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51 Cards in this Set
- Front
- Back
affective domain
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The material is presented in a way that appeals to the learner's beliefs, feelings, and values
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Auditory Learning
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Aurally, through what they hear
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Behavioral Objective
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represent the desired changes or additions to current behaviors and attitudes
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Cognitive Domain
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The learner takes in and processes information by listening to or reading the material
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feedback
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return of information about the process
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Kinesthetic Learning
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By actually performing a task or handling items
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Psychomotor domain
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The learner processes the information by performing an action or carrying our a task
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charting
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Is used to track the application of the nursing process
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Case management system charting
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which tracks variances from the clinical pathway
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Charting by exception
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Which focuses on deviations from pre-defined norms using preset protocols and standards of care
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Computer-assisted charting
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Where data are input to the computer.
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Computerized provider order entry (CPOE)
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Provides for efficiency of work flow because when orders are entered into the computer there is automatic routing to the appropriate clinical areas for action
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focus charting
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which centers on the patient from a positive perspective.
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Medical records (chart)
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Contains all orders, tests, treatment, and care that occurred during the time the person was under the care of the health care provider
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PIE charting
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P-problem
I-enterventions E-evaluation this type of charting follows the nursing process and uses nursing diagnoses while placing the plan of care within the nurses progress notes |
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Problem oriented medical record (POMR) charting
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Which focuses on the problems experienced by the patient as a result of being ill or on the defined nursing diagnoses reflecting those problems
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Protocols
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Standard procedures
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Source-oriented (narrative) charting
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which focuses on the patient's disease
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Automony
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Control over personal decisions
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Beneficence
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Doing good
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Beneficent paternalism
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Health care provider making decisions for the patient based on "I know what's best for you." discount patient autonomy
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ethics
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Rules or principles that govern correct conduct
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fidelity
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in nursing to be faithful to the charge of acting in the patient's best interest when the capacity to make free choice is no longer available
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justice
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Giving patients their due and treating them fairly
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Morals
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Ethical habits of a person
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Nonmaleficence
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First, DO NO HARM
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Nursing ethics
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System of principles governing conduct of nurses
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Privacy
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Both a legal and ethical issue. Patient's right to choose what is done to his/her body, based on personal eliefs, feelings, and attitude
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Values
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Assigned to an idea or action. Freely chosen and affected by age, experience, and maturity.
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Cues
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Are pieces of data or information that influence decisions
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Data
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Pieces of information on a specific topic
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Database
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All the information gathered about the patient.
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Defining Characteristics
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Are those characteristics that must be present for a particular nursing diagnosis to be appropriate for that patient?
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Etiologic factors
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Are the causes of the problem
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Expected outcomes
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Is a specific statement of the goal the patient is expected to achieve as a result of nursing intervention
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Goal
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Is a broad idea of what is to be achieved through nursing interventions
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Inferences
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Conclusion made based on observed data
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Interview
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Conversation where facts are obtained
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Nursing diagnoses
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Indicates the patient’s actual health status or the risk of a problem developing the causive or related factors and specific defining characteristics
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Objective data
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Information obtained through senses and hands on physical examination
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Signs
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Are abnormalities that can be verified by repeat examination
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Subjective data
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Data obtained from the patient verbally. What the patient says.
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Symptoms
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Are data the patient has said are occurring that cannot be verified by examination
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Chart
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Document
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Clinical pathway/care map
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Is a step-by-step approach to the total care of the patient.
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Continuous quality improvement
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Process of continually evaluate nursing care to identify specific areas that need changes for improvement
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Dependent Nursing action
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Action requiring a physician order.
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Documentation
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The recording of pertinent data on the clinical record
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Evaluation
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Judgment of the effectiveness of the intervention or plan
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Implementation
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Performing an intervention and assessing the response
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Independent Nursing Action
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An action that does not require a physician’s order, but does require critical thinking.
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