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Week 5/Test 2 - Critical Thinking & Nursing Process

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More on assessments

•When begin assessment, think critically about what to assess for specific patient in specific situation. •As you are forming your relationship & connecting with patient, patient will begin to share info. •Determine which questions or measurements are appropriate on basis of what initially learn from pt about health concerns & history, clinical knowledge, & experience with other patients. In most cases patient will reveal info that directs you to conduct a quick screening.

Consider these factors during implementation

•Who is the patient? •How do the patient's attitudes, values, and cultural background affect how you provide care? •What does an illness mean to a patient and his or her family? •Which clinical situation requires you to intervene? •How does a patient perceive the interventions that you will deliver? •In what way do you best support or show caring as you intervene?

The American Nurses Association (ANA)

•defines standards of professional nursing practice, which include standards for the evaluation step of the nursing process. •The standards define the duties that all registered nurses are expected to perform competently. •One ANA standard for evaluation is to share results of care with patients and their families according to federal and state regulations.

NANDA-I classification of nursing diagnosis

•provides the standards for the patterns of data for each nursing diagnosis. These standards are the defining characteristics or risk factors described earlier.

During planning a valuable resource for selecting outcomes is the Nursing Outcomes Classification (NOC). The purposes of NOC are:

•to identify, label, validate, and classify nurse-sensitive patient outcomes; •to field test and validate the classification; and •to define and test measurement procedures for the outcomes and indicators using clinical data.

Goals in planning

- A broad statement that describes the desired change in a patient's condition, perceptions, or behavior - An aim, intent, or end - Apply medical, sociobehavioral, and nursing sciences - Must be: relevant to patient needs, specific, singular, observable, measurable, and time limited. - Use critical thinking attitudes in selecting interventions with greatest likelihood of success

Hand-off reporting

- A critical time when nurses collaborate and share important information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventions. - Transferring essential information from one nurse to the next during transitions in care. - Ask questions, clarify, and confirm important details about a patient's progress and continuing care needs. - Sometimes done at pt bedside offering opportunity for pt involvement - Written care plans organize this info

Definition of critical thinking

- Ability to think in systematic & logical manner with openness to question & reflect on reasoning process. - Continuous process to improve how to apply yourself in pt care, characterized by open-mindedness, continual inquiry, and perseverance, & willingness to look at each patient situation & determine which assumptions are true & relevant. - Recognizing an issue exists, analyzing info, evaluating info, & drawing conclusions.

Role of the patient in goal/ outcome setting

- Always partner with patients when setting their individualized goals. - Mutual goal setting includes the patient and family (when appropriate) in prioritizing the goals of care and developing a plan of action. - Act as a patient advocate. • For patients to participate in goal-setting, need to be alert & have some degree of independence in completing ADLs, problem solving, and decision making. •They also need to understand priority problems and have willingness/motivation to resolve those problems. •Unless goals are mutually set and there is a clear plan of action, patients may not fully participate in the plan of care, leading to suboptimal outcomes. •Patients need to understand and see the value of nursing therapies, even though they are often totally dependent on you as the nurse. •When setting goals, act as an advocate or support for the patient to select nursing interventions that promote his or her return to health or prevent further deterioration when possible.

Nursing Health History - Interpreting and Validating Assessment Data

- Ensures collection of complete database - Leads to second step of nursing process • When interpreting, determine the presence of abnormal findings, recognize that further observations are needed to clarify information, and begin to identify the patient's health problems. The patterns of data reveal meaningful and usable clusters. •Validation of assessment data is comparison of data with another source to determine data accuracy. Validate findings from the physical exam and observation of patient behavior by comparing data in the medical record and consulting with other nurses or health care team members.

Preventing complications

- Identify risks to the patient - Adapt interventions to the situation - Evaluate the relative benefit of a treatment vs. the risk - Initiate risk-prevention measures * Knowledge & experience help you identify risk of complications. Assessments reveal current level of risk.

Clinical Judgment

- Includes making appropriate conclusions about interventions to address a patient's response to health conditions or a life process - Requires nurse to use or modify standard approaches, sometimes improvise new ones

Expected outcome

- Measurable change that must be achieved to reach a goal - Many times, several must be met to meet a single goal

Writing goals & expected outcomes

- Must be patient-centered - Use SMART acronym: Specific Measurable Attainable Realistic Timed •Each goal & outcome should address only one behavior, perception, or physiological response. Expected outcomes must also be singular. Specificity allows you to decide if there is a need to modify the plan of care. •Nurses need to be able to measure or observe if change takes place in a patient's status. Terms describing quality, quantity, frequency, length, or weight allow you to evaluate outcomes precisely. •For a patient's health to improve, he or she must be able to attain the outcomes of care that are set. A goal and an outcome likely are attainable when mutually set with the patient. If mutually set, it increases the patient's motivation and cooperation. Your knowledge background helps to select goals and outcomes that should be met on the basis of typical responses to clinical interventions. •Set goals and expected outcomes that a patient is able to realistically reach. Realistic goals give patients a sense of hope. Be aware of the patient's physiological, emotional, cognitive, and sociocultural potential and the economic cost and resources available. •Each goal and outcome is time limited so the health care team has a common time frame for problem resolution. •Time frames help you and the patient determine if the patient is making progress at a reasonable rate. If not, you must revise the plan of care. Time frames also promote accountability in delivering and managing nursing care.

Recognize errors or unmet outcomes

- Must have an open mind, actively pursue truth, be patient and confident, and engage in self-reflection - Systematic use of evaluation - Self-reflection and correction of errors (Reflection-in-action occurs when there is a trigger event, often involving a breakdown in practice. It involves a nurse's ability to recognize how a patient is responding and then adjusting interventions as a result.) (Reflective reasoning improves the accuracy of making any diagnostic conclusions.)

Types of interventions

- Nurse initiated - HC provider initiated - Collaborative

Establishing priorities

- Ordering of nursing diagnoses or patient problems uses determinations of urgency and/or importance to establish a preferential order for nursing interventions. - Organization of a vision of desired outcomes. - Classification of priorities - Consider Maslow's Hierarchy (nutrition, O2, temp) - Order of priorities changes as a patient's condition changes. - Priority setting begins at a holistic level when you identify and prioritize a patient's main diagnoses or problems. - Patient-centered care requires you to know a patient's preferences, values, and expressed needs. - Ethical care is a part of priority setting. When ethical issues make priorities less clear, discuss w fam, pt, and other hc providers. - Can change in matter of mins. Always reorder.

Consulting other HC professional

- Planning involves consultation with members of the health care team. - Consultation is a process by which you seek the expertise of a specialist such as your nursing instructor, a physician, or a clinical nurse educator to identify ways to handle problems in patient management or in planning and implementation of therapies. - Consultation occurs at any step in the nursing process, most often during planning and implementation. - First identify the general problem, direct the consultation to the right professional, and provide the consultant with relevant information about the problem. - Most often occurs during planning & implementation - Consultation is based on the problem-solving approach, and the consultant is the stimulus for change.

Types of nursing diagnoses

- Problem-focused - Risk - Health promotion

Clinical judgment

- Question, wonder, & explore different perspectives & interpretations to find solution that benefits patient - Use knowledge & experience when deciding if pt is having complications that call for notification of HC provider or if teaching plan for pt is ineffective & needs revision. - Separates RNs from techs. Techs are directed by nurses to perform certain aspects of care & report any important observations to keep RNs informed. - RN responsible for making decisions on basis of clinical info. - When clinical situation develops, RN must learn to recognize it, interpret meaning, & respond appropriately.

Nursing health history - Diagnostic & Lab data

- Results provide further explanation of alterations or problems identified during the health history and physical examination - Compare laboratory data with the established norms for a particular test, age group, and gender.

Tips for making decisions during implementation

- Review the set of all possible nursing interventions for a patient's problem - Review all possible consequences associated with each possible nursing action - Determine the probability of all possible consequences - Judge the value of the consequence to the patient seek out supervision from instructors or experienced nurses, or review agency policy and procedures

Nursing Interventions Classification (NIC)

- The Iowa Intervention Project developed a set of nursing interventions that provides a level of standardization - The NIC model includes three levels—domains, classes, and interventions—for ease of use. - NIC interventions are linked with NANDA International nursing diagnoses.

Discharge education

- The nurse discusses the discharge instructions with the client and provides a printed copy. - Identify safety concerns. - Review symptoms and possible complications. - Step by step instructions for changing dressings - Directions on how to take medications.

Physical care techiques in direct care

- The safe and competent administration of nursing procedures (protect yourself & patients from injury, use safe patient-handling techniques, use proper infection control practices, stay organized, and follow applicable practice guidelines.) - Lifesaving measures (use when a patient's physiological or psychological state is threatened. Such measures include administering emergency medications, instituting cardiopulmonary resuscitation, intervening to protect a confused or violent patient, and obtaining immediate counseling from a crisis center for a severely anxious patient.)

Discharge planning

- This begins on admission for every patient - It determines whether the patient can return home - Assess if the client will need other services. - Do they need referrals to community resources?

Nursing health history - data documentation

- Use clear, concise appropriate terminology (for subjective data, use quotations & be careful about generalizations) - Becomes baseline for care

Observation of patient behavior

- Verbal and nonverbal behaviors (see if what they say matches objective observations) - Observations direct you to gather additional objective information to form accurate conclusions about the patient's condition. - An important aspect of observation includes a patient's level of function: the physical, developmental, psychological, and social aspects of everyday living. Obs of func often occurs in the home or in a health care setting during a return demonstration.

Concept maps

- Visual representation of all patient's nursing diagnoses that allows you to diagram interventions for each. - Group and categorize nursing concepts to give you holistic view of patient's hc needs and help you make better clinical decisions in planning care. - Help you learn interrelationships among nursing diagnoses to create unique meaning & organization of info. - analyze relationships among diagnoses. Draw dotted lines between nursing diagnoses to indicate relationship to one another. - Patients present multiple health probs & related nursing diagnoses so not always realistic to write columnar plan.

Interpreting and Summarizing Findings

- When you evaluate the effect of interventions, you interpret or learn to recognize relevant evidence about a patient's condition - Early detection is first line of defense - Compare actual and expected findings - Steps to objectively evaluate the degree of success in achieving outcomes of care

What questions does critical thinking ask?

- Why? - What am I missing? - What do I really know about this patient's situation? - What are my options? • Nurses who apply critical thinking in work, focus on options for solving problems & making decisions rather than rapidly & carelessly forming quick, simple solutions. •Critical thinking is more than just problem solving. It is continuous attempt to improve how to apply yourself when faced with problems in patient care.

Components of nursing health history

- biographical information - reason for seeking health care - patient expectations - present illness or health concerns - health history - family history - psychosocial history - spiritual health - review of systems

Achieving patient goals

- invest time in carrying out required treatments. Nurses implement care to meet patient goals. - At times, multiple interventions may be needed. - Priorities help nurses to anticipate and sequence nursing interventions. - Patient adherence

Standardized nursing interventions

- many hc systems have mechanisms for standardizing the more common types of interventions.- Standardized interventions most often set a level of clinical excellence for practice. - Nurse- and health care provider-initiated standardized interventions that are available in the form of clinical guidelines or protocols, preprinted (standing) orders, and Nursing Interventions Classification (NIC) interventions. - American Nurses Association (ANA) standards. - Quality and Safety Education for Nurses (QSEN) skill competencies: authoritative statements of the duties that all RNs are expected to perform competently, regardless of role, patient population they serve, or specialty.

Related factors for NANDA-I diagnoses

- pathophysiological (biological or physiological) - treatment-related - situational (environmental or personal) - maturational (aging-related)

Types of assessments

- patient-centered interview during health history. - physical exam - periodic assessments during rounding or administering care

Clinical Judgment - Health problems are product of:

- physical health - lifestyle - culture - relationship with family and friends - living environment - experiences. With experience, learn to creatively seek new knowledge, act quickly when events change, & make quality decisions for pts' well-being. Will find nursing to be rewarding & fulfilling through clinical judgments you make.

Formulating a nursing diagnosis statement

-Actual Problem: A firm dx supported by findings. -Potential: Tentative Has not happened but could. DO NOT use AS EVIDENCE BY:

Nursing process as a competency

-Assessment -Diagnosis -Planning -Implementation -Evaluation •The purpose of the nursing process is to diagnose & treat human responses to actual or potential health problems. Use of process enables nurses to help patients meet agreed-on outcomes for better health.

Sources of data

-Patient (interview, observation, physical exam)—best source of info -Family & significant others (with pt agreement) -Health care team -Medical records -Scientific literature • Take quality time to be with patient, even if for a few minutes. Establishing nurse-patient therapeutic relationship allows you to know patient as a person. This relational process mobilizes hope for a patient and nurse; allows for acceptable interpretation & understanding of the patient's illness, pain, fear, and anxiety; and helps patient use support from hc providers. •Connecting with patient by showing interest in his or her problems & concerns helps you collect relevant database. Research has shown that hearing accounts of patients' health and illness experiences, watching them, & coming to understand how they typically respond develops type of knowing that fosters good clinical judgments. • Rounding is vital opportunity to build trust with pts, increasing likelihood you will gain more info that will help you identify & communicate their hc problems more accurately & effectively.

Related factors for NANDA-I diagnoses include four categories:

-pathophysiological (biological or psychological) -treatment-related -situational (environmental or personal) -maturational

Collaboration steps

1) Assess situation & identify general problem area. 2) Direct consultation to right professional 3) Provide consultant with relevant info about the problem area & seek a solution. 4) Do not influence consultants. 5) Be available to discuss a consultant's findings and recommendations. 5) Incorporate consultant's recommendations into the care plan.

Name & order components of formulating nursing diagnosis

1) Problem What is wrong with the pt? 2) Related-to What caused the problem? 3) E/B Signs & symptoms. Evidence of the problem.

Two stages of assessment:

1) collect & verify data from patient (primary source) & from family, hc providers, & med records (secondary sources) 2) analyze the data

Eleven attitudes define the central features of a critical thinker and how a successful critical thinker approaches a problem:

1) confidence (belief in oneself) 2) thinking independently (considering other ideas & concepts before forming opinion) 3) fairness (justly dealing with a situation) 4) responsibility and accountability (knowledge that you are accountable for your decisions, actions, and critical thinking) 5) risk taking (leads to advances in care) 6) discipline (misses few details, is orderly or systematic when collecting information) 7) perseverance (determination to find effective solutions) 8) creativity (finding solutions outside the standard routines of care while following standards of practice) 9) curiosity (asking "why?" and "what if?") 10) integrity (questioning & testing their own knowledge & beliefs) 11) humility (admitting limitations in knowledge and skill).

Three levels of NIC model

1) domains 2) classes 3) interventions

Five preparatory activities for implementation:

1) reassessing the patient 2) reviewing and revising the existing nursing care plan 3) organizing resources and care delivery 4) anticipating and preventing complications 5) implementing nursing interventions.

5 components of critical thinking model for clinical decision making

1)Specific knowledge base 2) Experience 3) Nursing process competency 4) Attitudes for critical thinking 5) Professional standards • Aims of nursing practice: Ability to think critically, improve clinical practice, & decrease errors in clinical judgments • Knowledge prepares you to better anticipate & identify pt's problems by understanding their origin & nature. Includes info & theory from basic sciences, humanities, behavioral sciences, and nursing. Nurses use knowledge base in different way than other hc disciplines because think holistically about pt problems. The depth & extent of knowledge influence ability to think critically about nursing problems. • Clinical learning experiences necessary to acquire clinical decision-making skills. Knowledge combined with clinical expertise from experience defines critical thinking. With experience begin to understand clinical situations, anticipate & recognize cues of pt's health patterns, & interpret the cues as relevant or irrelevant. • In your practice you will apply critical thinking components during each step of the nursing process.

Steps to objectively evaluate the degree of success in achieving outcomes of care:

1. Examine outcome criteria to identify exact desired patient behavior or response. 2. Evaluate a patient's actual behavior or response. 3. Compare established outcome criteria with the actual behavior or response. 4. Judge the degree of agreement between outcome criteria and the actual behavior or response. 5. If there is no agreement (or only partial agreement) between the outcome criteria and the actual behavior or response, what is/are the barrier(s)? Why did they not agree?

Modification of an existing care plan includes 4 steps:

1. Revise data in the assessment column to reflect the patient's current status. (Date any new data to inform other members of the health care team of the time that the change occurred.) 2. Revise the nursing diagnoses. (Delete nursing diagnoses that are no longer relevant and add and date any new diagnoses. Revise related factors and the patient's goals, outcomes, and priorities. Date any revisions.) 3. Revise specific interventions that correspond to the new nursing diagnoses and goals. (Be sure that revisions reflect the patient's present status.) 4. Choose the method of evaluation for determining whether you achieved patient outcomes.

Comprehensive assessment

2 approaches: 1) structured database format on basis of an accepted theoretical framework or practice standard, which provides categories of info for you to assess. • Watson and Foster's model of "The Attending Caring Nurse" •Gordon's model of 11 functional health patterns •Nola Pender's "Health Promotion Model" 2) problem-oriented. Focus on a patient's presenting situation & begin with problematic areas such as incisional pain or limited understanding of postoperative recovery. Ask patient follow-up questions to clarify & expand assessment so you can understand full nature of problem.

What labeling format do you use for health promotion & problem focused nursing diagnoses?

2-part format: NANDA-I diagnostic label followed by related factor.

Classes (NIC Model)

30 classes that offer useful clinical categories

Interventions (NIC Model)

554 interventions, defined as any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. Each intervention includes a variety of nursing activities from which to choose and which a nurse commonly uses in a plan of care.

Domains (NIC Model)

7 domains are highest level (level 1) of the model, and broad terms are used to organize more specific classes and interventions.

Vocab - Goal

A broad statement that describes a desired change in a patient's condition, perceptions, or behavior.

Vocab - Problem focused nursing diagnosis

A clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community.

Health promotion nursing diagnosis

A clinical judgment concerning motivation and desire to increase well-being and actualize human health potential. • Responses expressed by readiness to enhance specific health behaviors & can be used in any health state. •Health promotion diagnoses may apply to an individual, family, group, or community. •The diagnoses have only defining characteristics, although a related factor may be used to improve understanding of the diagnosis.

Nursing diagnosis

A clinical judgment concerning vulnerability of an individual, family, or community, that a nurse is licensed and competent to treat. - Patients are actively involved. - Ever changing on the basis of a patient's needs. - second step of nursing process that classifies health problems within domain of nursing. - Nursing diagnoses + collaborative problems represent the range of patient conditions that require nursing care

Concept mapping nursing diagnosis

A concept map helps you critically think about a patient's diagnoses and how they relate to one another. -Helps organize and link data about a patient's multiple diagnoses in a logical way. -Graphically represents the connections among concepts that relate to a central subject. - Central focus on patient, not condition

Vocab - Adverse reaction

A harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention.

Interprofessional collaboration

A partnership between a team of hc providers (such as nurses, therapists, dietitians, and physicians) & a patient in a participatory, collaborative & coordinated approach for shared decision making around health issues.

Vocab - Standing order

A preprinted document containing orders for routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems

Vocab - Decision making

A product of critical thinking that focuses on problem resolution.

A complete diagnostic statement will also include:

A related factor (appropriate for problem-based and some health promotion diagnoses). The related factor is identified from the patient's assessment data and is the reason the patient is displaying the nursing diagnosis.

Vocab - Data cluster

A set of cues (objective or subjective), the signs or symptoms gathered during assessment. - compare with standards to reach conclusion about pt response to health problem - Data clusters form patterns

Nursing Interventions Classification (NIC) interventions

A standard nursing intervention that differentiates nursing practice from that of other health care disciplines by offering a language that nurses use to describe a set of actions in delivering nursing care •offer a level of standardization to enhance communication of nursing care across settings and to compare outcomes. The NIC system has been incorporated into many hc info systems. By using NIC you will learn the common interventions recommended for the various NANDA-I nursing diagnoses.

Vocab - Review of Systems ROS

A systematic approach for collecting SUBJECTIVE info from patients about presence or absence of health-related issues in each body system

Review of systems (ROS)

A systematic approach for collecting SUBJECTIVE info from patients about presence or absence of health-related issues in each body system. Ask patient about normal functioning of each body system and any noted changes.

Clinical practice guidelines and protocols

A systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations •The National Guidelines Clearinghouse (NGC) •Clinicians within a hc agency sometimes review the scientific literature and their own standard of practice to develop guidelines and protocols in an effort to improve the standard of care at their facility. •University of Iowa (2014) Hartford Center •Advanced practice nurses (APNs) who provide primary care for patients in a variety of settings frequently follow diagnostic and treatment protocols for their interventions.

Vocab - concept map

A visual representation of patient problems and interventions that shows their relationships to one another.

A newly licensed nurse is reporting to the charge nurse about the care she gave to a patient. She states, "the patient said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hours ago. The prescription reads every 4 hours PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the patient 40 minutes later, and he said his pain is going away" The charge nurse should inform the newly licensed nurse that she left out which of the following steps in the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation

A. Assessment

A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as the objective data? (Select all that apply) A. Respiratory rate is 22/min with even, unlabored breathing. B. The patient's partner states, "He said he hurts after walking about 10 minutes". C. Pain rating is 3 on a scale of 0-10. D. Skin is pink, warm and dry. E. The assistive personnel reports the client walked with a limp.

A. Respiratory rate is 22/min with even, unlabored breathing. D. Skin is pink, warm and dry. E. The assistive personnel reports the client walked with a limp.

PES

Acronym for 3-part nursing diagnosis •P (problem)—NANDA-I label—Example: Impaired Physical Mobility •E (etiology or related factor)—Example: incisional pain •S (symptoms or defining characteristics)—Briefly lists defining characteristic(s) that show evidence of the health problem. Example: evidenced by restricted turning and positioning

Vocab - PES

Acronym for 3-part nursing diagnosis •P (problem): NANDA-I label Example: Impaired Physical Mobility •E (etiology or related factor) Example: incisional pain •S (symptoms or defining characteristics): Briefly lists defining characteristic(s) that show evidence of the health problem. Example: evidenced by restricted turning and positioning

Vocab - Independent Nursing Interventions

Actions that a nurse initiates without supervision or direction from others

Vocab - Back channeling

Active listening prompts

ADLs

Activites of daily living. Direct care. Ambulation, eating, dressing, bathing, and grooming Either temporary, permanent, or rehabilitative Care can range from assistive to complete care

Vocab - Acute vs chronic illness

Acute illness: patient's clinical condition often changes. Chronic illness: slow, subtle changes, although acute exacerbations can occur.

Self-management

Aim is to minimize the impact of chronic disease or sudden acute illness on physical health status and functioning and to enable people to cope with the psychological effects of an illness. There are relevant, objective, and appropriate evaluative indicators of self-management, including self-efficacy, health behavior or attitude, health status, health service use, quality of life, and psychological indicators.

Reviewing and revising the existing nursing care plan - implementation

Allows you to validate a patient's nursing diagnoses, review the care plan, and determine whether the nursing interventions remain the most appropriate for the patient's needs

Patient-centered critical thinking

Always keep patient as center of focus as try to solve clinical problems. When work in busy setting, use criteria that includes clinical condition of patient. To manage wide variety of problems associated with groups of patients, skillful, prioritized clinical decision-making is critical.

Vocab - Collaborative problems

An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's health status

Collaborative problems

An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's health status.

Vocab - Related factor

An etiological or causative factor for the diagnosis

Vocab - Short-term goals

An objective behavior or response that you expect a patient to achieve in a short time, usually less than a week.

Vocab - Long-term goals

An objective behavior or response that you expect a patient to achieve over a longer period, usually over several days, weeks, or months

Open-ended question

An open-ended question gives a patient discretion about the extent of his or her answer, and does not presuppose a specific answer. They prompt patients to describe a situation in more than one or two words.

A patient is admitted to the hospital with shortness of breath. As the nurse assesses this patient, the nurse is using the process of: A. evaluation. B. data collection. C. problem identification. D. testing a hypothesis.

Answer: B Rationale: Assessment is the first stage of the nursing process, and is the process of gathering data to formulate the nursing diagnosis and care plan.

When caring for a patient who has multiple health problems and related medical diagnoses, nurses can best perform nursing diagnoses and nursing interventions by developing a: A. critical pathway. B. nursing care plan. C. concept map. D. diagnostic label.

Answer: C Rationale: As noted above, concept maps help the nurse organize nursing interventions for a patient with multiple problems.

Nursing intervention

Any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. Ideally nursing interventions are evidence based, providing the most current and effective approaches for delivering patient-centered care.

Gordon's model of 11 functional health patterns

Approach to comprehensive assessment that offers a holistic framework for assessment of any health problem provides for a comprehensive review of a patient's health care problems.

Watson and Foster's model of "The Attending Caring Nurse"

Approach to comprehensive assessment that supports caring needs & concerns from patient's frame of reference. Uses caring theory as a guide for identifying caring needs & assessing the meaning of both subjective and objective concerns.

Working phase

Ask open-ended questions. Use attentive listening & other therapeutic communication techniques that encourage patient to tell their story. Do not rush patient. Initial interviews are more extensive. Gather info about patient's concerns & then complete all relevant sections of nursing history. Ongoing interview allows you to update a patient's status and concerns, focus on changes previously identified, and review new problems.

Critical thinking approach to assessment

Assessment involves collecting information from the patient and from secondary sources, along with interpreting & validating the info to form a complete database. •Experience, knowledge, standards, & attitudes all influence critical thinking in assessment. •Critical thinking is vital part of assessment. While gathering data about a pt, you synthesize relevant knowledge, recall prior clinical experiences, apply critical thinking standards & attitudes, and use professional standards of practice to direct your assessment in a meaningful and purposeful way.

The use of diagnostic reasoning involves a rigorous approach to clinical practice and demonstrates that critical thinking cannot be done: A. logically. B. haphazardly. C. independently. D. systematically.

B. haphazardly

A patient is suffering from shortness of breath. The correct goal statement would be written as: A. the patient will be comfortable by the morning. B. the patient will breath unlabored at 14 to 18 breaths per minute by the end of the shift. C. the patient will not complain of breathing problems within the next 8 hours. D. the patient will have a respiratory rate of 14 to 18 breaths per minute.

B. the patient will breath unlabored at 14 to 18 breaths per minute by the end of the shift. Rationale: quality, quantity, length

Back channeling

Back channeling includes active listening prompts such as "all right," "go on," or "uh-huh." These indicate that you have heard what a patient says, are interested in hearing the full story, and are encouraging the patient to give more details.

Before beginning an interview

Be prepared. Review patient's med record when info is available & previous medical or nurse's note entry. Were problems identified that need clarification or follow-up? Does the patient's admitting diagnosis or other diagnoses suggest lines of questions for you to ask? Hands-off info may frame a clinical problem about which you want to learn more.

Self-report

Being able to evaluate behavioral change can be more difficult, which often relies on a patient's self-report. When using self-report, it is very important that the patient understands questions posed and why his or her response is important to gauge behavior change.

A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (Select all that apply). A. Writing a prescription for morphine sulfate as needed for pain. B. Inserting a nasogastric tube. C. Showing a patient how to use progressive muscle relaxation. D. Performing a daily bed bath after the evening meal. E. Repositioning a client every 2 hours to reduce pressure ulcer risk.

C. Showing a patient how to use progressive muscle relaxation. D. Performing a daily bed bath after the evening meal. E. Repositioning a client every 2 hours to reduce pressure ulcer risk.

problem-focused nursing diagnosis

Clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community. - Includes defining characteristics - Includes related factor

Vocab - Health promotion nursing diagnosis

Clinical judgment concerning motivation & desire to increase well-being & actualize human health potential.

Vocab - Nursing diagnosis

Clinical judgment concerning the human response to health conditions/ life processes, or vulnerability for that response by an individual, family, or community that a nurse is licensed and competent to treat

Vocab - Risk nursing diagnosis

Clinical judgment concerning vulnerability of individual/family/group/community for developing an undesirable human response to health conditions or life processes.

Close-ended questions

Closed-ended questions limit answers to one or two words such as "yes" or "no" or a number or frequency of a symptom. They require short answers and clarify previous information or provide additional information, and do not encourage the patient to volunteer more information than you request.

Vocab - Validation

Comparison of data with another source

Comprehensive assessment moves from ____ to ______.

Comprehensive assessment moves from general to specific. Certain aspects of situation stand out as most important. Then ask more focused questions on basis of patient's responses & physical signs.

Nola Pender's "Health Promotion Model"

Comprehensive assessment that supports that several factors motivate individuals to adopt behaviors that maintain and improve health. Considers: - How important is it to be healthy? - What does it mean to be healthy? - What are the benefits and barriers to health improvement? - How much control do patients have over the healthcare system & their health?

Concept mapping

Concept mapping is a nonlinear picture of a pt to be used for comprehensive care planning. Primary purpose of concept mapping is to better synthesize relevant data about a pt, including assessment data, nursing diagnoses, health needs, nursing interventions, and evaluation measures. Mapping organizes or connects info in a unique way so diverse info you have about a pt begins to form meaningful patterns & concepts.

Reflection-in-action

Continuous examination of results of an intervention - Once you deliver an intervention, you continuously examine results by gathering subjective and objective data from the patient, family, and health care team members. - At the same time you review knowledge regarding a patient's current condition, the treatment, and the resources available for recovery. - By reflecting on previous experiences caring for similar patients, you are in a better position to know how to evaluate your patient.

Reassessing a patient - implementation process

Continuous process with each patient interaction - NOT the evaluation of care or determination of a patient's response to an intervention, but it is the gathering of additional information to ensure that the plan of care is still appropriate

Vocab - Nursing interventions

Contributions from all disciplines involved in patient care any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes

Interdisciplinary care plan

Contributions from all disciplines involved in patient care. •focuses on patient priorities and improves the coordination of all patient therapies and communication among all disciplines.

Effective communication requires:

Courtesy Comfort Connection Confirmation

By the second post -operative day, a client has not achieved satisfactory pain relief. Based on this evaluation which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hours. C. Change the plan of care to provide different pain relief interventions. D. Teach the patient about the plan of care for managing his pain.

D. Teach the patient about the plan of care for managing his pain.

Nursing health history

Data about the patient's current level of wellness.

Vocab - Nursing health history

Data about the patient's current level of wellness.

Health care provider initiated interventions

Dependent—Require an order from a physician or other health care professional - Require specific nursing responsibilities & technical nursing knowledge. Based on the health care provider's response to treat or manage a medical diagnosis. Advanced practice nurses who work under collaborative agreements with physicians, or who are licensed independently by state practice acts, are able to write dependent interventions. -do not automatically implement the therapy, but determine whether it is appropriate for the patient.

PQRST

Descriptive pain scale: Provokes Quality Radiates Severity Time

Vocab - Nursing process

Diagnose and treat human responses

What is format for risk diagnosis?

Diagnostic label only. Related factor can help, but not standard. No E/B if it's tentative!

Counseling

Direct care method that helps patients use problem-solving processes to recognize and manage stress and facilitate interpersonal relationships. Many techniques foster cognitive, behavioral, developmental, experiential, and emotional growth in patients.

Preventative measures

Direct care. Primary prevention: health promotion including health ed programs, immunizations, and physical and nutritional fitness activities. Secondary prevention: focuses on people who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. It includes screening techniques and treating early stages of disease. Tertiary prevention: involves minimizing the effects of long-term illness or disability, including rehabilitation measures.

Care plan revision

Discontinuing a care plan Modifying a care plan -Reassessment (Sort, validate, and cluster all new data to analyze and interpret differences from the original database.) -Redefining diagnoses (Is diagnosis correct? Is etiological factor accurate and current?) -Goals and expected outcomes -Interventions (2 factors: appropriateness of intervention selected & correct application. Also consider increasing or decreasing frequency of interventions.) DOCUMENT ALL MODS

NANDA North American Nursing Diagnosis Association

Established in 1982. Purpose: To develop, refine, and promote a taxonomy of nursing diagnostic terminology for use by all professional nurses. Changed its name to NANDA International (NANDA-I). NANDA-I continually develops and adds new diagnostic labels to the list.

Related factors

Etiology or causative factor for diagnosis. Allows you to individualize a problem-focused nursing diagnosis for specific patient need.

What provides the basis for sound clinical practice guidelines and improvement of quality care?

Evidence-based research

Standards against which the nurse judges whether goals have been met and care was successful.

Expected outcomes

Patient expectations

Find out what patients expect to happen to them while seeking treatments for their health. Assess whether expectations have been met. If not met, patients consider care as poor.

Diagnostic conclusions

Formed after nursing assessment. Can be used to form nursing diagnosis. Include problems treated primarily by nurses (nursing diagnoses) & those treated by several disciplines (collaborative problems).

Problem-solving

General critical thinking Involves evaluating situation over time, identifying possible solutions, & trying solution over time to make sure it is effective. Becomes necessary to try different options if problem recurs.

Decision-making

General critical thinking Product of critical thinking that focuses on problem resolution. Following a set of criteria helps to make a thorough and thoughtful decision: may be personal; based on an organizational policy; or, a professional standard. Person has to weigh each option against set of personal criteria, test possible options, consider consequences of decision, & make final decision. Involves moving back & forth when considering all criteria. Leads to informed conclusions supported by evidence & reason.

Scientific method

General critical thinking Systematic, ordered approach to gathering data and solving problems Has five steps: 1) identify the problem 2) collect data 3) formulate a question or hypothesis 4) test the question or hypothesis 5) evaluate results of the test or study.

Vocab - SMART

Goals should be: Specific Measurable Attainable Realistic Timed

Vocab - High, Intermediate, and Low classification of intervention priorities

High: Emergent Intermediate: Non-life threatening Low: Affect patient's future well-being

Classification of priorities (used when ordering intervention priorities)

High—Emergent Intermediate—non-life-threatening Low—Affect patient's future well-being

Cognitive skills

Include critical thinking and decision-making skills. Always use good judgment and sound clinical decision making when performing any intervention.

Vocab - Clinical practice guidelines

Includes nursing diagnoses, goals and/or expected outcomes, specific nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patient's clinical needs and situation.

Nurse-initiated intervention

Independent—Actions that a nurse initiates • Require no order & no supervision or direction from others. Autonomous actions based on scientific rationale. Benefit a patient in a predicted way related to nursing diagnoses & patient goals •Nurse Practice Acts in majority of states say independent nursing interventions pertain to ADLs, health education & promotion, & counseling.

Vocab - Cue

Info you obtain through use of the senses.

IADLs

Instrumental ADLs. Direct care. Skills such as shopping, preparing meals, house cleaning, writing checks, and taking medications. Nurses help pts adapt to IADLs. Occupational therapists best for this.

Psychomotor skills

Integration of cognitive and motor activities.

Vocab - Collaborative interventions

Interdependent interventions are therapies that require the combined knowledge, skill, and expertise of multiple health care providers

Vocab - Collaborative Interventions

Interdependent interventions are therapies that require the combined knowledge, skill, and expertise of multiple health care providers.

Collaborative interventions

Interdependent—Requires combined knowledge, skill, and expertise of multiple health care professionals - During planning, review necessary interventions & determine whether the collaboration of other health care disciplines is necessary. In a patient care conference, the multidisciplinary health care team selects and assigns interdependent nursing interventions. - do not automatically implement the therapy, but determine whether it is appropriate for the patient.

Vocab - Direct care

Interventions are treatments performed through interactions with patients

Initial interview

Involves collecting nursing health history & gathering info about a patient's condition. Later interviews assess more about a patient's presenting situation and discuss specific problem areas. Begin by introducing yourself, your position, explaining purpose of interview. Explain why collecting data & assure patients that all of information is confidential. Ask the patient for their list of concerns / problems. Professionalism & competence that you show when interviewing pts strengthens nurse-pt relationship.

Vocab - Problem solving

Involves evaluating a situation over time, identifying possible solutions, and trying a solution over time to make sure that it is effective.

Partnering

Involves one RN and one LPN and/or NAP who are consistently scheduled to work together. The partners commit to healthy interpersonal relationships, trust in one another, and advance each other's knowledge. It is recognized that the RN has the authority to make the delegation decisions.

Vocab - Diagnostic reasoning

It is the analytical process for determining a patient's health problems.

Vocab - Evidence based knowledge

Knowledge based on research or clinical expertise, makes you an informed critical thinker.

Leading question

Leading questions are the most risky because of possibly limiting the information provided to what a patient thinks you want to know.

Vocab - Close-ended questions

Limits answers to 1-2 words

During clustering of cues, your analysis does what?

Makes you alert to thinking less about individual data points and instead to begin to see a pattern form.

Vocab - Diagnostic label

NANDA-I approved diagnoses

Unit-based Scenario

NAP serves the unit. The NAP works off a task list usually found in the job description and has minimal direction from or interaction with RNs. Limited 1:1 delegation occurs. Lack of communication can cause conflicts.

Meeting with colleagues

Nurses depend on others to help them think like nurses. Way to develop critical thinking skills is to meet regularly with colleagues, such as faculty members or preceptors, to discuss & examine work experiences & validate decisions. Connecting with others will help you learn that you do not need to know everything because support is available from colleagues.

Critical thinking in planning nursing care

Nurses need to: -Know the scientific rationale for the intervention. -Possess the necessary psychomotor and interpersonal skills. -Be able to function within a setting to use health care resources effectively.

Nursing care plan

Nursing diagnoses, goals and expected outcomes, nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patient's clinical needs and situation. -Reduces the risk for incomplete, incorrect, or inaccurate care -Changes as the patient's problems and status change - Gives all nurses a central document that outlines a patient's diagnoses/problems, the plan of care for each diagnosis/problem, and the outcomes for monitoring and evaluating patient progress. - Guideline for coordinating nursing care, promoting continuity of care, and listing outcome criteria to be used later in evaluation. - Enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care.

Goals are based on what kind of behavior that you expect a pt to acheive?

Objective

Vocab - Objective data

Observations or measurements of health status

Objective data

Observations or measurements of patient's health status •Ex: Inspecting condition of surgical incision or wound, describing observed behavior, & measuring blood pressure. •Measured on basis of accepted standard such as Fahrenheit or Celsius measure, inches or centimeters , or a rating scale. When you collect objective data, apply critical thinking intellectual standards so you can correctly interpret your findings.

How to determine whether data obtained is consistent with patient verbal data

Observe a patient's nonverbal communication such as use of eye contact, body language, or tone of voice

Delegation

Often, nurses who develop patient's plan of care do not deliver the care. Three approaches for delegation based on the way RN and nursing assistive personnel (NAP) assignments are made: 1) Unit-based scenario 2) Pairing 3) Partnering

Documentation & informatics

Once you identify a patient's nursing diagnoses, enter them either on the written plan of care or in the EHR of the agency. -Computer helps organize data into clusters -Enhances ability to select accurate diagnoses •When initiating an original care plan, place the highest-priority nursing diagnosis first. - Date nursing diagnosis at time of initiation. When caring for a patient, review list and identify nursing diagnoses with the greatest priority, regardless of chronological order.

Pairing

One RN works with a licensed practical nurse (LPN) and/or a NAP for a shift. The RN and LPN and/or NAP are not intentionally scheduled to work the same shift each day. For a given shift they work together, or are paired, and care for the same group of patients. Delegation usually increases with pairing.

Goals and outcomes should address how many behaviors/diagnoses? Expected outcomes should be what?

One. Singular.

Critical pathways

Patient care plans that provide the multidisciplinary hc team with sequential activities/tasks -Main purpose is to deliver timely care at each phase of the care process for a specific type of patient. - *Defines transition points* in pt progress & draws coordinated map of activities hc team can do to help make transitions as efficiently as possible.

Vocab - subjective data

Patient's verbal description of health status

Subjective data

Patient's verbal descriptions of health problems • often reflects physiological changes, which you further explore through objective review of body systems.

Interdisciplinary care plans

Plans that represent the contributions of all disciplines caring for a patient. Always be clear, concise, and to the point when you communicate nursing interventions.

Standing orders

Preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problem •Licensed prescribing hc providers in charge of care at time of implementation approve & sign standing orders. •Give nurses legal protection to intervene appropriately in best interests of patients with rapidly changing needs.

Probing

Probing encourages a full description without trying to control the direction the story takes, using "Is there anything else you can tell me?" or "What else is bothering you?"

Inference

Process of drawing conclusions from related pieces of evidence & previous experience with the evidence. - Part of diagnostic reasoning. - When making inference, form patterns of info from data before making diagnosis. When uncertain of diagnosis, continue data collection. Critically analyze changing clinical situations until able to determine pt's unique situation.

Vocab - Inference

Process of drawing conclusions from related pieces of evidence, & previous experience with the ordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing interventions. Judgment or interpretation of cues.

Health history

Provides you with information regarding the patient's past history. Has there been a hospitalization? A procedure? Medication uses? Prescription, over the counter, herbal, natural? Use of alcohol, tobacco, caffeine, recreational drugs? Sleeping patterns? Exercise habits? Nutritional habits? Recent losses? Religious influences? Relationships? Allergies? Also, include patient habits and lifestyle patterns.

Quality and Safety Education for Nurses (QSEN)

QSEN Institute has established standard competencies in knowledge, skills, and attitudes (KSAs) for the preparation of future nurses. The goal of QSEN is to prepare nurses so they can continuously improve the quality and safety of the health care systems within which they work.

Reason for seeking health care

Record the patient's response in quotations to indicate subjective response. Clarification of patient's perception identifies potential needs for symptom management, education, counseling, or referral to community resources.

Professional standards for critical thinking

Refer to ethical criteria for nursing judgments, evidence-based criteria used for evaluation, and criteria for professional responsibility. Excellent nursing practice is a reflection of ethical standards. Nurses routinely use evidence-based criteria to assess patients' conditions and determine the efficacy of nursing interventions.

When a goal is not met:

Repeat the nursing process sequence for that nursing diagnosis.

Effective communication (4 C's)

Requires: courtesy, comfort, connection, confirmation.

Spiritual health

Review with patients their beliefs about life, their source for guidance in acting on beliefs, and the relationship they have with family in exercising their faith. Also assess rituals and religious practices that patients use to express their spirituality.

Evaluative Measures

Same as assessment measures, but you perform them at the point of care when you make decisions about a patient's status and progress. Collect over a period of time; look for trends - Evaluative measures are assessment skills and techniques - Evaluating behavior - Self-management - Nursing Outcomes Classification (NOC)

Diagnostic reasoning

Specific critical thinking Analytical process for determining pt's health problems. Accurate recognition of pt's problems is necessary before decide on solutions & implement action. Requires you to assign meaning to behaviors & physical signs/symptoms presented by pt. Expert nurse sees context of a pt situation, observes patterns & themes, & makes decisions quickly.

Clinical decision-making

Specific critical thinking Makes decision that identifies problem, reducing severity of problem or resolving problem completely. Occurs through in-depth knowledge of patient's patterns of responses within clinical situation & knowing patient as a person. Two components: - nurse's understanding of specific patient - his or her subsequent selection of interventions.

Psychosocial history

Support system? Spouse? Children? Friends? Family members? Stress coping mechanisms?

Vocab - Motivational interviewing

Technique often used in counseling that allows hc worker to become helper in the change process

Motivational interviewing

Technique often used in counseling that allows you to become a helper in the change process.

2- part format in labeling health promotion and problem-focused nursing diagnosis:

The NANDA-I diagnostic label followed by a statement of a related factor.

Exception to use of term "nursing diagnosis" as part of nursing process

The National Council of State Boards of Nursing (NCSBN, 2013), which administers the NCLEX® examination, defines the nursing process as a scientific, clinical reasoning approach to patient care that includes assessment, analysis, planning, implementation, and evaluation.

Vocab - Critical thinking

The ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process.

Vocab - Medical diagnosis

The identification of a disease condition based on a specific evaluation of physical signs & symptoms, a patient's medical history, and the results of diagnostic tests and procedures

Vocab - Expected outcome

The measurable change (patient behavior, physical state, or perception) that must be achieved to reach a goal.

Vocab -Diagnostic label

The name of the nursing diagnosis approved by NANDA-I (Describes characteristics of the human response to health conditions)

diagnostic label

The name of the nursing diagnosis as approved by NANDA-I. Describes the essence of a patient's response to health conditions in as few words as possible. All NANDA-I approved diagnoses have a definition. The definition describes the characteristics of the human response identified and helps to select the correct diagnosis.

Commitment

The nurse makes choices without assistance assuming responsibility for these choices. This results from expert level knowledge, experience, developed intuition , reflection and flexible attitude.

Vocab - Priority setting

The ordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing interventions.

Benefits of establishing trusting nurse-pt relationship

The patient feels comfortable asking you questions about the health care environment, planned treatments, diagnostic testing, and available resources.

What makes a nurse an informed critical thinker?

The use of evidence-based knowledge, or knowledge based on research or clinical expertise - Focuses on options for solving problems & making decisions rather than rapidly & carelessly forming quick, simple solutions. - cognitive skills & habit of asking questions, staying well informed, being honest in facing personal biases, and always being willing to reconsider and think clearly about issues. * considers what is important in each clinical situation: - imagines & explores alternatives - considers ethical principles, - makes informed decisions about care of patients

Why perform assessment?

To gather info needed to make an accurate judgment about a patient's current condition.

Reflective journaling

Tool for developing critical thought and reflection by clarifying concepts. •Which experience, situation, or information in clinical experience is confusing, difficult, or interesting? •What is meaning of experience? What feelings did you have? What feelings did your patient or family have? What influenced the experience? •Do feelings, guesses, or questions remind you of any experiences from past or something you think is a desirable future experience? How does it relate? •What are connections between what is being described & what you learned about nursing science & theory?

Vocab - Reflection

Turning over a subject in the mind and thinking about it seriously

Reflection:

Turning over a subject in your mind and thinking about it seriously. - Not intuitive - Think about previous situations & consider: What did I notice before? How did I act? What could I have done differently? What should I do next time in the same situation? - When reflect on past experiences, perceive that knowledge increases and critical thinking moves to higher level. - Play back situation & honestly review everything you remember - Reflective reasoning improves accuracy of diagnostic conclusions. - By reviewing previous actions, will see successes and opportunities for improvement. - Be cautious in using reflection. Reliance on it can block thinking & not allow you to look at newer evidence or subtle aspects of situations you have not encountered.

QSEN Skill Competencies (Quality & Safety Education for Nurses)

Type of standardized nursing intervention. Authoritative statements of duties RNs are expected to perform competently, regardless of role, pt population they serve, or specialty.

NIC & NOC

Use nursing diagnostic language and the Nursing Interventions Classification (NIC) and NOC is becoming more common in electronic medical records, improving the quality, consistency, and accuracy of what is documented.

Standards of practice

Used as evidence of the standard of care that registered nurses (RNs) provide their patients •The ANA standards are formally reviewed on a regular basis. The newest standards include competencies for establishing professional and caring relationships, using evidence-based interventions and technologies, providing ethical holistic care across the life span to diverse groups, and using community resources and systems. In addition, the standards emphasize implementing a timely plan following patient safety goals.

Nursing Health History - Concept Mapping

Visual representation that allows you to graphically show the connections among a patient's many health problems •strategy that develops critical thinking skills by helping a learner understand the relationships that exist among patient problems. •Foster reflection and help students evaluate critical thinking patterns and see the reasons for nursing care. Your first step in concept mapping is to organize the assessment data you collect. Placing all of the cues together into the clusters that form patterns leads you to the next step of the nursing process, nursing diagnosis. •Through concept mapping you obtain a holistic perspective of your patient's health care needs, which ultimately leads you to making better clinical decisions.

When is ability to recognize incorrect therapies particularly important?

When administering meds or implementing procedures You are legally responsible for complications resulting from error!

Identifying areas of assistance

When you are asked to admin a new med, operate new equipment, or admin a procedure with which you are unfamiliar: 1) Seek the information you need to be informed about a procedure. 2) Collect all equipment needed for the procedure. 3) Have another nurse who has completed the procedure correctly and safely provide assistance and guidance.

When and how to consult

When: The exact problem remains unclear How: Begin with your understanding of the patient's clinical problem. - Direct the consultation to the right professional. - Provide the consultant with relevant information about the problem area: Summary, methods used to date, and outcomes - Do not influence consultants. - Be available to discuss the consultant's findings. - Incorporate the suggestions.

Types of implementation skills

You are responsible for knowing when one type of implementation skill is preferred over another and for having the necessary knowledge and skill to perform each. - Cognitive skills - Interpersonal skills - Psychomotor skills

Risk nursing diagnosis

a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem.

Vocab - Scientific method

a methodical way to solve problems using reasoning

Vocab - Interdisciplinary care plans

a systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations

When do you reject a diagnosis under consideration?

absence of certain defining characteristics suggests that you reject a diagnosis under consideration.

Biographical info

age, address, occupations, marital status, health care insurance

Short-term goal

an objective behavior or response that you expect a patient to achieve in a short time, usually less than a week. In an acute care setting, you often set goals for over a course of just a few hours.

Long-term goal

an objective behavior or response that you expect a patient to achieve over a longer period, usually over several days, weeks, or months.

Evaluation is ___, occurring through ____ of the nursing process.

continuous, each step

University of Iowa (2014) Hartford Center

has evidence-based practice (EBP) guidelines for geriatric nursing.

Diagnostic process

includes critical analysis & interpretation of assessment data that reveal a patient's response to health problems with the goal of identifying patient needs and formulating nursing diagnoses.

Vocab - Indirect care

interventions are treatments performed away from a patient but on behalf of the patient or group of patients

Root cause for most reported adverse or sentinel events that occur in health care organizations.

miscommunication

Related factor is appropriate for which types of diagnoses?

problem-based & health promotion

The National Guidelines Clearinghouse (NGC)

public resource for evidence-based clinical practice guidelines. The NGC guidelines are linked to a particular term derived from the U.S. National Library of Medicine (NLM) Medical Subject Headings (MeSH), a controlled vocabulary for disease/condition, treatment/intervention, and health services administration.

Ways to develop critical thinking skills

reflective journaling meeting with colleagues concept mapping

Evaluation indicators

specific recommended evaluative measures (i.e., the patient's physical condition, behaviors, or perceptions that are measures of outcome achievement)

Defining characteristics

support each problem-focused diagnosis

Vocab - Defining characteristics

support each problem-focused diagnostic judgment

Nursing interventions definition

treatments or actions based on clinical judgment and knowledge that nurses perform to enhance patient outcomes.

Assessment data

used to develop nursing diagnosis, identify collaborative problems, & develop individualized care plan.

Cultural diversity includes:

values, beliefs, health practices, ethnicity, and gender.

Five-step nursing process

• Central to your ability to provide timely & appropriate care to patients. • Make clinical judgments from assessment to identify patient's response to health problems in form of nursing diagnoses. • Then create a plan of care. Set goals and expected outcomes and selecting interventions (nursing and collaborative) individualized to each of the patient's nursing diagnoses. • Next step, implementation, involves performing planned interventions. After performing interventions, evaluate pt's response & determine whether interventions were effective

Critical thinking competencies:

• General critical thinking -Scientific method -Problem solving -Decision making • Specific critical thinking -Diagnostic reasoning and inference-analytical -Clinical decision making • Nursing process

Intuition

• Inner sensing that facts do not support something. • Should spark the nurses spirit of inquiry. • Ask: Did vital signs reflect client's present status?

Consultation (more info)

• Requires good intrapersonal and interprofessional collaboration. • Increases your knowledge about patient's problems and helps you learn skills & obtain resources. • An objective consultant enters a clinical situation and more clearly assesses & identifies nature of a problem, whether it is patient, personnel, or equipment-oriented. •Most often you consult with hc providers working in your clinical area. Sometimes consult over the phone. • STEP 1: assess situation & ID general problem area. • STEP 2: direct consultation to right professional such as another nurse or social worker. • STEP 3: provide consultant with relevant info about the problem area & seek a solution. Include brief summary of the problem, methods used to resolve problem so far, & outcomes of these methods. Also share info from the patient's medical record, conversations with other nurses, and patient's family. • STEP 4: do not prejudice or influence consultants. Consultants are in the clinical setting to help identify and resolve a nursing problem, and biasing or prejudicing them blocks problem resolution. Avoid bias by not overloading consultants with subjective and emotional conclusions about patient and problem. • STEP 5: be available to discuss a consultant's findings and recommendations. Private, comfortable atmosphere for consultant and patient to meet. A common mistake is turning the whole problem over to the consultant. The consultant is not there to take over the problem but to help you resolve it. When possible, request the consultation for a time when both you and the consultant are able to discuss the patient's situation with minimal interruptions or distractions. •STEP 5: incorporate the consultant's recommendations into the care plan. The success of the advice depends on the implementation of the problem-solving techniques. Always give the consultant feedback regarding the outcome of the recommendations.

Termination of interview

• Requires skill. Summarize discussion with a patient & check for accuracy of info collected. Give patient a clue that interview is coming to an end. End interview in a friendly manner, telling patient when you will return to provide care.

History of nursing diagnosis

•1950, First introduced. •1953, Fry proposed the formulation of a nursing diagnosis. •1973, first national conference held. •1980 and 1995, the American Nurses Association (ANA) included diagnosis as a separate activity in its publication "Nursing: a Social Policy Statement." •1982, North American Nursing Diagnosis Association (NANDA) was founded.

Cue vs Inference

•A cue is info you obtain through use of the senses. •An inference is your judgment or interpretation of cues. •Always try to interpret cues from patient to know how in depth to make assessment. Assessment is dynamic & allows you to freely explore relevant patient problems as you discover them.

Data clustering

•A data cluster is a (objective or subjective) set of cues, the signs or symptoms gathered during assessment. •Compared with standards to reach a conclusion about a patient's response to a health problem. •Each clinical criterion is an objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a diagnostic conclusion.

Planning nursing care

•After making a medical diagnosis, a hc provider will choose interventions & communicate plan to hc team. •After identifying patient's nursing diagnoses & collaborative problems, nurse prioritizes diagnoses, sets patient-centered goals and expected outcomes, and chooses nursing interventions appropriate for each diagnosis. •Requires communicating closely with patients, their families, and the health care team, and ongoing consultation with team members. •The nursing diagnoses that you identify direct your selection of individualized nursing interventions and the goals and outcomes you hope to achieve. •A plan of care is dynamic and changes as the patient's needs change.

Nurse-initiated interventions are: A. determined by state Nurse Practice Acts. B. supervised by the entire health care team. C. made in concert with the plan of care initiated by the physician. D. developed after interventions for the recent medical diagnoses are evaluated.

•Answer: A •Rationale: Individual nurse practice acts determine nurse-initiated interventions.

You have finished with several nursing interventions. To evaluate interventions, you need to examine the: A. appropriateness of the interventions and the correct application of the implementation process. B. nursing diagnoses to ensure that they are not medical diagnoses. C. care planning process for errors in other health care team members' judgments. D. interventions of each nurse to enable the nurse manager to correctly evaluate performance.

•Answer: A •Rationale: When evaluating, the nurse needs to look at the patient's condition, the interventions used to improve the patient's status, and whether or not they were appropriate.

Your patient has met the goals set for improvement of ambulatory status. You would now: A. modify the care plan. B. discontinue the care plan. C. create a new nursing diagnosis that states goals have been met. D. reassess the patient's response to care and evaluate the implementation step of the nursing process.

•Answer: B •Rationale: When goals are met, the care plan for that goal is discontinued.

Consultation occurs most often during which phase of the nursing process? A. Assessment B. Diagnosis C. Planning D. Evaluation

•Answer: C •Rationale: When a nurse is unsure of how to proceed in the planning process, he or she will seek out another colleague's knowledge and experience to assist in planning interventions for the patient.

The nursing process organizes your approach while delivering nursing care. To provide the best professional care to patients, nurses need to incorporate nursing process and: A. decision making. B. problem solving. C. intellectual standards. D. critical thinking skills.

•Answer: D •Rationale: The nursing process & critical thinking go hand-in-hand in providing patient-centered care. The nursing process cannot be completed without critical thinking in forming nursing diagnoses, setting goals, interventions, and evaluation.

You are writing a care plan for a newly admitted patient. Which one of these outcome statements is written correctly? A. The patient will eat 80% of all meals. B. The nursing assistant will set the patient up for a bath every day. C. The patient will have improved airway clearance by June 5. D. The patient will identify the need to increase dietary intake of fiber by June 5.

•Answer: D •Rationale: Outcome statements should have measurable and realistic goals. In this case, the goal is both measurable (will identify the need to increase dietary intake by June 5) and realistic.

Concept mapping is one way to: A. connect concepts to a central subject. B. relate ideas to patient health problems. C. challenge a nurse's thinking about patient needs and problems. D. graphically display ideas by organizing data. E. all of the above.

•Answer: E •Rationale: Concept mapping helps the busy nurse, with numerous patients, focus on healing patients on an individual basis.

Levels of critical thinking:

•Basic: Nurse trusts expert & thinks concretely based on rules. •Complex: Nurse begins to express autonomy by analyzing data & results from knowledge, experience, intuition, & flexible attitude.

Cultural relevance of nursing diagnosis

•Consider patients' cultural diversity when selecting a nursing diagnosis. Ask questions such as: -How has this health problem affected you and your family? -What do you believe will help or fix the problem? -What worries you most about the problem? -Which cultural practices are important to you? - What do you expect from us, your nurses, to help maintain some of your cultural practices? - What cultural practices do you do to keep yourself and your family well? •Cultural awareness and sensitivity improve your accuracy in making nursing diagnoses.

Critical thinking synthesis

•Critical thinking & nursing process go hand-in-hand in making quality decisions about pt care •Critical thinking is reasoning process by which you reflect on & analyze thoughts, action, & knowledge. •As beginning nurse, important to learn steps of nursing process & incorporate elements of critical thinking.

Data interpretation

•Critical to select correct diagnostic label for a patient's need. •When comparing patterns, judge whether grouped signs & symptoms are expected for a patient and whether they are within the range of healthy responses. -By isolating any defining characteristics not within healthy norms, you can identify a specific problem.

Family history

•Data about immediate and blood relatives, which determines risks of a genetic or familial nature. Blood relative health issues? Recent losses?

Present illness or health concerns

•Determine when the problems began, how severe, intensity, quality, what makes them worse, and what makes them better. •Use PQRST: provokes, quality, radiate, severity, time. •Concomitant symptoms: Does the patient experience other symptoms along with the primary symptom?

Nursing diagnosis examples

•High Risk •Impaired knowledge •Acute pain related to •Activity intolerance •Self care deficit •Risk for

Language

•Language should be clear & concise demonstrating focused thinking. •Did I use language appropriate for client? •Did I communicate message clearly to provider?

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