,what is considered the hospital's span of responsibility for the patient? - ANS-admission to 30
days post-discharge
transitional care model (TCM) - ANS-Naylor
transitional care nurse visits pt in hospital and then weekly at home for 30 days post-discharge.
in the second month, she conducts follow-up phone calls.
Care Transitions Program - ANS-Coleman
* transition coaches provide education & guidance
* visit pt in hospital, then follow-up with 1 home visit & phone calls for 4 weeks after discharge
* "red flags" & PHR
Project RED and Project BOOST - ANS-other care transitions models that use risk assessment
to determine post-discharge needs & telephone follow-up to reinforce discharge plan
PCMH and Guided Care Program - ANS-other care transitions programs that focus on a
long-term relationship with pt
rapid response team - ANS-interprofessional team that responds when pt shows signs of
deterioration to recognize & reverse the problem
LPN/LVN responsibilities - ANS-* ADLs
* vital signs & lab specimens
* wound care
* some med admin
do not have the same authority as RN & cannot make decisions independently
UAP responsibilities - ANS-* vitals
* ADLs
works under supervision of RN & requires monitoring, cannot take on expanded responsibility
w/o training and demonstrating competency
5 rights of delegation - ANS-1. Right task
2. Right circumstance
3. Right person
4. Right direction/communication
5. Right supervision/evaluation
respiratory therapist (RT) - ANS-specializes in airway management
, * administers oxygen, nebulized meds
* assesses respiratory/lung function
community health worker (CHW) - ANS-* basic healthcare training focusing on behavioral
health, patient engagement & motivation
* may address single or multiple health issues
* often focus on communities in which they have experience
patient and family advisory council (PFAC) - ANS-empower pts & families to participate in care
improvement
* provide feedback on processes
* evaluate new programs
patient situations enhanced by interprofessional collaboration - ANS-* complex pts with
multisystem diseases (ex. CHF, COPD)
* catastrophic traumatic injury
* elderly with limited resources
* impaired mental status
culture - ANS-dynamic behavior patterns based on beliefs, values, communication, customs,
language, roles & relationships
* associated with ethnic, racial, religious & social groups
* shared with following generations
cultural awareness & sensitivity - ANS-awareness: recognition that personal beliefs & values
impact cultural health beliefs and (potentially) the view of those who are different
sensitivity: understanding, thoughtfulness, and kindness that promotes inclusiveness and equity
bias - ANS-opinion that is unfair or prejudicial in some way
* implicit bias: subconscious & may be visible through subtle behaviors (ex. more relaxed with
one type of patient, more aloof with others)
Culture Care Diversity & Universality Theory - ANS-nurses must first know the patients they are
caring for > informed & able to provide care congruent with patient's beliefs
* awareness
* examine & address differences/similarities of global cultural care
* transcultural nursing - desire to cross the divide
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