADPIE: 3 types of planning

125.

comprehensive
planning

ADPIE: initial plan for care of clients based

on comprehensive assessments they have
completed (ex. do this upon admission to
health care facility)

126.

ongoing
planning

ADPIE: planning done throughout the

provision of care; while obtaining new
information and evaluating responses to
care, they modify and individualize the
initial plan of care

127.

discharge

ADPIE: planning that is a process of

anticipation and planning for a client's
needs after discharge

128.

upon admission

when should you start the discharge plan

129.

plan

ADPIE: nurses set priorities, determine

client outmodes, select specific nursing
interventions

130.

implementation

ADPIE: nurses base the care they provide

on assessment data, analysis and the
plan of care to select and perform
appropriate therapeutic interventions

141.

experience

critical thinking: understanding of clinical

situations, recognizes/analyzes cues for
relevance, incorporates experience into
intuition

131.

evaluation

ADPIE: step that determines whether or

not to modify the plan of care; did the
client meet the planned outcomes, where
the interventions appropriate and
effective, should i modify the outcomes or
interventions?

142.

competence

critical thinking: scientific methods, problem

solving, decision making, diagnostic
reasoning/inference, clinical decision
making, nursing process

143.

confidence

critical thinking; attitudes: feels sure of

abilities

144.

independence

critical thinking; attitudes: analyzes ideas for

logical reasoning

145.

fairness

critical thinking; attitudes: is objective and

nonjudgemental

146.

responsibility

critical thinking; attitudes: adheres to

standards of practice

147.

risk taking

critical thinking: precise, clear language

demonstrating focused thinking and
communicating unambiguous messages
and expectations to clients and other
health care team members

critical thinking; attitudes: takes calculated

changes in finding better solutions to
problems

148.

discipline

critical thinking; attitudes: develops a

systematic approach to thinking

149.

critical thinking: inner sensing that facts

do not currently support something,
should spark the nurse to search the
data to confirm or disprove the feeling

perseverance

critical thinking; attitudes: continues to work

at a problem until there is a resolution

150.

integrity

critical thinking; attitudes: practices

truthfully and ethically

132.

reflection,
language,
intuition

3 distinct levels of critical thinking

133.

reflection

critical thinking: purposefully thinking

back or recalling a situation to discover its
meaning and gain insight into the event:
why did I say or do this, did the original
plan of care achieve optimal outcomes?

134.

135.

language

intuition

136.

basic, complex,
commitment

3 levels of critical thinking

151.

humility

critical thinking; attitudes: acknowledges

weaknesses

137.

basic

critical thinking: a nurse trusts the

experts and thinks concretely based on
the rules; results from limited nursing
knowledge and experience, as well as
inadequate critical thinking process

152.

health history

admission process: current illness, current

meds, prior illness, chronic disease, surgery,
previous hospitalization, other relevant data

153.

vitals, height,
weight,
allergies,
meds

admission process: baseline data

154.

psychosocial

admission process: alcohol, tobaccos, drug,

caffeine use, history of mental illness, history
of abuse, history of homelessness, home
situation, significantothers

155.

nutrition

admission process: current diet, any

chewing or swallowing problems, recent
weight gain/loss

156.

safety
assessments

admission process: history of falls, sensory

deficits (vision, hearing), use of assistive
devices

157.

indications
for transfer or
discharge

indications for transfer or discharge

change in level of care, another setting
required for appropriate care, facility does
not offer necessary care, client no longer
needs inpatient care and is ready to return
home

138.

complex

critical thinking: nurse begins to express

autonomy by analyzing and examining
data to determine the best alternative;
results from an increase in nursing
knowledge, experience, intuition, and
more flexible attitudes

139.

commitment

critical thinking: nurse expects to make

choices without help from others and
fully assumes the responsibility of those
choices

140.

knowledge,
experience,
competence,
attitudes,
standards

5 components of critical thinking

158.

long term care

exception to beginning discharge plan upon admission

159.

discharge
planning

assess if client can return to previous residence, determine if client will need assistance at home, assess residence to
determine if client will need equipment/adaptations, make a referral to social worker for community resources,
communicate health status to community service provider

160.

standards for
discharge
education

identify safety concerns at homes, review s/s of potential complications, provide # for provider, provide name and #
for community resource,s dietary guidelines, amount/frequency of therapies, how to take meds and why
adherence is important

161.

transfer
documentation

documentation: medical diagnosis and care provides, demographic info, overview of health status/plan of clare, any
alterations that precipitate immediate concern, notification of any assessments or care essential in next few hours,
recent vitals/meds, allergies, diet/activity orders, special equipment, advance directives, family involvement

162.

discharge
documentation

documentation: type of discharge, date/time, who went with client, transportation, where client went, summary of
client's condition at discharge, description of unresolved difficulties and procedure for follow up, disposition of
valuables/meds, discharge instructions

163.

discharge
instructions

instructions for procedures at home, precautions to take when performing procedures/taking meds, s/s of
complications to report, names/numbers of health care providers and community resources, plan for follow up
care/therapy