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Managed care

any method of financing and organizing the delivery of health care in which costs are contained by controlling the provision of benefits and services


Medical Necessity

services or items reasonable and necessary for the diagnosis or treatment of illness, injury, or to improve the functioning of a malformed body member.


Acute care hospital or medical center

Provide emergency care, surgeries, inpatient care, diagnostic testing, and usually some types of outpatient care.


Long-term acute care hospital (LTACH)

Focuses on patients with serious medical problems that require intense, special treatment for a long period of time, 20-30 days. They may be transfers from ICU


Skilled Nursing Facility

Provides a less intense level of care than that found in a traditional or long term acute care hospital. Usually a transitional care setting.


Requirements for Skilled Nursing Facility

  • Patient must have been hospitalized for at least 3 days prior
  • Patient must enter nursing home within 30 days of a hospitalization
  • There is a 100 day stay at maximum per year
  • Patient must be making regular progress as documented by the medical professionals

Rehabilitation Facility

Level of care in which the patient can receive intense physical, occupational, and speech therapy services.

Alternative rehab facilities focus on chemical dependency and mental health issues.


Residential Care Facilities

Care given in settings where the patients, or residents, stay for long periods of time


Outpatient Care

Designed to meet patient needs in 1 day and then allow him or her to return home


Hospital outpatient care

Outpatient surgery, cardiac, pulmonary, physical occupational, and speech therapy/rehab, laboratory, radiation, and diagnostic testing, mental health


Team Nursing

Consisting of CNA, UAP and nurses to provide care for a group of patients. Often used in the acute care hospital, rehab setting, and long term care setting.


Client-centered care

Patient takes control of and manages own care. Often seen in rehab facilities to allow patients to achieve independence by having their own voice in their rehab, schedule, goals, and method of attaining those goals.


Primary Care Nursing

One nurse is responsible for all aspects of nursing care for their assigned patients. No UAP or CNA, no other nurses to assist. Often seen in ICU. These nurses must be able to work quickly and efficiently in a crisis or under stress.


Case Management

Nurses providing case management services act simultaneously as coordinators, facilitators, impartial advocates and educators. Hospitals


Third Party Payer

Insurance company



HMO payment system. PCP is gatekeeper, paid a set amount/member/month to manage health care of those members.


Health Management Organization (HMO)

A cost-containment program featuring a primary care physician as the gatekeeper to eliminate unnecessary testing and procedures.


Preferred Provider Organization (PPO)

A group of health-care providers contract with a health insurance company to provide services to a specific group of patients on a discounted basis.


Point of Service Plan

Similar to HMO, PCP is gatekeeper but it is not capitated. Insured can seek care from providers in or outside the network


Critical thinking

Using skillful reasoning and logical thought to determine the merits of a belief or action


Primary data

When the patient provides information


Secondary Data

Information obtained from family/friends/patient chart


Prioritizing Diagnoses

Nursing diagnoses address physical, psychosocial, and environmental needs of patients, with some of them being a higher priority than others


NANDA-I Lists Northern American Nursing Diagnoses Association International)

Make diagnoses easy to find. Main topic first, risk for, readiness for enhanced, acute, chronic, family, impaired, disturbed, and deficient. On care plans are written as they would logically be read, not as appears on the list.


Defining Characteristics

Signs, symptoms, exhibited by the patient.


Expected outcomes

  • realistic, specific action to be taken by the patient
  • action that the patient is willing and able to perform
  • action that is measurable
  • definite time frame for the action to have been accomplished

Types of Nursing Interventions

  • direct patient care-nurse interacts directly with the patient
  • Indirect patient care-nurse provides assistance other than with the patient
  • independent interventions-nurses determine that interventions are needed and provided without consulting anyone else

Collaborative Interventions

Involve working with other health-care professionals


Initial Implementation Steps

  1. Check providers order. Confirm order is appropriate and current
  2. Referring to facility procedures unless already known
  3. Gather needed equipment and supplies. Confirm consent form
  4. Wash hands
  5. Obtain assistance
  6. Identify patient using 2 methods
  7. Introduce yourself with name and title
  8. Explain procedures in lamented terms
  9. Provide privacy
  10. Use standard precautions/body mechanics
  11. Assessments to ensure patient sill requires the procedure/can tolerate
  12. Continue to observe during procedure for pain, discomfort, other problems

Ending Implementation Steps

  1. Evaluate patient response
  2. Ensure patient is safe and comfortable, in proper body alignment, w/clean linens and call light
  3. Bed should be at a safe height
  4. Hand hygiene
  5. Ask patient about needs and inform them when you plan to return
  6. Leave room door open or closed according to patient preference
  7. Document interventions and effectiveness according to policies
  8. Properly disposing of used supplies, PPE, and trash, return equipment to proper location


  • Are nursing diagnoses correct?
  • established realistic, reachable goals?
  • Determined the correct priorities for your nursing diagnoses?
  • Selected and implemented the correct interventions?
  • Has patient condition changed?

Computerized Care Plans

Care plan is saved in the computer, available to all nursing staff with passwords. RN highlights appropriate nursing diagnoses on computer screen then selects corresponding goals and nursing interventions listed for that diagnoses


Standardized care plan

Preprinted documents with typical nursing diagnoses and corresponding intervention choices.


Multidisciplinary care plans

Include choices of different nursing diagnoses w/options the nurse may select in order to individualize the patients care


Critical Pathways/clinical pathways

Interventions are provided each day and they change as the patient improves and requires less comprehensive nursing care


Student care plans

Used to help students make connections between the patient's medical diagnoses, medications, lab and diagnostic tests, assessment data, nursing diagnoses, nursing orders or interventions, and evaluations.


Preparing to care for patients prior to clinical experience

  1. Research-further research after reading the patient chart prior to patient care
  2. Possible nursing diagnoses- done through the information available
  3. Expected outcomes for each nursing diagnoses
  4. Develop your interventions-determine what you will do for this patient
  5. Meet and assess the patient
  6. Evaluate your nursing diagnoses-do you need to make any changes?
  7. Implement your interventions
  8. Evaluate your care plan

Continuity of care

Nurses provide continuous care for a patient 24 hours a day. Nurses document an ongoing account of all pertinent patient data 24 hours a day


Permanent record of care

A permanent record of the patient's condition, diagnoses, results of diagnostic tests and procedures that were performed, all medical and interdisciplinary care that was provided as well as the patient's outcome.


Report form

Work shift will begin with an initial patient report, documents reported information


Incident reports

  • medication error
  • patient injury
  • visitor injury
  • employee injury
  • safety hazard or failure to repair reported broken or damaged equipment
  • Failure of appropriate provider response to emergency
  • failure to perform ordered care
  • loss of patient's personal belongings
  • lack of availability of vital patient care supplies or equipment

Patient chart or medical record

avoid taking shortcuts

use only approved abbreviations

be accurate


Source oriented records

Nurse's notes

providers progress notes

vital signs

rehab therapy


Problem oriented record

  • database
  • problem list
  • plan of care
  • progress notes

Data to document

  • physical and emotional assessment
  • nutrition
  • hygiene
  • activity level
  • physicians visits
  • Elimination-I&O
  • Nursing care
  • Patient's response to interventions
  • Safety issues
  • Lab and diagnostic testing
  • All patient complaints

Narrative charting

  • written in chronologic order, relates to patient health status
  • provides continual description of patient's condition, complaints, and problems

Guidelines for paper documentation

  • use black or blue ink
  • write neatly and legible
  • sign each entry
  • include the date and time with each entry
  • follow chronological order
  • make entries in a timely manner
  • be succinct
  • use punctuation
  • do not leave blank lines
  • use continued notes
  • correct mistaken entries
  • keep the medical record intact


Contains written data used for quick reference about each resident's care. The page lists all the care that should be provided for that specific resident in a long-term care facility


Weekly assessment data in a long-term care facility

  • use of all prostheses
  • activity level
  • elimination control and habits
  • nutrition versus malnutrition
  • ability to communicate
  • visitors and support system
  • social activities
  • ability to perform activities of daily living

Five documentation mistakes that carry increased risk of malpractice

Failure to document:

  • Assessment findings
  • medications administered
  • pertinent health history
  • physician's orders
  • documenting on the wrong chart

Communication Process

An exchange of information, feelings, needs, and preferences between two people.



A return message that indicates the message has been received, processed, and comprehended.


Shared Meaning

Indicated the message was communicated as intended



The distance, or personal space, people place between themselves and others.


4 Personal space-distance zones

Intimate, casual-personal, social-consultative, public-12 ft if possible


Factors that affect communication

Personal space, body position, language, culture, attitude, emotion


Denotative meaning

Literal meaning, absent of any interpretation


Connotative meaning

The emotional associations that can be attached to the word. Words such as love, death, and cancer are emotionally charged and can elicit emotional responses that distract the listener because of past experiences resulting in a message that is distorted and altered.


Passive or avoidant (style of communication)

Characterized by the desire to avoid confrontation and the inability to share feelings or needs with others. Individuals have trouble asking for help and allow others to take advantage of them. Feelings of anger, emotional pain, and anxiety


Aggressive (style of communication)

Characterized by putting one's own needs, rights, and feelings before those of others. Superior attitude, try to humiliate others and communicate in an angry, hostile way with no regard for the feelings of others.


Assertive (style of communication)

Characterized by standing up for one's self without violating the basic rights of others. Show respect for others, express their own feelings in an honest and direct way. Enhances self worth. Most effective communication style for nurses to practice


DESC Method ( promote assertive communication)

D-describe the behavior

E-explain the impact of the behavior

S-state the desired outcome

C-consequences should grab the person's attention.


Therapeutic Communication

Patient centered. To promote a greater understanding of a patient's needs, concerns, and feelings.


Examples of barriers to communication

asking questions that can be answered with a yes or no response

giving false reassurance

asking too many personal, probing questions

giving advice

belittling a patient's feelings

expressing disapproval


Therapeutic Communication Techniques

Providing general leads

Using silence

Offering self

Using open-ended questions or statements.

Using restatement (validation)

Seeking clarification

Giving information

Using reflection

Looking at alternatives










Upward communication

Upward communication- interaction with those in authority over you and is formal by nature.


Expressive aphasia

A disturbance in speech planning and production. Cannot produce fluent speech. Inappropriate words, slow monotone utterances, single-word responses.


Receptive aphasia

A deficit in auditory comprehension or in receiving information. Patient can hear but cannot understand what is said. Abnormal language, impaired reading and writing skill, speech sounds with normal rhythm, rate and fluency.


Global aphasia

(Expressive and receptive) A deficit of planning, production, and comprehension of language. Patients can speak and understand only a few words. Meaningless speech sounds, possible perseveration, or repetition of one word or thought. Communication is very difficult


Communicating with aphasia

Have patients attention-touch them if necessary, speak slowly, use short sentences, repeat what you said, use gestures, demonstration and facial expression if necessary, speak in a normal tone of voice, be respectful and sensitive, ask yes-or-no questions-write messages if necessary, listen carefully, allow the patient time to speak without interruption, try to make the patient a partner in the communication.


Patients can approach death with a sense of peace and without fear when...

  • fear is relieved
  • pain is managed
  • the needs for reconciliation with loved ones are met
  • spiritual needs are met

Medicating the dying patient

Keep the patient as comfortable as possible. Explain that they do not have to wait till pain is severe to ask for relief. It is their right to die with dignity and comfort. Addiction is not a concern at this point.



With sickness



Good death


Palliative Care

Comfort care. Not just terminal care. It incorporates medication administration, nursing care and other therapies to alleviate uncomfortable symptoms such as pain, nausea, and vomiting, dyspnea. Has no effect on the disease itself.


Hospice Care

Designed and available for patients in the later stages of terminal illness.

Relieving pain and discomfort, lessening patient and family fears and anxiety, actively including the patient and family in both patient care and decision making, providing both the patient and the family emotional support through the various stages of the grieving process, providing respite for the caregivers



Make arrangements for provision of care in order that the family members may have a time to get away, rest, and rejuvenate without the strain and worry of continual caregiving.


Terminally ill clients do not want..

  • to die in pain
  • to die alone
  • to be a burden to their family

3 Ways a DNAR can be documented

  • patient may sign DNAR form
  • Patient's health-care proxy can sign the form
  • Health-care provider can write a DNAR order on the patient's chart