1125 Exam #1 Clinical Judgement & Health Information Technology
#13 Health Promotion (Implementation)
*Adolescents* Health screening has traditionally been an important aspect of adolescent health care. The goal has been to detect health problems at an early age so that they can be treated at that time. Today, health promotion goes beyond the mere screening for illnesses and disabilities and includes extensive efforts to promote positive health practices at an early age. Because health habits and practices are formed early in life, adolescents should be encouraged to develop positive health attitudes. For this reason, more programs are being offered to adolescents to help them develop good health habits. Although the negative results of practices such as smoking, risky sex, alcohol and drug abuse, and poor nutrition are explained in these educational programs, emphasis is also placed on values training, self-esteem, and healthy lifestyle practices. The projects are designed to appeal to a particular age group, with emphasis on learning experiences that are fun, interesting, and relevant. Hinkle, Pg. 58
#15 Patient Education (Assessment) (Taylor 489)
*Assessment* Usually, patients themselves are the best source of assessment information. Patients are considered primary sources of information. By using effective interviewing techniques (see Chapter 20), you can obtain the data needed to identify learning needs. In addition, relevant information can be obtained before actually meeting the patient by reviewing the patient's past and current medical records. These records are considered secondary sources of information; they can provide a history of medical problems as well as documentation of the nursing assessments, nursing diagnoses, nursing physical examinations, and nursing interventions that have been performed. The patient's family and significant others are also valuable sources of assessment data. They are sometimes needed to provide assessment data when the patient cannot communicate because of health problems, language barriers, or impaired sensory functions. At other times, family members or significant others might be the most appropriate source of certain information; for example, if seeking information about how much salt is used in the family's cooking, you could speak with the person who prepares the meals at home and include that person in any teaching about food preparation. The patient's permission is needed before family members are involved in the teaching-learning process.
#9 Patient Education; Diagnosis (Teaching/Learning) (Taylor 490)
*Diagnosing:* If the patient lacks the required knowledge, attitudes, or skills to support health promotion, you should diagnose the deficit. Use diagnoses or problem statements approved by the North American Nursing Diagnosis Association-International (NANDA-I) as a guide when diagnosing learning needs (see Chapter 12). If you believe that a patient's knowledge deficit is the primary problem, write a diagnosis identifying a specific knowledge deficit as the problem, followed by its etiology and the related signs and symptoms. For example, Deficient Knowledge: Breastfeeding related to inexperience, as manifested by anxiety and multiple questions. A knowledge deficit usually results in an actual or potential problem; therefore, the knowledge deficit is written as the etiology (second part of the diagnostic statement): for example, Imbalanced Nutrition: Less Than Body Requirements related to mother's lack of knowledge about infant feeding and deficient learning readiness (as manifested by mother's quick frustration when breastfeeding, refusal to engage in learning process, infant's weight loss). If you learn that a pregnant woman plans to breastfeed but knows nothing about breastfeeding, "Deficient Knowledge: Breastfeeding" is the problem statement. The goal is to increase the mother's knowledge. If, on the other hand, you observe a newborn failing to gain weight appropriately, and it is reasonable to suspect that the mother's lack of knowledge about how to breastfeed is interfering with the infant's nutritional intake, "Deficient Knowledge: Breastfeeding" is the etiology. The goal is to ensure the infant's proper nutrition. Related nursing diagnoses include the following: Ineffective Health Maintenance Ineffective Therapeutic Regimen Management Noncompliance Self-Care Deficit (specify) Taylor, Pg. 490
#11 Health Promotion, Teaching (Implementation)
*FACTORS INFLUENCING COMMUNICATION* Factors influencing communication include level of development; gender; sociocultural differences; roles and responsibilities; space and territoriality; physical, mental, and emotional state; and environment. *Developmental Level* The rate of language development is directly correlated with the patient's neurologic competence and cognitive development. Thus, it is helpful to understand the process of language development and the stages of intellectual and psychosocial development. This helps you communicate effectively with patients and family of all age ranges. The stages of development are presented in Chapters 17, 18, and 19. Knowing how each age group commonly perceives health, illness, and body functions should guide your interactions with patients. For instance, a 10-year-old child has limited understanding of what an infection is; therefore, explain things in simple terms so that the child cooperates with the treatment without being frightened. Because adolescents are developing abstract thinking, more detailed and accurate explanations can be given to them. Being familiar with commonly used slang usually helps when communicating with adolescents. Communicating with adults can be affected by their past positive or negative health-related experiences and by inaccurate information. When communicating with older patients, assess for any problems with hearing or sight (discussed later in this chapter), confusion, or depression, any of which could affect nurse-patient interaction. *Gender* Men and women have differing communication styles and might give different interpretations to the same conversation. Tannen (1990) believes that this is because girls and boys grow up communicating differently. Whereas girls generally play with "best friends" and use language to seek confirmation, minimize differences, and establish or reinforce intimacy, boys use language to establish their independence and to negotiate status activities in large groups. In contrast, Townsend (2009) states that gender roles are changing in American society because sexual roles are becoming less distinct. Factors contributing to this change are the growing use of the term "unisex" and the fact that women and men enter professions previously dominated by the other sex. It is necessary to be sensitive to the fact that men and women might communicate differently. As such, when working with patients of the opposite gender, you'll need to validate that both you and your patient are accurately receiving the message the other is trying to communicate. *Sociocultural Differences* Nurses need to recognize ways in which culture, economic condition, and overall lifestyle influence a patient's preferred mode of communicating. This helps one understand what the patient understands. Currently, approximately one in five U.S. residents speaks a language other than English (Ashton, 2012). Culture refers to the common lifestyles, languages, behavior patterns, traditions, and beliefs that are learned and passed from one generation to the next. The first step toward cultural competence requires becoming aware of your own personal cultural beliefs and identifying "prejudices or attitudes that could be a barrier to good communication" (Gerace & Salimbene, 2010). Likewise, understanding a patient's culture helps you understand nonverbal communication and deliver accurate nursing care to the patient and family. For example, women in some cultures might speak of personal things only to their spouses. For this reason, a maternal care nurse might talk with the patient's husband about the woman's postdelivery care. The health care system is a culture with its own customs, values, and language. Patients with limited proficiency in English have difficulty understanding medical instructions and understanding test results and diagnoses. Try to remain aware of these cultural variations and be careful to use lay terminology when speaking with patients, unless you know that the patient is a health care professional. Use of medical terminology (e.g., myocardial infarction for heart attack, cerebrovascular accident for stroke [brain attack], or cholecystectomy for gallbladder operation) usually alienates patients and can inhibit further communication. A patient's language proficiency should be evaluated upon admission to a health care facility, and medical interpreters should be available to facilitate any communication and improve the quality of care (Ashton, 2012). The recent Joint Commission Standards for Patient-Centered Communication and criteria for accreditation are discussed in detail in Chapter 21. *Roles and Responsibilities* A person's occupation might give the nurse a general supposition of that individual's abilities, talents, interests, and economic status. Stereotyping a person according to occupation, however, can be misleading and should be avoided. This can be particularly dangerous when nurses assume that patients who are health care professionals know everything about their condition and need little nursing assistance, teaching, and counseling. The challenge in the provision of care is to respect the patient's roles and responsibilities, especially because these influence their preferred manner of communicating, without denying the patient needed care. For example, a successful attorney might have a "take-charge" demeanor and seem utterly self-sufficient; a skilled nurse will note this but still provide an opening for the patient to verbalize his or her needs. "You seem well prepared for this procedure and in control, but I know that patients often have questions that never get answered or fears that remain unvoiced. Is there anything I can help you with while I'm here?" Similarly, be careful not to ignore an uncomplaining patient who never asks for anything, because the power differences in the health care professional-patient relationship may make communication intimidating. *Space and Territoriality* People are most comfortable in areas they consider their own. We generally feel relief when we come home, take our shoes and professional clothes off, and relax. This urge to maintain an exclusive right to certain space is termed territoriality. You might have already noticed that patients behave differently when being interviewed in their homes, at a health fair in the mall, or in an institutional setting. Similarly, health care professionals might behave differently when they are "on their own turf" in a health care setting compared to when they enter a patient's home as a guest caregiver. It is important to understand how territoriality influences the nurse-patient relationship. The actual physical difference between the nurse and patient during interaction is also important. Proxemics is the study of distance zones between people during communication (Videbeck, 2011). Each person has a sense of how much personal or private space is needed and what distance between people is optimum. Figure 20-3 demonstrates the four communication zones. Activities that are likely to occur during each of these zones include: *-Intimate zone:* interaction between parents and children or people who desire close personal contact *-Personal zone:* distance when interacting with close friends *-Social zone:* space when interacting with acquaintances such as in a work or social setting *-Public zone:* communication when speaking to an audience or small groups Some aspects of communication zones are dictated through culture, and some are idiosyncratic. Anywhere from 18 inches to 4 feet might be optimal distance to sit from a patient during an intake interview. For example, European Americans and African Americans require more personal space between two people who are speaking than other cultures (Mediterranean, Hispanic, Asian, Middle Eastern, East Indian) who are comfortable at a closer distance when speaking (Videbeck, 2011). People in the United States usually are comfortable standing about 3 feet away from each other when speaking (Pagana, 2011b). It is best to take cues from patients, noting whether they are moving backward from you if you are too near or leaning forward to get closer to you. Because many nursing interventions place one in proximity to a patient and entail forced intimacy, be sensitive to how offensive this might be to certain patients who are accustomed to large areas of private space. Develop the habit of seeking the patient's permission before touching areas within a patient's private zones. Although most people consider their hands, arms, shoulders, and back within a social zone, increasing levels of privacy are according to (1) mouth and feet; (2) face, neck, and front of body; and (3) genitalia. *Physical, Mental, and Emotional State* The degree to which people are physically comfortable and mentally and emotionally free to engage in interactions also influences communication. A full bladder, a dull headache, crushing chest pain, anxiety about a pending diagnosis or concern about what is happening at home or at work, and fear can all negatively influence communication. For example, patients who think that a nurse wants to hurt them will be difficult to interview. Be sensitive to the patient's physical, mental, and emotional barriers to effective communication. Cognitively impaired patients present special communication challenges. For example, an older patient who has aphasia and is agitated due to pain from an abscessed tooth might be unable to communicate with the nurse. The accompanying box, Examples of Nursing Interventions and Nursing Outcomes Classifications (NIC/NOC), suggests helpful cognitive stimulation activities and expected outcomes when communicating with these patients. Values Communication is influenced by the way people value themselves, one another, and the purpose of any human interaction. Nurses who believe that teaching is an important aspect of nursing and who value empowering patients will communicate this to patients. Conversely, a nurse who believes teaching is an unimportant chore is unlikely to be an effective teacher. Similarly, the patient's motivation (or lack of motivation) to develop new self-care behaviors cannot help but influence nurse-patient communication. Environment Communication happens best when the environment facilitates an easy exchange of needed information. The environment most conducive to communication is one that is calm and nonthreatening. The goal is to minimize distractions and ensure privacy. The use of music, art, and interior decorations might help put the patient at ease. A patient with newly diagnosed human immunodeficiency virus (HIV) infection will find it difficult to discuss sexual history or genital warts in an area that lacks privacy. A toddler might find it easier to communicate if a parent, favorite stuffed animal, or blanket is nearby.
#23 HIT - Concept Map (Intervention)
*Health Information Technology* HIT "The application of information processing involving both computerhardware and software that deals with thestorage, retrieval, sharing, and use ofhealth careinformation, data, and knowledge for com- munication and decisionmaking." (B&T)*Attributes* Technology and Information Used to Support Clinical Judgment, Error Prevention, and Care Coordination *Antecedents* Hardware and Software Multiple Patient Data Available Data Standards and Terminology Policies and Procedures Privacy and Security Informatics Workforce Organizational Skills *Related Concepts* Communication Health Policy Teamwork & Collaboration Patient Centered Care *Sub-Concepts* Electronic Health Record Meaningful Use Health Information Exchange Nursing Informatics *Positive Consequences* Support Practice Confidentiality Information Transferability Continuity of Care Accurate Information at the Point of Care Reduction in Practice Errors *Negative Consequences* Sentinel Events Errors in Patient Care Documentation Errors Breach in Confidentiality Inaccurate Decisions
#20 Health; Definition (Intervention)
*Health:* state of optimal functioning or well-being Pg. 45 *****************
#29 Documentation: SBAR (Taylor 360 Box 16-4)
*I* Identity/Introduction State NAME, TITLE, and UNIT *S* Situation I am calling about: (Patient Name and Room Number) The PROBLEM I am calling about is: *B* Background State Admission Diagnosis and Admission Date State Pertinent Medical History Brief Synopsis of Treatment if pertinent Most recent Vital Signs Changes in VS or Assessment from Prior assessment *A* Assessment Give your conclusions about the present situation. Words like "might be" or "could be" are helpful. A diagnosis is not necessary. If the situation is unclear, at least try to indicate what body system might be involved. State how severe the problem seems to be. If appropriate, state that the problem could be life threatening. *R* Recommendation Say what you think would be helpful or needs to be done (medications, treatment, tests, X-rays, EKG, CT, transfer to critical care, physician evaluation, consultant evaluation Ask about any Changes in Orders *R* Readback Restate orders you have been given. Clarify how often to do vital signs. Under what circumstances to call back.
Safety Attributes
*Injury Free as defined by:* -TJC (The Joint Commission) -OSHA (Occupational Safety &Health Administration) -QSEN Standards (Quality & Safety Education for Nurses)
#40 Primary, Secondary, Tertiary Prevention (Nursing Process) (Hinkle 51 Table 3-2)
*Primary* Weight loss Diet Exercise Smoking cessation Reduced alcohol consumption Avoidance of illicit drugs Farm safety Seat belts and child safety seats Immunizations Water treatment Safer sex practices Effective parenting *Secondary* Screenings (Blood pressure, cholesterol, glaucoma, HIV, skin cancer) Pap smears Mammograms Testicular examinations Family counseling *Tertiary* Medication Medical therapy Surgical treatment Rehabilitation Physical therapy Occupational therapy Job training
#19 Health Promotion; Adolescents (Intervention)
*Safety:* -Encourage drivers' education classes for adolescents, if available. -Discuss the relationship of alcohol and drug consumption to motor vehicle crashes. -Provide information about water safety, gun safety, and sports safety. *Nutrition:* -Encourage a diet based on the food groups, with added calories during the adolescent growth spurt. -Refer for counseling for extremes in either underweight or overweight. -Discuss nutritional problems that may result from too much fast food and too many soft drinks. -A balance of food intake, exercise, and rest is important. *Sexual Development:* -Secondary sex characteristics are fully developed. -Both males and females are physically capable of reproduction. -Discuss sexual behavior openly and honestly with adolescents. *Growth&Development:* -The adolescent is primarily influenced by the peer group. -Risk-taking behavior, especially in males, is common. -Maintaining open communications with teens is important. -Encourage increasing independence in the adolescent and young adult, but continue to provide love and support. -Assist with clarifying values and goals for future occupation. *Promoting Health&Preventing Illness:* -Have immunizations and boosters as recommended. CDC recommends a series of three HPV vaccinations for women ages 13-26 who did not receive them when they were younger. Gardasil, one of the FDA-approved HPV vaccines, is also recommended for men through 26 years of age to protect against genital warts. -Have regular physical, vision, and dental examinations. -Always have a physical examination before participating in sports activities. -Do a breast self-exam (females) and a testicular self-exam (males) each month. -Learn to say "no" to pressures to have sexual activity. -Engage in safe-sex practices if sexually active. -Have an annual Pap test and pelvic examination if sexually active. -Know the dangers of STIs (from genital, oral, and anal sex) and have HIV testing if safe sex is not practiced. Taylor, Pg. 414 Chart 18-5
#12 Health Promotion (Implementation)
*Sample SBAR (Situation-Background-Assessment-Recommendation) Communications* *SBAR Scenario #1* RN calling physician regarding patient's elevated temperature, breathing difficulties, and deteriorating condition *S—*Jeff's temperature this evening shot up to 103 degrees and his respirations are labored; RR of 40, HR of 95 BPM, and O2 Sat of 82% on room air. He is pale and also drooling. *B—*Jeff was transferred two days ago from the state home for children with respiratory difficulties. Jeff is a 9-year-old with a genetic disease that includes severe mental retardation. *A—*I am concerned about Jeff's deteriorating condition. *R—*Another nurse is staying with Jeff, offering O2 and positioning and suctioning, but I need you to come to the bedside and assess this patient. *SBAR Scenario #2* RN calling team manager regarding home hospice patient's inadequate pain management *S—*Ms. Tadesse is grimacing and moaning—she appears uncomfortable. *B—*She is in end-stage breast cancer and her family has been told that death is imminent—expected sometime this week. *A—*Her daughter has been administering the PRN morphine sulfate as ordered, but it no longer seems to be keeping her mother comfortable. *R—*Should we have the palliative care physician re-evaluate her analgesics and recommend a better pain management regimen? Taylor, Pg. 169, Box 9-1
#21 Health Promotion and Goals; Tertiary Prevention (Taylor 52)
*Tertiary health promotion* and Illness prevention begins after an illness is diagnosed and treated, with the goal of reducing disability and helping rehabilitate patients to a maximum level of functioning. Nursing activities on a tertiary level include teaching a patient with diabetes how to recognize and prevent complications, using physical therapy to prevent contractures in a patient who has had a stroke or spinal cord injury, and referring a woman to a support group after removal of a breast because of cancer. Nurses play an important role in monitoring the responses of the patient to the prescribed therapy and in providing services to facilitate the patient's recovery or improve quality of life while living with the effects of an illness or injury. (Taylor 52)
#2 Reduction in Risk Potential; School Aged Children (Taylor 407) (Taylor 699 Chart 26-1)
*Topic:* Safety *Teaching Tips:* -Teach and require pedestrian traffic safety. -Wear seat belts and bicycle helmets. -Emphasize bicycle, scooter, skate, and skateboard safety. -Provide swimming lessons and water safety rules. -Rural children should be taught farm safety. -Teach how to "stop, drop, and roll" to extinguish clothing fire. -Teach the dangers of dangerous products and chemicals. -Keep guns locked up. Teach gun safety rules. -Teach use of proper equipment for contact sports. -Be alert for concussion sports injuries, use proper equipment, and follow treatment recommendations for concussions. Taylor, Pg 407 *Risks:* Burns, Drowning, Broken bones, Concussions (TBI), Inhalation or ingestion, Guns and weapons, Substance abuse *Teaching Tips:* -Teach accident prevention at school and home. -Teach child to wear safety equipment when playing sports. -Reinforce teaching about symptoms that require immediate medical attention. -Continue immunizations as scheduled. -Provide drug, alcohol, and sexuality education. -Reinforce use of seat belts and pedestrian safety. Taylor, Pg. 699 Chart 26-1
#4 Health Promotion Antecedents
-Knowledge of importance of Health Promotion -Knowledge of available services for Health Promotion -Access to these services -Ability to incorporate Health Promotion activities -Readiness to learn -Value health (Concept Map)
Safety Antecedants
-Knowledge of risk -Culture of Safety
Exemplars for Safety
-Standard Precautions -National Patient Safety Goals -Environmental Safety & Med Admin - (Skills)
#33 Nursing Diagnosis; Teaching (Teaching/Learning)
A nursing diagnosis is a diagnosis that relates specifically to a patient's and family's learning needs and serves as a guide in the development of the teaching plan. A teaching plan communicates the following information to all members of the nursing team: -The goals of the teaching strategies -The teaching strategies that are appropriate for goal attainment -The expected outcomes, which identify the desired behavioral responses of the learner -The critical time period within which each outcome is expected to be met -The patient's behavioral responses (which are documented on the teaching plan) -The same rules that apply to writing and revising the plan of nursing care apply to the teaching plan
#25 Science of Informatics, Advantages
According to the ANA Scope and Standards of Nursing Informatics Practice, nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in their decision making in all roles and settings. This approach uses information structures, information processes, and information technology (ANA, 2008). As more nurses have become informaticists, the tangible benefits of their efforts become clear: -Increases in the accuracy and completeness of nursing documentation -Improvement in the nurse's workflow and an elimination of redundant documentation -Automation of the collection and reuse of nursing data -Facilitation of the analysis of clinical data (Joint ----Commission indicators, core measures, federal- or state-mandated data and facility-specific data; Barthold, Duecker, Guinn, & MacCallum, 2009). Taylor, Pg. 363
#22 Fall Risk (Intervention) (Taylor 706 Box 26-5)
Complete a risk assessment. Indicate risk for falling on patient's door and chart. Keep bed in low position. Keep wheels on bed and wheelchair locked. Leave call bell within patient's reach. Instruct patient regarding use of call bell. Answer call bells promptly. Leave a night light on. Eliminate all physical hazards in the room (clutter, wet areas on the floor). Provide nonskid footwear. Leave water, tissues, bedpan/urinal within patient's reach. Document and report any changes in patient's cognitive status to the physician and other nurses at the change of shift. Use alternative strategies when necessary instead of restraints. As a last resort, use the least restrictive restraint according to agency policy. If restraint is applied, assess patient at the required intervals.
#28 Documentation: Adult Learners
Document the teaching plan as part of the nursing plan of care. Document all nursing efforts to educate the patient and family about health care management, and also document the patient's response. If a patient refuses health education or refers you to a family member (e.g., "Talk to my wife about my pills; she'll be giving them to me at home"), document this in the patient's record. If patient education greatly increases the patient's anxiety and the patient requests not to be given any more information, document the patient's initial response to teaching, the patient's request that it be stopped, and, if you complied, your reason for doing so. Because a lack of time is frequently offered as the reason for failing to document patient education, assess what type of patient documentation is performed routinely in your setting. If possible, develop forms or checklists that will facilitate rapid documentation. For example, preoperative checklists make it easy to record preoperative teaching and are often introduced as evidence in court that preoperative teaching was done. Similarly, other forms have been developed for documenting diabetic patient teaching, teaching after a myocardial infarction, and teaching postpartum and baby care to mothers. The teaching role of the nurse is discussed in Chapter 21. Taylor, Pg. 127
#7 Health Administration: Medication Administration (Teaching & Learning)
Ensure that the (1) *Right Medication* is given to the (2) *Right Patient* in the (3) *Right Dosage* (in the right form) through the (4) *Right Route* at the (5) *Right Time* for the (6) *Right Reason* based on the (7) *Right (Appropriate) Assessment Data* using the (8) *Right Documentation* and monitoring for the (9) *Right response* by the patient. Additional rights have been suggested to include (10) *The Right to Education*, ensuring that patients receive accurate and thorough information about the medication, and (11) *The Right to Refuse*, acknowledging that patients can and do refuse to take a medication.
#3 Health Promotion and the definition of Health (Taylor 49)
Health promotion is the behavior of a person who is motivated by a personal desire to increase well-being and health potential. In contrast, illness/disease prevention, also called health protection, is behavior motivated by a desire to avoid or detect disease or to maintain functioning within the constraints of an illness or disability. Taylor, Pg. 49
#6 Health Promotion & Prevention (Taylor 49-50)
Health promotion is the behavior of a person who is motivated by a personal desire to increase well-being and health potential. In contrast, illness/disease prevention, also called health protection, is behavior motivated by a desire to avoid or detect disease or to maintain functioning within the constraints of an illness or disability. Health promotion and illness prevention activities are traditionally described as occurring on primary, secondary, and tertiary levels. *RISK FACTORS* *Age:* -School-aged children are at high risk for communicable diseases. -After menopause, women are more likely to develop cardiovascular disease. *Genetic factors:* -A family history of cancer or diabetes predisposes a person to developing the disease. *Physiologic factors:* -Obesity increases the possibility of heart disease. -Pregnancy places increased risk on both the mother and the developing fetus. *Health habits:* -Smoking increases the probability of lung cancer. -Poor nutrition can lead to a variety of health problems. *Lifestyle:* -Multiple sexual relationships increase the risk for sexually transmitted infections (e.g., gonorrhea or AIDS). -Events that increase stress (e.g., divorce, retirement, work-related pressure) may precipitate accidents or illness. *Environment:* -Working and living environments (such as hazardous materials and poor sanitation) may contribute to disease. Taylor, Pg 49-50
#1 National Patient Safety Goals (Taylor 169)
In 2006, the Joint Commission National Patient Safety Goals required hospitals to implement a standardized approach to handoff communications that includes: -The handoff situation -Who is, or should be, involved in the handoff communication -Opportunities for people involved in hand-offs to ask and respond to questions -An outline for when to use certain communication techniques, such as repeat-back or read-back or the Situation-Background-Assessment-Recommendation (SBAR) technique -What print or electronic information should be available during the handoff Taylor, Pg. 169 *2018 Hospital National Patient Safety Goals* -Identify Patients Correctly -Improve staff Communication -Use medicines safely -Use alarms safely -Prevent infection -Identify patient safety risks -Prevent mistakes in surgery (Found under Modules)
#24 HIT - Advantages of Computer Documentation (Taylor 363)
Increases in the accuracy and completeness of nursing documentation Improvement in the nurse's workflow and an elimination of redundant documentation Automation of the collection and reuse of nursing data Facilitation of the analysis of clinical data (Joint Commission indicators, core measures, federal- or state-mandated data and facility-specific data; Barthold, Duecker, Guinn, & MacCallum, 2009).
#8 Patient Education (Assessment) (Taylor 479) (Taylor 127)
Patient education is the process of influencing the patient's behavior to effect changes in knowledge, attitudes, and skills needed to maintain and improve health. Research supports the fact that educated patients experience better health and have fewer complications. This results in fewer hospitalizations and emergency department, clinic, and physician visits. To be successful, patient education must be ongoing and interactive. It must also take into account the patient's plan of care, educational level, and need for care across the continuum from the hospital to home care to long-term care. Patient education plans should be developed in collaboration with the entire health care team, including members of the hospital team (e.g., dietitians, respiratory therapists, social workers, pharmacists) as well as home care agencies, wellness facilities, and long-term care agencies. The basic purpose of teaching and counseling is to help patients and families develop the self-care abilities (knowledge, attitude, skills) they need to maximize their functioning and quality of life (or to have a dignified death). For example, a patient newly diagnosed with diabetes must (1) acquire knowledge about diabetes as a disease process and related medical management and self-care; (2) value health sufficiently to make certain lifestyle modifications (attitude); and (3) master certain skills, such as insulin injection. When done effectively, teaching and counseling are powerful tools for helping patients achieve health goals. Teaching provides the knowledge that patients need to make informed health care decisions and to implement a plan of care. Taylor, Pg. 479 Also look on Pg. 127 Titled Patient Education
#38 Critical Thinking (Nursing Process) (Taylor 210)
People use critical thinking skills whenever they want to use clear, focused thinking to achieve a result. You can think critically about how to survive the day's challenges, to find a partner for life, to pass a licensing exam, or to become president! Critical thinking applied to clinical reasoning and judgment in nursing practice (Alfaro-LeFevre, 2014, p. 8): Is guided by standards, policies, and procedures, ethics codes, and laws (individual state practice acts) Is based on principles of nursing process, problem solving, and the scientific method (requires forming opinions and making decisions based on evidence) Carefully identifies the key problems, issues, and risks involved, including patients, families, and major care providers in decision making Is driven by patient, family, and community needs, as well as nurses' needs to give competent, efficient care (e.g., streamlining paperwork to free nurses for patient care) Calls for strategies that make the most of human potential and compensate for problems created by human nature (e.g., finding ways to prevent errors, using information technology, and overcoming the powerful influence of personal views) Is constantly re-evaluating, self-correcting, and striving to improve (Taylor 210)
#32 Technical Skills of Nursing Practice (Nursing Process) (Taylor 203)
Some people are naturally "good with their hands" and quickly master intricate procedures that involve working with technical equipment. Others have to practice procedures many times before they feel competent handling the equipment and performing clinical activities independently. Whatever your natural level of technical skill, developing the following habits can help you master the manual skills essential in the nursing process: -When a procedure demands manual dexterity and/or a complex series of steps, practice the necessary skill until you feel confident in your ability before attempting to perform it with a patient. -Take time to familiarize yourself with new equipment before using it in a clinical procedure. -Understand how it works and what supplies are needed to ensure optimal functioning. If possible, anticipate problems and know how to remedy them. -Identify nurses who are technical experts, and ask them to share their secrets. Many experienced clinicians have developed quality, time-saving techniques they are willing to share. -Never be ashamed to ask for help when feeling unsure of how to perform a procedure or manage equipment. Don't overlook the patient or family caregiver as a source of helpful hints for care they routinely provide. Never forget that the patient's well-being and sometimes the patient's life depend on your technical competence. Many nursing procedures are described in the clinical chapters in this text. Performance checklists break each procedure down into its component parts, allowing you to evaluate your performance of each step of the procedure. This type of self-knowledge enables you to identify quickly and remedy any deficiencies in technical skills. (Taylor 203)
#35 Nursing Process
TABLE 10-2 Overview of the Nursing Process Review Chart, Taylor, Pg. 216
#37 Patient Teaching (Nursing Process)
Teaching is a planned method or series of methods used to help someone learn. The person using these methods is the teacher. Learning is the process by which a person acquires or increases knowledge or changes behavior in a measurable way as a result of the experience. You assume the role of teacher and your patient assumes the role of learner when there are identifiable learning needs. This teacher-learner relationship is enhanced by the helping relationship (see Chapter 20), in which mutual respect and trust are established. You build on this trust by sharing information that you and your patient mutually identify as important. Like other clinical interventions, effective patient teaching demands analytic and problem-solving skills. To maximize the effectiveness of patient teaching, remember the acronym TEACH: *T:* Tune into the patient. *E:* Edit patient information. *A:* Act on every teaching moment. *C:* Clarify often. *H:* Honor the patient as a partner in the education process. Learning to be an effective teacher is a critical component of professional development. A basic understanding of the teaching-learning process helps you develop your own teaching and learning skills. The process of patient teaching, which resembles the nursing process, consists of several steps that are necessary to provide teaching and to measure learning (Box 21-2). This process is often condensed because of limited time or resources, but the basic principles apply each time teaching-learning occurs. Taylor, PG. 482
#39 Nursing Process (Hinkle 35) (Taylor 215)
The *Nursing Process* is a deliberate problem-solving approach for meeting people's health care and nursing needs. Although the steps of the nursing process have been stated in various ways by different writers, the common components cited are assessment, diagnosis, planning, implementation, and evaluation. *Assessment*: The systematic collection of data through interview, observation, and examination to determine the patient's health status as well as any actual or potential health problems (Analysis of data is included as part of the assessment. Analysis may also be identified as a separate step of the nursing process). Diagnosis: Identification of the following two types of patient problems: Nursing diagnoses: According to Carpenito (2017), "Are clinical judgments about individual, family, or community responses to actual or potential health problems/life processes" that can be managed by independent nursing interventions (p. 9). Collaborative problems: According to Carpentino (2017), "Certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using physician-prescribed and nurse-prescribed interventions to minimize the complications of the events" (p. 9). Planning: Development of measurable goals and outcomes as well as a plan of care designed to assist the patient in resolving the diagnosed problems and achieving the identified goals and desired outcomes Implementation: Actualization or carrying out of the plan of care through nursing interventions Evaluation: Determination of the patient's responses to the nursing interventions and the extent to which the outcomes have been achieved
#18 Becker's Health Belief Model (Intervention) (Hinkle 56)
The Health Belief Model was designed to foster understanding of why some healthy people choose actions to prevent illness while others do not. Developed by Becker (1974), the model is based on the premise that four variables influence the selection and use of health promotion behaviors. Demographic and disease factors, the first variable, include patient characteristics, such as age, gender, education, employment, severity of illness or disability, and length of illness. Barriers, the second variable, are defined as factors leading to unavailability or difficulty in gaining access to a specific health promotion alternative. Resources, the third variable, encompass such factors as financial and social support. Perceptual factors, the fourth variable, consist of how the person views his or her health status, self-efficacy, and the perceived demands of the illness. Further research has demonstrated that these four variables have a positive correlation with a person's quality of life (Becker, Stuifbergen, Oh, et al., 1993).
#27 Documentation
The ability to communicate clearly is a critical nursing skill. Accurate, concise, timely, and relevant documentation provides all the members of the caregiving team with a picture of the patient. The patient record is the chief means of communication among members of the interdisciplinary team. Legally speaking, a nursing action that was not documented was not performed. If accused of negligent care, a nurse might tell the court of having faithfully assessed the patient's needs, diagnosed problems, and implemented and evaluated an effective plan of care. However, unless the patient's health records contain documentation supporting these claims, the court has no reason to accept the nurse's word rather than that of the patient or family who are claiming that such care was not given.The primary reason for documentation of assessment data is to promote effective communication among multidisciplinary health team members to facilitate safe and efficient client care. Documented assessment data provide the health care team with a database that becomes the foundation for care of the client. It helps identify health problems, formulate nursing diagnoses, and plan immediate and ongoing interventions. If the nursing diagnosis is made without supporting assessment data, incorrect conclusions and interventions may result. The initial and ongoing assessment documentation database also establishes a way to communicate with the multidisciplinary team members. Weber Pg. 45
#14 Therapeutic Communication (Implementation) (Taylor 457)
The ability to communicate with patients and other nurses is essential for effective use of the nursing process. Knowledge of the communication process and effective communication techniques is fundamental to all steps of the nursing process. At the same time, the nursing process provides the guidance and direction needed to communicate with patients clearly, effectively, and compassionately. *Implementing* Nurses assume many roles when they implement the plan of care. Verbal and nonverbal communication enhance basic caregiving measures and are used to teach, counsel, and support patients and their families during the implementation phase. Even a simple nursing order, such as "encourage patient to drink 100 mL of fluid every hour while awake," requires countless messages to be sent and received between the nurse and the patient. The nurse explains the importance of an adequate fluid intake, along with the amount and frequency of intake. The patient, in turn, speaks of his or her ability or inability to meet targeted objectives. The patient's verbal and nonverbal messages are assessed during each nurse-patient interaction. The implementation of the plan of care is then documented in the patient's record. *Evaluating* Nurses often rely on verbal and nonverbal cues from patients to verify whether patient objectives or goals have been achieved. Communication, through the exchange of positive and negative messages between the nurse and the patient, also facilitates the revision of parts of the care plan. Taylor, Pg. 457
#34 Nursing Care Plan
The essential activities involved in the nursing process are assessing, diagnosing, planning, implementing, and evaluating. The nursing process is used by the nurse to identify the patient's health care needs and strengths, to establish and carry out a plan of care to meet those needs, and to evaluate the effectiveness of the plan to meet established outcomes. The nursing process allows nurses to use critical thinking and clinical reasoning when providing care that is individualized and holistic, and to define those areas of care that are within the domain of nursing.
#26 Rosenstock; Health Beliefs (Taylor 52) (Taylor 490)
The health belief model (Rosenstock, 1974) focuses on what people perceive or believe to be true about themselves in relation to their health. This model is based on three components of individual perceptions of threat of a disease: (1) perceived susceptibility to a disease, (2) perceived seriousness of a disease, and (3) perceived benefits of action. (Taylor 52) A patient's health beliefs can have great influence on *motivation*. The health belief model identifies several health beliefs as critical for patient motivation (Rosenstock, 1974). *Motivation* is enhanced when: Patients view themselves as susceptible to the disease in question Patients view the disease as a serious threat Patients believe there are actions they can take to reduce the probability of contracting the disease Patients believe the threat of taking these actions is not as great as the disease itself (Taylor 490)
#5 Health Promotion: Older Adult (Taylor 438) (Taylor 439 Chart 19-7)
The nurse should teach the patient and family general health-promotion activities. This is important because older people often believe themselves "too old" to worry about nutrition, exercise, health screenings, and immunizations. In addition to the recommended screenings, examinations, and immunizations outlined in Table 19-1, the following should be emphasized: -Eat a diet that includes all food groups; is low in fat, saturated fat, and cholesterol; balances calories with physical activity; has recommended amounts of fruits, vegetables, and grains; and uses sugar and salt in moderation. -Make exercise a part of daily activities. -Multiple studies have demonstrated that regular aerobic exercise can reduce the risk for dementia and that resistance training may improve cognition (Brauser, 2012). -Discuss with your primary physician whether to include a vitamin D supplement as part of your daily routine. Vitamin D is considered moderately beneficial for helping prevent hip fractures and other broken bones in older adults (CDC, 2012a; Lehne, 2013). -Drink alcohol in moderation. -Do not smoke. Taylor, Pg. 438 Also, Look on Pg. 439,Chart 19-7
