N302 Chapter 2


Nurse practice acts


legal documents developed at the state level that define professional nursing's scope of practice and outline nurses' rights, responsibilities, and licensing requirements in providing care to individual clients, families, and communities.


Scope of practice


a broad term that refers ot the legal and sthical boundaries of practice for professional nurses established by each stateand defined in written state statutes.


Confidentiality


providing only that information needed to provide care for the client to other health professionals directly involved in the care of the client.


Informed consent


giving the client enough information on which to base a knowledgeable decision. This is another legal aspect. For a legal consent to be valid, it must include these three things:1. consent must be voluntary2. the client must have full disclosure about hte risks, benefits, cost, potential side effects or adverse reactions, and otehr alternatives to treatment3. the client must have the capacity and competency to understand the information and to make an informed choice.


What is HIPAA?


Health Insurance Portability and Accountability Actimplemented in 2003. designed to protect the privacy of client records.


Advance directive


written statement or document executed by a competent adult that is designed to provide medical personnel, family members, and others with information as to hte person's wishes regarding the nature and extent of medical care to be provided in the future shoud he or she lose decision-making capacity.


Subjective data


refers to the client's perception of data and what the client says about the data.


Objective data


refers to data that are directly obseravable or verifiable through physical examination or tests.


inference


educated guess about the meaning of a behavior or statement. To make it factual, check it with the client.


health care outcome


"the change in health status between a baseline time point and a final time point"should be client-centered and describe in specific, measureable terms.


Outcomes should be.....


based on diagnosesdocumented in measureable termsdeveloped collaboratively with the client an dother health providersrealistic and achievable


Independent nursing interventions


interventions that nurses can provide without a physicians order or direction form another health professional. --ex: health education, health promotion strategies, and counseling


dependent nursing interventions


require an oral or a written order from a physician to implement.


What is the NIC?


Nursing interventions classification


What is the NOC?


nursing outcomes classification


What are NNN terminologies?


NANDA, NIC, and NOC classifications


clinical pathways


represent a standardized, integrated multidisciplinary care plan, which includes the assessment and care given by all disciplines involved with a client's care.