Nursing 102 Final Exam
Describe components of non-verbal communication.
*influenced by environment* - grooming - clothing - gestures - posture - facial expression - eye contact - tone and volume of voice - actions
Define Gracious Space
- "A spirit and a setting where we invite the 'stranger' and learn in public" - a technique and way of being that shapes our interactions with others - a framework for working w/ conflict and a way to guide conflict towards transformation - involves cultural humility and confident humility
Attributes of a Critical Thinker
- A critical thinker: (1) raises questions and problems and formulates them clearly and precisely; (2) gathers and assesses relevant information, using abstract ideas for interpretation; (3) arrives at conclusions and solutions that are well-reasoned and tests them against relevant standards; (4) is open-minded and recognizes alternative ways of seeing problems, and has the ability to assess the assumptions, implications, and consequences of alternative viewpoints; (5) communicates effectively w/ others as solutions to complex problems are formulated ***Reflective Thinking --> asking self questions during and after nurse-patient interactions***
Identify the characteristics of a gracious space environment
- A gracious space environment makes it possible for people to trust enough to: => be vulnerable => voice disagreement => be curious => be compassionate => engage in hard conversations w/o being hard => be inclusive
Define evidence based practice and the relationship to lifelong learning and technology
- A process that provides a method for considering the best available evidence combined with the nurse's expertise and the desires of the patient - It involves asking the right questions and finding the most recent data and evidence to support and guide delivery of care.
Discuss the role and potential biases of participant and non-participant observation in the acquisition of data.
- Biases whether it be participant or non-participant have the ability to influence data acquisition *Participant:* - The interview typically involves a face-to-face interaction with the patient that requires the nurse to use the skills of interviewing, observation, and listening. - The information that the patient gives can be biased and reflect what the patient wants the nurse to hear. *Non-participant:* - Physical examination is the second method for obtaining data. - Nurses use physical assessment techniques of inspection, auscultation, percussion, and palpation to obtain these data. - The objective data can be biased because the nurses may end up forming opinions based on what they see.
Describe the role of active duty military nurses in austere environments
- Deliver life-saving care to combat-injured military service members and civilians in the battlefield, at Combat Support Hospitals (CSH), and during air transport out of the battle zones and to Landstuhl Regional Medical Center - Assess for traumatic brain injury, potential life-threatening events (e.g., bleeding, hemodynamic status), complications of surgery, and pain, and manage these events - Support, prepare, and inform combat-injured and their families about what to expect across all transitions of care => Acute Care => Rehabilitative Care => Ambulatory Care => Reintegration
Discuss the uses of the electronic medical record (electronic health record) in professional nursing practice
- Digitalized medical records allow for access across disciplines and across distance, w/ the goal to improve continuity of health care no matter where a person requires medical treatment - In many institutions, nurses enter patient data into computers at the bedside. - Designed to connect clinicians so that patient data can be shared and health care personalized
Discuss threats to patient safety and potential errors in health care.
- Errors: "failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim" - improper patient identification, poor communication, mislabeled medications, poor infection precaution, surgical mistakes, malfunctioning alarm systems
BSN Essentials I, III, IV, & IX
- Essential I: *Liberal Education for Baccalaureate Generalist Nursing Practice* => A solid base in liberal education provides the cornerstone for the practice and education of nurses - Essential III: *Scholarship for Evidence Based Practice* => Professional nursing practice is grounded in the translation of current evidence into one's practice - Essential IV: *Information Management and Application in Patient Care Technology* => Healthcare policies, including financial and regulatory, directly and indirectly influence the nature and functioning of the healthcare system and thereby are important consideration in professional nursing practice - Essential IX: *Baccalaureate Generalist Nursing Practice* => The baccalaureate-graduate is prepared to practice w/ patients, including individuals, families, groups, communities, and populations across the lifespan and across the continuum of healthcare environments => The baccalaureate graduate understands and respects the variations of care, the increased complexity, and the increased use of healthcare resources inherent in caring for patients
Discuss the domains of knowledge areas integral to the nurse's use of information systems, including electronic health records
- Helping role - Teaching-coaching function - Diagnostic & patient monitoring function using EHR to document all the activities done to deliver care to the patient - Administering & monitoring therapeutic interventions & regimens - Monitoring & ensuring quality of health care practices - Organizational & work-role competencies
Discuss the role that appraisal of the environment plays in the delivery of safe, effective nursing care.
- Identify patients correctly (e.g., 2 identifiers: name, date of birth) - Improve staff communication (e.g., report critical test results to right staff in timely fashion) - Use medications safely => Label all medicines on/off sterile field & pcd (process challenge devices) => Take extra care with patients on blood thinners => Record & pass along correct information about patient's medications from home to facility & back home - Use alarms safely. Are they heard & responded to on time? - Prevent infection (e.g., hand hygiene per CDC or WHO) - Identify patient safety risks (e.g., pts most likely to commit suicide) - Prevent mistakes in surgery & procedures (e.g., right surgery, right site, time out prior to surgery to avoid mistakes)
Describe the role of active duty military and civilian nurses in military hospitals
- Identify physiological and behavioral health issues - Address concerns, fears, worries, and uncertainty surrounding injuries and potential for recovery - Listen and comfort at times when the devastation of injuries can be exceptionally difficult to handle - Share in the triumphs of overcoming challenges and recovery - Support families and colleagues when sadly there is loss of life - Collaborate in camaraderie of team-based military health care that is exceptional and enduring
Self-Assessment: Critical Thinking
- Inquisitive/curious/seeks truth - Self-informed/finds own answers - Analytic/confident in own reasoning skills - Open-minded - Flexible - Fair-minded - Honest about personal biases/self-aware - Prudent/exercises sound judgment - Willing to revise judgment when new evidence warrants - Clear about issues - Orderly in complex matters/organized approach to problems - Diligent in seeking information - Persistent - Reasonable - Focused on inquiry
Describe the Defense and Veterans Pain Rating Scale (DVPRS)
- Is the pain really what the experiencing person says it is? - Tested on 350 Services Members at the Walter Reed National Military Medical Center - DoD/VA Pain Supplemental Questions: 1) Circle the one # that describes how, during the past 24 hours, pain has interfered w/ your usual activity (0-10, w/ 10 indicating "completely interferes") 2) Circle the one # that describes how, during the past 24 hours, pain has interfered w/ your sleep 3) Circle the one # that describes how, during the past 24 hours, pain has interfered w/ your mood 4) Circle the one # that describes how, during the past 24 hours, pain has interfered w/ your stress
Explain the effect of generational diversity on nurse-colleague relationships.
- Knowing the characteristics and core values of each generation can help nurses of diverse ages understand colleagues and patients who are much younger or older than they are *However, take care not to stereotype anyone*
Nursing Leadership according to: Marla E. Salmon
- Leadership is finding the issue you care about and then doing something about it - Criteria: => Transforming interest into leadership => Input of others for effective leadership => Common ground versus consensus - Critical Question: => Why is collaboration important in effective leadership?
Nursing Leadership according to: Linda Aiken
- Leadership is thinking about goals and priorities. - Criteria: => Systems supporting excellence => Patient safety context => Global and local action for nurses - Critical Questions: => What are the roles nurses may have in the health care delivery system? => Why is it important to put patient goals into a safety context? => What is the benefit of having nurses with expertise (expert nurses) in the health care setting?
Explain how nurses can operationalize gracious space in their practice
- Pay Attention to Spirit: compassion, empathy, sensitivity, curiosity, "being" Gracious Space - Create Intentional Spaces - Invite the 'Stranger': when diverse perspective is beneficial (holding off judging based on different perspectives) => deep respect for difference despite... - Learn in Public: open your heart and mind to the thinking of others (be willing to learn and be influenced) - Build Trust: through character, competence, consistency, and information - Inquire: seek first to understand - Listen Deeply and Slow Down - Step back and reflect on assumptions - Give opinions w/o fear of criticism
Define the attributes of the professional nurse
- Professionalism - Clinical judgement - Leadership - Care coordination
Discuss the role of reflection in the communication process.
- Self-awareness means recognizing behaviors and feelings and knowing that feelings cannot be controlled, but behavior can => This requires nurses to reflect on their thoughts, feelings, actions, and beliefs - Being self-aware allows you to understand your responses and look past your own negative responses to particular patients in order to create and maintain a healthy professional space to provide effective care - Become self aware of what is comforting or rewarding & what is uncomfortable - 6 Caps: 1) White cap: (data available, describe the events, facts and figures) 2) Red cap: (looking at the situation using intuition) What was your gut reaction and emotion? What did you feel? 3) Black cap: (negative side of the situation) 4) Yellow cap: (thinking positively) Describe the benefits and value of the experience in present and future roles 5) Green cap: (growth or creative hat) What could you change to improve patient/staff experience? 6) Blue cap: (pulling the pieces together) What can you learn from this experience? What further knowledge do you need? How did your emotions impact your appraisal of the situation? *Reflective Questions to Ask Self:* - "How did I come across to the patient? What did I say? - "What did my body language say?" - "If I had only....." - "What I will do the next time?"
Discuss the role of nurses in managing costs
- Staff nurses have the most frequent and direct contact w/ patients and can have a positive impact on reducing unnecessary spending - Nurses should be advocates for their patients' personal finances - 1st step = become cost conscious - Change supply use patterns => post price of supplies on shelves => cut down on "borrowing" b/w units => transfer all patients' bedside equipment, medications, and supplies carefully - Make staff nurses aware of less-expensive alternatives - Start or expand a revenue-generating recycling program - Nurses must recognize patients will have to pay some portion of charges personally - Question unnecessary or repetitive tests - Suggest generic drugs rather than name brands - Teach patients and their families how to monitor their health conditions and detect problems early to avoid repeated hospitalizations - Hand washing to prevent infections, turning patients on schedule to avoid pressure ulcers, and vigilance to reduce the risk of falls - Medicare no longer reimburses facilities for the treatment of 8 "reasonably preventable" hospital-acquired conditions ("never conditions") (e.g., pressure ulcers, catheter-associated urinary tract infections, falls with injury and burns, and vascular catheter-associated infections)
What is QSEN?
- The Quality and Safety Education for Nurses (QSEN) project funded by the Robert Wood Johnson (RWJF) Foundation - QSEN project addresses the challenge of preparing future nurses with the knowledge, skills, and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work - QSEN has defined quality and safety competencies for nursing and proposed targets for the KSAs to be developed in nursing pre-licensure programs for each competency: *patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics* (Phases 1 & 2) - Phase 3: Three goals: (1) promoting continuing innovation in the QSEN competencies and dissemination of these innovations; (2) developing faculty expertise required for students to achieve quality and safety competencies; and (3) create mechanisms to sustain the will to change among nursing program through nursing textbooks, accreditation and certification standards, licensure exams, and continued competency requirements
Model for Structured Reflection
- Write a description of an experience that seems significant in some way. - What issue seemed significant to pay attention to? - How was I feeling and what made me feel that way? - What was I trying to achieve? - Did I respond effectively and in tune with my values? - What were the consequences of my actions on the patient, others, and myself? - How were others feeling? - What made them feel that way? - What factors influenced the way I was feeling, thinking, or responding? - What knowledge did or might have informed me? - To what extent did I act for the best? - How does this situation connect w/ previous experiences? - How might I respond more effectively given this situation again? - What would be the consequences of alternative actions for the patient, others, and myself? - How do I now feel about this experience? - Am I now more able to support myself and others as a consequence? - Am I now more available to work w/ patients/families and staff to help them meet their needs?
Describe the relationship between cost-containment and quality management initiatives
- although nurses should always be cost-conscious, patient care should always come first - quality of patient care should not diminish w/ reduced costs
Appreciate the interplay of care, compassion and communication.
- being compassionate helps foster a safe environment for patients, improve quality of care, and increase trust and comfort b/w patients and nurses - compassion promotes effective communication between patients, families, and staff => patients are more willing to open up to nurses they trust
Utility of Gracious Space
- bring openness and creativity - make decisions w/o all the information - resolve conflicts, difficult issues and divergent viewpoints - utilize more data than can be processed to make decisions - work w/ diverse groups towards a common goal
Discuss factors, including biases, which may influence effective communication with colleagues and patients.
- context/setting/environment (e.g., laptops) - emotions - knowledge level - generational - religion and spiritual orientation - ethnic identity - socioeconomic status - sexual orientation - gender ****Box 9-7 Black****
Board of Directors Responsibilities (Not-for-Profit Organizations)
- determination of the organization's mission - strategic planning - financial oversight - selection and evaluation of the CEO - board self-evaluation and education
Describe the shared governance model, and explain its use in nursing
- founded on philosophy that employees have both a right and a responsibility to govern their own work and time within a financially secure, patient-centered system - promotes decentralization and participation at all levels of nursing - role of the clinical nursing staff is to be responsible for the professional practice of their nursing unit by adhering to standards and benchmarks of quality care - role of the nurse manager and other nurse leaders is to set expectations, facilitate, coordinate, support, and create partnerships with the staff in achieving the identified goals - promotes improved patient outcomes and enhanced nurse job satisfaction brought about by increased autonomy - Example: self-scheduling, in which staff members determine their own schedules based on established guidelines for staffing the unit set forth by the manager
Articulate the concept of gracious space
- graciously listening, engaging, and responding appropriately to the diverse viewpoints and/or polarity of possible solutions that exist for delivering safe, cost-effective, and quality healthcare solutions
Identify the key members of the interdisciplinary health care team, and explain what each contributes
- group composed of individuals representing various disciplines who work together toward a common end 1) Nurses - providers of care, educators, managers, researchers, collaborators, patient advocates 2) Physicians - responsible for medical diagnoses and interventions designed to restore patient health 3) Physician Assistant - performs many functions of physician under direct supervision of physician 4) Unlicensed Assistive Personnel - work under supervision of nurses to assist w/ basic patient care (e.g., CNAs assist w/ personal hygiene; measure and record vital signs, heights, weights, inputs, and outputs; collect and test specimens; report and record patients' condition and treatments; help patients meet nutritional needs) 5) Technologists - assist in diagnosis of patient problems - lab technologists handle patient specimens (e.g., blood, feces, urine, body tissues) to be examined for abnormalities, and manage blood banks - radiology technologist perform imaging procedures 6) Therapists - help patients w/ special challenges - Physical therapists assist patients to regain maximum possible physical activity and strength - Occupational therapists work w/ physical therapists to develop plans to assist patients in resuming ADLs after illness or injury 7) Social Workers - assist patients and their families as they face the impact of illness and injury 8) Dieticians - focus on therapeutic value of foods and on teaching about appropriate diets and healthful nutrition - manage patients' nutritional intake as part of healing process 9) Pharmacists - prepare and dispense medications, instruct patients and other health workers about medications, monitor the use of controlled substances such as narcotics, and work to reduce medication errors 10) LPN/LNVs - care for patient under direction of physicians and RNs - provide basic bedside care: vital signs, prepare and give injections and enemas, monitor catheters, and perform uncomplicated wound care; assist w/ bathing, dressing, hygiene, moving in bed, standing, walking
Appreciate how continued knowledge acquisition is necessary to implement safe, effective, salient nursing care via the nursing process.
- nursing process is dynamic, not linear - continued knowledge is necessary for growth and proper nursing care - the more knowledge you acquire, the more experienced of a nurse you will become - continuing one's education through lifelong learning is an excellent way to maintain and enhance your critical thinking skills
Key Components Necessary for Effective Inter-Professional Collaboration
- respect for other collaborators - confidence in own knowledge - willingness to learn - cooperative spirit - belief in a common purpose - value contributions of other disciplines - willingness to negotiate - excellent communication skills - self-awareness (e.g., biases, values, goals, agendas) - tolerance of differing opinions - not threatened by conflict - knowledge of one's own limits
Describe the major bodily changes for amputees
- risk of CVD due to lowered vascular supply - phantom pain - loss of a limb (must learn how to adjust) - PTSD
Describe the principles for selecting a care delivery model
- team leaders coordinating care for a group of patients and supervising multiskilled workers who have been trained to perform a variety of comfort measures (e.g., positioning and technical procedures such as taking vital signs or drawing blood) - the care delivery model should: 1) Facilitate meeting the organization's goals 2) Be cost-effective 3) Contribute to meeting patients' outcomes 4) Provide role satisfaction for nurses 5) Allow implementation of the nursing process 6) Provide adequate communication among all health care providers 7) Support RNs' responsibility for the overall direction of nursing care 8) Be designed to give RNs the responsibility, authority, and accountability for planning, organizing, and evaluating nursing care 9) Ensure that the skills and knowledge of each care provider are used for the best patient outcomes 10) Ensure that communication can occur 11) Ensure that the model advances professional nursing practice 12) Provide for care that is perceived by the patient as a coherent whole (unity of action by a team of RNs, LPN/LVNs, or others) 13) Provide the work groups of RNs, LPN/LVNs, and other workers the appropriate knowledge required to meet the nursing care needs of the patient
Challenges of Contemporary Practice Environments
- trapped in polite, superficial discussions - feel shut down and afraid to share ideas - remain defensive of position rather than learning - avoidance and disengagement as strategy for survival
Discuss aspects of the patient's built environment that can promote a healing environment
1) Ergonomics - Body injury due to poor design of beds/stretchers (safe patient handling) - medication labels - signage - single vs. multiple occupancy rooms - unit layout 2) Fabric/Ambient - lighting - acoustics - temperature - gardens/green space 3) Art & Aesthetics - art or paintings on wall - color (safety) => wall colors (comfort) 4) Services - maintenance - cleanliness - decontamination
Health Care System
1) Location - Hospitals - Nursing facilities (nursing homes, skilled nursing facility) - Community based settings (primary care offices, clinics, urgent care centers, schools, prisons) - Homes (home care, hospice) - Veterans administration (hospitals, long term care, community) 2) Services - Health promotion and maintenance (assists patients to remain healthy, prevent diseases & injuries, detect diseases early, promote healthier lifestyles) => *before risk factors are identified* - Illness prevention (addresses health problems *after risk factors are identified*) - Diagnosis and treatment - Rehabilitation and long-term care (restores patients to the fullest possible level of function and independence after injury or illness; disease management services) 3) Agency - *Public (Governmental):* => entitlement programs funded by federal and state governments => popular around the world (1) Federal - focus on health of all US citizens (2) State - programs that affect the health of state citizens (3) Local - service one community, one county - *Private (Voluntary):* => operates outside the bounds of government control => receives funding from patients and insurance companies - *Not-for-profit:* => uses profits to pay personnel, improve services, advertise services, provide educational programs, or contribute to the mission of agency - *For-profit:* => distribute profits earned to partners or shareholders => growth in past several decades due to potential for health care to be profitable => typically do not treat nonpaying patients 4) Type of Care => Primary: care when patient first enters health care system => Secondary: prevention of complications from disease, screening => Tertiary: care provided to acutely ill, long-term care, rehab and terminally ill 5) Levels of Prevention/Intervention => Primary prevention: aims to stop the development of disease or injury *before it occurs* => Secondary Prevention: attempts to stop or reverse a problem *before it becomes symptomatic* through early detection => Tertiary Prevention: focuses on reducing disability and restoring functionality to people *already affected* by disease or injury
List the phases of the traditional nurse patient relationship and describe the tasks of each.
1) Orientation or establishing - introductory phase/"getting to know you" phase - establish mutual trust to develop relationship - nurse and patient assess each other - by the end, 4 things will have happened: (1) enough trust for pt. to participate in relationship; (2) see each other as individuals; (3) pt.'s perception of major problems and needs will have been identified; (4) approximate length of the relationship will have been estimated, and nurse and patient will have agreed to work together on some aspect of the identified problems 2) Working - nurse and patient address tasks outlined in the previous phase - interpersonal comfort might develop - nurses should recognize that pts may exhibit alternating periods of intense effort and of resistance to change 3) Termination - activities that enable patient and nurse to end the relationship in a therapeutic manner - begins in orientation phase when participants estimate length of time it will take to accomplish desired outcomes
Describe current methods of payment for health care
1) Private/voluntary Insurance => insurance premiums are paid by either insured individuals or their employers or are shared b/w individuals and employers => periodic payments (premiums) are paid into the insurance plan, and certain health care benefits are covered as long as the premiums are paid => most insurers stipulate that costs of hospitalization are reimbursable only if treatment can't be performed on an outpatient basis, where costs are typically lower 2) Medicare => Title XVIII of Social Security Act => nationwide federal health insurance program established in 1965 => available to people age 65 years and older, regardless of recipient's income => covers disabled individuals and anyone w/ permanent kidney failure requiring dialysis or a kidney transplant => 4 basic programs: (1) Part A - Hospital Insurance; (2) Part B - Medical Insurance; (3) Part C - Medicare Advantage Plans; (4) Part D - Prescription Drug Coverage 3) Medicaid => Title XIX of the Social Security Act => group of jointly funded federal-state programs for low-income, elderly, blind, and disabled individuals established in 1965 4) Personal (Out-of-Pocket) Payment => least common b/c few can afford it => can take years to pay a single large medical bill *Workers' Compensation (additional mechanism for financing some health care services)* => small proportion of insurance coverage => varies from state to state but generally covers only workers who are injured on the job => usually covers treatment for injuries and weekly payments during the time the worker is absent from work for injury-related causes
Discuss seven primary roles of nurses in the health care delivery system
1) Provider of care - direct, hands-on patient care - take an active role in illness prevention and health promotion and maintenance 2) Educator - provide information about illnesses and teach about medications and rehabilitation needs - help patients understand how to deal with the life changes necessitated by chronic illness and teach how to adapt care to the home or community setting 3) Manager - bedside staff nurses must manage the care of a group of patients, prioritize how to accomplish patient care activities during an 8- or 12- hour period, and determine staff and patient assignments - review patient cases and coordinating services so that quality care can be achieved at lowest cost 4) Collaborator - vital to ensure that everyone agrees on the same patient outcomes - requires that nurses understand and appreciate what other health professionals have to offer - working w/ patients and families 5) Patient advocate - most important - stand up for patient's rights, advocating his or her best interests at all times - value patient self-determination, autonomy, and independence in decision making - call to patients' aid when they can't do this for themselves 6) Researcher - all nurses - according to the ANA's Scope and Standards of Practice, the RN integrates research findings into practice - investigate whether current or potential nursing actions achieve their expected outcomes, what options for care may be available, and how best to provide care
List and define QSEN Standards
1) Safety => Safe, effective delivery of patient care requires understanding of the complexity of care delivery, the limits of human factors, safety design principles, characteristics of high reliability organizations and patient safety resources 2) Teamwork and Collaboration => Safe, effective, satisfying patient care requires teamwork: collaboration with and communication among members of the team, including the patient and family as active partners 3) Patient-Centered Care => The patient and family are in a partnered relationship with their health care provider and are equipped with relevant information, resources, access, and support to fully engage in and/or direct the health care experience as they choose 4) Evidence-based Practice (EBP) => Safe, effective delivery of patient care requires the use of nursing practices consistent with the best available knowledge. This includes use of clinical expertise and patient preferences and values, in addition to current best research evidence. 5) Health Informatics => Technology is changing how patients manage their own health care needs and how nurses manage patient care. Nurses need new skills to use and contribute to the development of electronic health records, to find and evaluate the relevance of evidence to support clinical decisions, and to use data to solve patient and system problems. 6) Quality Improvement => Improving patient care requires a systematic process of defining problems in order to identify potential causes and develop strategies to improve care. This process requires the ability to measure care. We can only improve care if we can measure how well we are doing and compare our performance against others'.
Discuss the four elements of gracious space
1) Spirit - welcoming, compassionate, curious, humorous - bringing these elements w/ us into relationships = "being" Gracious Space 2) Setting - can support or impede our ability to feel productive, healthy, and connected w/ our work and w/ others - pay attention to simple hospitality (food, drink) and items that reflect your energy and personality, or goals for work (artwork, color, dramatic or elegant furniture) 3) Invite the stranger - "systems perspective" - the "stranger" refers to any individual who is not typically involved in the conversation; someone w/ a different background, perspective, skin color, gender, geographic orientation, or any other quality that makes him/her seem different - we need the "stranger" when we are considering complex and new ideas to open our viewpoints - it's good to remember that we are each the stranger to someone else 4) Learn in public - second "systems" approach - deep listening and learning to accept/embrace the diversity you have gathered into Gracious Space - requires humility, a willingness to explore assumptions, let go of the "right" way of doing things, and being willing to change one's mind
Differentiate among five nursing care delivery systems in use today
1) Team Nursing - democratic work groups w/ different skill levels represented by different team members - a group of nurses and ancillary workers are responsible for the care of a group of patients during a specified time period, usually 8 to 12 hours 2) Primary Nursing - an identified nurse for every patient during the patient's stay on a particular unit - goal: to deliver consistent, comprehensive care by identifying one nurse who is responsible, has authority, and is accountable for the patient's nursing care outcomes for the period during which the patient is in a unit 3) Case Management Nursing - allows the nurse to oversee patient care and manage the delivery of services from all health care disciplines throughout a patient's illness - keeps costs down by striving to achieve predetermined daily patient outcomes within a specified time period for patients in the same diagnostic group 4) Patient-Centered Care -implemented by a multidisciplinary team of health professionals - attitude of caregivers is that patients' needs have priority over the institution's needs
Principles for Determining Professional Boundaries
1) The nurse, not the patient, is responsible for delineating and maintaining boundaries 2) The nurse should work w/in the "zone of helpfulness," which is neither aloof nor too intense/emotionally involved 3) The nurse should examine any boundary crossing, be aware of its potential implications, and avoid repeated crossings 4) Variables such as the care setting, community influences, client needs, and the nature of therapy affect the delineation of boundaries 5) Actions the overstep established boundaries to meet needs of the nurse are boundary violations 6) The nurse should avoid dual relationships in which the nurse has a personal or business relationship w/ a patient, as well as the professional one 7) Post-termination relationship are complex because the client may need additional services, and it may be difficult to determine when the nurse-client relationship is truly terminated
Describe the phases of the nursing process
ADPIE 1) *A*ssessment: gathering subjective and objective data through the skills of interviewing, observing, listening, and examining - patient interview - patient physical exam - family/significant other - medical records - other health care members - literature review (READ at EVERY step!!) - other reasons/purposes: (a) Focused - regular assessment of known problem area or problem this situation of a patient could cause (e.g., immobility) (b) Organ system - more disease focused (e.g., certain floors have certain specialties) (c) Functional: ADL, IADL 2) Nursing *D*iagnosis (Analysis and Identification of the Problem): validating data against norms and then clustering it so that problems can be identified and their cause discerned - problem - what does this mean? clinical judgment about individual, family, or community responses to actual or potential health problem or life processes - data reproducible or solid inferences (way to validate data) - comparable data to norms - determine if there are relationships among data - cluster data and group to identify nursing problems/conclusions about status - prioritize problems - nursing diagnosis is a statement that describes a patient's ACTUAL or POTENTIAL response to a health problem that is w/in nursing scope of practice => 4 types of nursing diagnoses: (1) actual; (2) risk; (3) health promotion; (4) syndrome => Statement has 3 parts: (1) PROBLEM (label or concise term/phrase) that represents a pattern of related cues -ex. acute pain; (2) ETIOLOGY ("related to" [r/t] or etiology of problem) -ex. r/t inflammation from sunburn; (3) DEFINING CHARACTERISTICS or SIGNS/SYMPTOMS nurse identified in assessment -ex. Pt. verbal response of 6/10 on posterior trunk and back of legs 3) *P*lanning/interventions: identification of patient's goals and determining ways to reach those goals - Identify goals => what is to be accomplished => derived from problem/nursing diagnosis => specific, measurable, realistic outcomes - Select nursing interventions to achieve each expected outcome - Collaborate to identify outcomes and interventions w/ => patient and/or family => other health professionals - Goals/outcomes: patient and/or family centered - Goals are broad statements about what is to be accomplished: => used interchangeably w/ objective => short-term or long-term - Outcomes are specific: => under what conditions and how to meet goals => measurable: action verbs => realistic, personalized, time factor => may by more than one outcome criteria - interventions should be specific about who is doing what (nurse, pt., or family) and when, where, and how they are doing it - must have evidence to support choice - 4 types of care plans: (1) Individualized; (2) Standardized; (3) Computerized; (4) Clinical pathways 4) *I*mplementation of Planned Interventions: nursing orders are carried out - 2 types: (1) Independent: initiate interventions independently based on nursing problem or diagnosis (2) Dependent: health care provider initiated 5) *E*valuation: examining patient's progress in relation to goals and outcome criteria to determine whether a problem is resolved, in the process of being resolved, or not resolved - Review goals, outcomes, and interventions - Were goals and outcomes met? Why or why not? How did patient's situation change? - Were interventions implemented? Were they effective? What was pt's response? - Was the problem resolved? Was it a result of your interventions? If problem continues, review and revise goals, outcomes, and or interventions. Don't be afraid to reassess and adjust!!
Advantages and Disadvantages of Patient-Centered Care
Advantages: - expedites care - promotes patient convenience - capitalizes on professional competence of team members - emphasizes continuum of care and reduced fragmentation of care - uses resources efficiently - fosters teamwork, collaboration, and communication Disadvantages: - requires "right staff at right time" to meet patient needs - difficult to explain; uses several models of care delivery - requires a lot of RNs; must have both clinical and management skills
Advantages and Disadvantages of Primary Nursing
Advantages: - high patient and family satisfaction - promotes RN responsibility, authority, autonomy, and accountability - nurse can care for entire patient (physically, emotionally, socially, and spiritually) - patient knows nurse well, and nurse knows patient well - promotes patient-centered decision making - increases coordination and continuity of care - promotes professionalism - promotes job satisfaction and sense of accomplishment for nurses Disadvantages: - difficult to hire all RN staff - expensive to pay all RN staff - nurses are not familiar w/ other patients, making it difficult to "cover" for each other - may create conflicts b/w primary and associate nurses - stress of round-the-clock responsibility - heavy responsibility, especially for new nurses
Advantages and Disadvantages of Team Nursing
Advantages: - potential for building team spirit - provides comprehensive care - each worker's abilities used to the fullest - promotes job satisfaction - decreases nonprofessional duties of RNs Disadvantages: - ongoing need for communication among team members requires commitment of time - all team members must promote teamwork, or team nursing is unsuccessful - team composition varies from day to day, which can be confusing and disruptive and decreases continuity of care - may result in blurred role boundaries, resulting in confusion and resentment
Advantages of Case Management Nursing
Advantages: - promotes interdisciplinary collaboration - increases quality of care - is cost-effective - eases patient's transition from hospital to community services - nurse has increased responsibility Disadvantages: - requires additional training - requires nurses to be off the unit for periods of time - is time-consuming - is most useful only w/ high-risk patients and high-cost/high-volume conditions
Define critical thinking, nursing process, and clinical judgment
Critical thinking: - mode of thinking—about any subject, content, or problem—in which the thinker improves the quality of his/her thinking by skillfully taking charge of the structures inherent in thinking and imposing intellectual standards upon them - purposeful, self-regulatory judgment that results in interpretation, analysis, evaluation, and inference, as well as explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon that which judgment is based Nursing process: - universal intellectual standard by which problems are addressed and solved - method of critical thinking focused on solving patient problems in a professional practice Clinical judgment: - consists of informed opinions and decisions based on empirical knowledge and experience
Examples of Health Promotion and Maintenance, Early Detection, and Illness Prevention Activities
Health Promotion/Maintenance: - health education programs (e.g., prenatal classes) - exercise programs - health fairs - wellness programs (worksite/school) - nutrition education Early Detection: - mammograms - vision and hearing screening - cholesterol screening - periodic histories and physical examinations - blood glucose screening - osteoporosis screening Illness Prevention: - community health programs - promotion of health lifestyles to counteract risk factors - occupational safety programs (e.g., use of eye protection for work that endangers the eyes) - environmental safety programs (e.g., proper disposal of hazardous waste) - legislation that prevents injury or disease (e.g., seat belt/child restraint laws; motorcycle helmet laws)
Describe helpful and unhelpful communication techniques.
Helpful: - attentive listening - open-ended questions - empathy - reflection - humor - giving information - verbalizing the implied - silence Unhelpful: - giving false reassurance - using cliches - inappropriately changing the subject - being judgmental/disapproving - being defensive - parroting - patronizing
Novice Thinking vs. Expert Thinking
Novice Nurses: - organize knowledge as separate facts - rely heavily on resources (e.g., texts, notes, preceptors). - lack knowledge gained from actually doing (e.g., listening to breath sounds) - focus so much on actions that they may not fully assess before acting - need and follow clear-cut rules - are often hampered by unawareness of resources - may be hindered by anxiety and lack of self-confidence - rely on step-by-step procedures and follow standards and policies rigidly - focus more on performing procedures correctly than on the patient's response to the procedure - have limited knowledge of suspected problems; therefore they question and collect data more superficially or in a less focused way than more experienced nurses - learn more readily when matched with a supportive, knowledgeable preceptor or mentor Expert Nurses: - store knowledge in a highly organized and structured manner, making recall of information easier - have a large store house of experiential knowledge (e.g., what abnormal breath sounds sound like, what subtle changes look like) - assess and consider different options for intervening before acting - know which rules are flexible and when it is appropriate to bend the rules - are aware of resources and how to use them - are usually more self-confident, less anxious, and therefore more focused than less experienced nurses - know when it is safe to skip steps or do two steps together - are able to focus on both the parts (the procedures) and the whole (the patient response) - are comfortable with rethinking a procedure if patient needs require modification of the procedure - have a better idea of suspected problems, allowing them to question more deeply and collect more relevant and in-depth data - analyze standards and policies, looking for ways to improve them - are challenged by novices' questions, clarifying their own thinking when teaching novices
Discuss the role of inference making as related to nursing process.
Orlando's Nursing Process Theory: - specific to nurse-patient interactions - goal of the nurse: to determine and meet patients' immediate needs and to improve their situation by relieving distress or discomfort - Orlando emphasized deliberate action (rather than automatic action) based on observation of the patients' verbal and nonverbal behavior, which leads to inferences. - Inferences are confirmed or disconfirmed by the patient, leading the nurse to identify the patient's needs and provide effective nursing care - Nurses individualize care for each patient by attending to behavior, confirming with the patient ideas and inferences the nurse draws from interactions, and identifying pressing needs.
Differentiate between subjective and objective data and inferences or impressions.
SUBJECTIVE DATA - "symptoms" - information obtained from patients as they describe their needs, feelings, strengths, and perceptions of the problem - information supplied by family members/significant others - physical, psychosocial, and spiritual information - only source for this data is the patient (family) - ex. patient information, family/significant other, pain, dizziness, nausea, "I am in pain," "I don't have much energy" OBJECTIVE DATA - "signs" - measurable - information collected through observation and examination of the patient or through consultation with other health care providers - ex. patient physical exam, medical records, health care team members, literature review, pallor, vital signs (e.g., pulse rate, blood pressure), observable patient behaviors, yellow discoloration of skin, vomiting
Describe the four basic categories of services provided by the health care delivery system
Services: 1) Health promotion and maintenance => assists patients to remain healthy, prevent diseases & injuries, detect diseases early, promote healthier lifestyles (*before risk factors are identified*) => require patients' active participation and cannot be performed solely by health care providers 2) Illness prevention => addresses health problems *after risk factors are identified*) => ex. family history of disease and genetic predispositions => requires patients' active participation 3) Diagnosis and treatment 4) Rehabilitation and long-term care => restores patients to the fullest possible level of function and independence after injury or illness; disease management services
What characteristics do today's nurses have in common, and in what ways do they differ?
Should be: - organized - confident - accountable - technologically savvy Should have: - strong assessment, communication, & interpersonal skills Qualities that differ depending on area of employment: - entrepreneurial spirit - a broad knowledge base or specialized knowledge - an advanced education - willingness to practice autonomously
Describes how interdisciplinary communication (e.g. SBAR) affects the safety of patient care.
Situation: describe the situation Background: provide background of patient's condition Assessment: provide the client's assessment data Recommendation: make a recommendation based on the assessment
Demonstrate awareness of professional boundaries by listing differences in social, interprofessional, and patient communication.
Social Communication: - evolve spontaneously - not time-limited - not necessarily goal-directed; broad purpose is pleasure, companionship, sharing - centered on meeting both parties' needs - problem solving is rarely/occasionally a focus - may or may not include nonjudgmental acceptance - outcome is pleasure for both parties Interprofessional Communication: - evolve through recognized phases; interactions are planned and purposeful - limited in time w/ termination date often predetermined - goal-directed; systematic exploration of identified problem areas - centered on meeting patient's needs; do not address nurse's needs - problem solving is a primary focus - includes nonjudgmental acceptance - outcome is improved health status of patient Patient Communication: - purposeful - patient-centered - congruent non-verbal and verbal messages, which facilitate health - major goal: foster patient's self-disclosure and enable positive changes to health; empower them to make health decisions
One important advantage of clinical ladder programs for hospital-based Registered Nurses is that they: a) Allow career advancement for nurses who choose to remain at the bedside. b) Encourage nurses to move into management positions in which they can influence patient care on a broader scale. c) Encourage Registered Nurses to become politically active and guide the profession of nursing. d) Provide training to staff nurses so they can move seamlessly across departments.
a) Allow career advancement for nurses who choose to remain at the bedside. ***A clinical ladder is a multiple-step program that begins with entry-level staff nurse positions. Today, clinical ladder programs allow nurses to progress while staying in direct patient care roles.***
Which of the following is NOT true about nursing diagnoses? a) A nursing diagnosis could be statements about both actual and potential problems. b) A nursing diagnosis is supported by objective data, rather than subjective data. c) A nursing diagnosis could be applied not just to individuals but to families and communities. d) A nursing diagnosis consists of three parts: problem, etiology, and defining characteristics.
b) A nursing diagnosis is supported by objective data, rather than subjective data.
Consider the following nursing diagnosis. "Acute pain related to inflammation from sunburn." Which of the following is the etiology? a) Acute pain b) Inflammation c) Sunburn d) Skin assessment
b) Inflammation
Which of the following is true about goals in the nursing process? a) Goals should include both realistic objectives and "reach" objectives to motivate patients b) Goals should focus on a single, specific outcome criteria c) Goal completion timelines could be short term or long term d) Goals should be separated into two sections to involve the patient: one that is provider-initiated, and one that is patient-centered.
c) Goal completion timelines could be short term or long term
Which of the following is NOT a major goal of nurse-patient communication? a) Foster patient's self-disclosure (patient reveals information about him/herself) b) Enable positive changes to health c) Empower them to make health decisions d) Increase patient compliance with medical interventions
d) Increase patient compliance with medical interventions
