fundamentals CH 15
physician-initiated interventions or dependent nursing actions
carrying out physician-prescribed orders
Implementing
carrying out the plan of care
Assessing
collection, validation, and communication of patient data
Evaluating -purpose
continue, modify, or terminate nursing care
Nursing process assessment data are documented TIMELY
current date recorded for the team
A nursing diagnosis is not
diagnostic tests, treatments, equipment (fasting blood glucose, insulin therapy, etc)
Intuitive problem solving
direct understanding of a situation based on a background of experience, knowledge and skill that makes expert decision making possible -should validiate intuitions
Nursing Process is Systematic
each nursing activity is part of an ordered sequence of activies; each activity depends on the accuracy of the activity that precedes it and incluences the actions that follow it
standing orders
empower the nurse to initiate actions that ordinarily require the order or supervision of a physician
A student nurse is performing a sterile dressing change on a patient's abdominal incision. While establishing her sterile field, the nurse drops her forceps on the floor and is unable to continue w/ the dressing change b/c she has no extra supplies in the room and no one in the room to assist her by bringing new forceps. THe student has failed to organize:
equipment and personnel
Evaluating -activities
identify factors that contribute to patient's sucess or failure
Evaluating
identify factors that positively or negatively influence outcome achievement -revise plan of care if needed
unlicensed assistive personnel
individuals who are trained to function in an assistive role to the licensed registered nurse (RN) in the provision of patient activities as delegated by and under supervision of the registered professional nurse.
nurse-initiated interventions, or independent nursing actions
involve carrying out nurse-prescribed interventions resulting from their assessment of patient needs written on the nursing plan of care, as well as any other actions that nurses initiate without the direction or supervision of another healthcare professional.
Assessing -Purpose
make a judgement of patient's health status, ability to manage healthcare, need for nursing
Evaluating -activities
measure how well patient achieved desired outcomes
Evaluating
measuring how patient met outcomes specified in plan of care
Evaluating -activities
modify plan of care if needed
collaborative interventions, or independent nursing actions
performed jointly by nurses and other members of the healthcare teams
Assessing -Purpose
plan individualized holistic care draws on patient's stregths and responsice to changes in patient's conditions
evidence-based practice (EBP)
problem-solving approach to making clinical decisions, using the best evidence available (collected from published research, national standards and guidelines)
nursing
protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering and advocay in the care of individuals, families and communities and populations
Domains of Critical thinking -Empirical dimension
reasoning can only be as sound as the evidence it is based on
Domains of Critical thinking -Implications & consequences
significance of implications
Scientific problem solving
systematic, seven step problem solving process -problem identification -data collection -hypothesis formation -plan of action -hypothesis testing -interpretation of results -evaluation
Nursing process assessment data are documented COMPLETELY
systemtatic guide that ensures recorded data describe patient's functional ability to meet each basic human need and responses to health and illness
Trial and error problem solving
testing any # of solutions until one is found that works for that particular problem
A nursing diagnosis is not
therapeutic nursing goals (develop diabetic self-care behaviors)
A nursing diagnosis is not
therapeutic patients needs (needs to exercise)
Domains of Critical thinking -Question at issue or central problem
to settle a question, you must understand what it requires
Delegation
transfer of responsiblity for the performance of an activity to another individual while retaining accountability for the outcome.
Assessing -Data Collection
use assessment, critical thinking, intuitive reasoning skills
Protocols
written plans that detail the nursing activities to be executed in specific situations
Outcome identification & planning -Activities
-Establish priorities -Write outcomes, develop evaluative strategy
Diagnosing -Activities
-Formulate and validate nursing diagnoses -Develop prioritized list of nursing diagnoses
Diagnosing -Activities
-Interpret and analyze patient data -Identify patient strengths and health problems
Characteristics of the Nursing Process
-Systematic -Dynamic -Interpersonal -Outcome Oriented -Universally Applicable in Nursing Situations
Examples of standing orders
-admission protocols for obstetric and gynecology patients
Implementing -activities
-carry out the plan of care -continue data collection and modify plan of care as needed -document care
Domains of Critical thinking -Assumptions
-clarity of assumptions -justifiability -consistency
Domains of Critical thinking -Purpose
-clarity of purpose -significance of purpose -achievability of purpose -consistency of purpose
Domains of Critical thinking -Concepts and ideas
-clear -relevant -depth of concepts
Outcome identification & planning -Purpose
-develop individualized plan of nursing care -identify patient strengths to facilitate achievement of desired outcomes
A nursing diagnosis is not
-medical diagnosis (diabetes mellitus-it's a medical illness)
A nursing diagnosis is not
-medical pathology (hypoglycemia)
Outcome identification & planning -Activities
-select nursing interventions -communicate plan of nursing care
A registered nurse who provides care in a subacute setting is responsible for overseeing and delegating to unlicensed assistive personnel (UAP). Which of the following principles should the nurse follow when delegating to UAP?
-take frequent mini-reports from UAPs to ensure changes in patient status are identified -know what clinical cues the UAP should be alert for and why -make frequent walking rounds to assess patients
Domains of Critical thinking -Purpose-Problems
-unclear purpose -trivial purpose -unrealistic purpose -contradictory purpose
Evaluative statement
6/8/12-goal partially met; patient refused to ambulate in the morning but did walk to the bathroom once in the afternoon w/ assistance of one nurse. Recommendation: Review reason for progressive ambulation w/ patient; assess motivation to increase independence.
Maslowe's Hierarchy 5. Self-actualization Needs
Accomplishments
Planning -Formulate nursing diagnosis (NANDA)
Actual -Existing presently
Types of Nursing Diagnosis
Actual Potential Risk for... Possible...
Approved Diagnoses:
Acute Pain Chronic Pain Nausea
Which of the following nursing interventions is most likely to be allowed within the parameters of a protocol or standing order?
Administering a glycerin suppository to a constipated patient who has not responded to oral stool softeners
An elderly patient w/ a diagnosis of pneumonia is producing large amounts of secretions w/ his cough and is occasionally gurgling when he breaths. The nurse has responded by increasing the height of the patient's bed and suctioning the patient's mouth. THe nurse has most likely performed which of the following?
An independent nursing action
Evaluation
Analysis -Assessment Goal met or unmet -Revision as appropriate
Diagnosing
Analysis of patient data to identify patient strengths, health problems that independent nursing intervention that prevent or resolve
Maslowe's Hierarchy 4. Self-esteem Needs
Appearance, feelings of confidence
Steps in Nursing Process
Assessing -Data Collection
Maslowe's Hierarchy 2. Safety/Security Needs
Assistive devices, psychological/emotional care
Problem (formulation of a nurisng diagnoses statement)
Bathing/Hygiene Self-care deficit r/t -identifies what is unhealthy about the patient (need for change)
Examples of goals/outcomes -Impaired Physical mobility
Before discharge, patient will ambulate length of hallway independently
Examples of goals/outcomes -Imbalanced nutrition more than body requirements
By 12/6/12, patient will reach target weight of 122 lb
Verbage for Nursing Diagnosis
Characteristics -Data collected
Planning -Formulate nursing diagnosis (NANDA)
Collaborative Complications -Related or in relation to a comorbidity
Nursing Practice
Complex Holistic Collaborative Nursing Process
A staff nurse has asked you, a nursing student, to perform an intervention that you have not been trained to perform. What is the appropriate approach to take?
Consult w/ your nursing instructor before performing the procedure
Assessing -Activities
Continously update the database Validate data Communicate data
Diagnosing -Purpose
Develope a prioritized list of nursing diagnoses
Data Validation
Discrepancy Clarification
Mrs. Still is an 89-year-old woman who has been admitted to the hospital w/ a diagnosis of failure to thrive. She has become constipated in recent days, in spite of maintaining a high fluid intake and taking oral stool softeners. She admits to her nurse that the problem is rooted in the fact that she feels mortified to attempt a bowel movement on a commade at her bedside where staff and other patients can hear her.
Environment
Assessing -Activities
Establish database: -Nursing history -Physical assessment -Review patient record -Consult w/ patient's support people and healthcare professionals
Steps in Nursing Process
Evaluation -Reflection and Analysis
An elderly patient is receiving care on a rehab medicine unit during her recovery from a stroke. She complains that the physical therapist, occupational therapist, neurologist, primary care physician, and speech language pathologist, "don't seem to be on the same page " and that "everyone has their own plan for me." How can the nurse best respond to the patient's frustration?
Facilitate communication between the different professionals and attempt to coordinate care
Maslowe's Hierarchy 3. Love and Belonging Needs
Family/significant other relationships
Etiology
Fear of falling in the tub and obesity as manifested by -identifies factors that are maintaining the unhealthly response-causitive factors
Diagnosing
Focus on "need for nursing care" as opposed to "need for physician or therapy care"
Maslowe's Hierarchy 1. Physiological Needs
Food, oxygen, elimination, warmth, comfort
Planning
Formulate nursing diagnosis (NANDA)
Components of a NANDA nurisng diagnoses
Imbalanced nutrition: More than body requirements
Steps in Nursing Process
Implementation - Nursing/Healthcare Team Driven -Intervention
Types of Assessment
Initial Admission Assessment Focused Assessment
A nurse has delegated a task to an unlicensed assistive personnel (UAP) member. How will this nurse assure that this UAP understands the instructions to perform this task?
Instruct the UAP to repeat your instructions to be sure you have communicated clearly
Nursing process assessment data are documented CONCISELY
Irrelevant data and meaningless generalizations are avoided
The nurse ascertains that a patient is failing to follow the plan of care that was collaboratively developed. Further investigation determines that the plan of care is not appropriate for this patient. What is the nurse's next step in correcting this problem?
Making changes in the plan of care based upon assessment data
The organization of nursing care on a medical unit is structured according to the Nursing Interventions Classification (NIC) taxonomy. According to the NIC, which of a nurse's following actions would be classified as a Domain II (Physiologic: Complex) intervention?
Managing a patient's supplementary oxygen
Implementation
Nurse initiated Physician initiated Collaboratively initiated
A patient is being prepared for discharge to his home will require several interventions in the home environment. The nurse informs the discharge planning team, consisting of a home healthcare nurse, physical therapist, and speech therapiset, of the patient's discharge needs. This interaction is an example of which professional nursing relationship?
Nurse-healthcare team
Implementation
Nursing focused "Nurse will ..."
Which of the following would you expect to find in the Nursing Interventions Classification Taxonomy?
Nursing interventions, each with a label, a defininition and a set of activities that a nurse performs to carry it out, with a short list of background readings.
Nursing process assessment data are documented FACTUALLY
Patient behaviors are recorded rather thatn the nurse's interpretation of these behaviors
Goal Setting
Patient focused Specific Action verb
Goals or Outcomes
Patient focused, measurable, time limited
Data Collection Sources
Patient, Family, Significant Other Patient Record
A school nurse notices that Jill is losing weight and wants to perform a focused assessment on Jill's nutritional status, fearing that she might have an eating disorder. How should the nurse proceed?
Perform the focused assessment. This is an independent nurse-initiated intervention.
Implementation
Pertinent to specific goal Supported by scientific literature
The nurse administered acetaminophen 650 mg to a patient complaining of a headache after reviewing the medication orders of the patient's chart. THis is an example of which type of nursing intervention?
Physician-initiated intervention
A patient with suspected metastases of her breast cancer is extremely anxious while she awaits the results of her last computed tomography (CT) scan. The nurse has administered a sublingual benzodiazepine to treat her acute anxiety and has engaged the patient in a therapeutic dialogue in an effort to alleviate her stress. Which of the following Nursing Interventions Classification (NIC) domains has the nurse utilized?
Physiologic; Complex; Behavioral
Steps in Nursing Process
Planning - Patient Driven -Diagnosing Nursing Problems -Prioritizing -Goal Setting (Outcomes)
Planning -Formulate nursing diagnosis (NANDA)
Potential -Possibly developing
Domains of Critical thinking Purpose
Principle: all reasoning has a purpose
Verbage for Nursing Diagnosis
Problem -Identified concern
After learning about a patient's limited financial resources and limited insurance benefits, the home care nurse modifies nursing interventions related to a patient's care instructions. The nurse modifies the plan of care based upon which patient variable?
Psychosocial background
Many of the homeless patients who are supposed to receive care for HIV/AIDS miss their appointments at a clinic b/c it is located in a high-rise building on a university campus. Several of the patients state that the clinic is difficult to find and in an intimidating environment. THis demonstrates that which of the following variables influencing outcome achievement is being inadequately addressed?
Psychosocial background of patients
Nursing process assessment data are documented ACCURATELY:
Questionable data validated
Approved Diagnoses:
Readiness for Enhanced Comfort Impaired Comfort Social Isolation
Evaluation
Reflection on action
Verbage for Nursing Diagnosis
Related to, or Manifested by, or Evidenced by
A graducate nurse recently attended a conference on acute coronary syndrome. In preparing a plan of care for a patient admitted w/ acute coronary syndrome, the nurse considers the info. she learned at the conference. Which nursing variable is the nurse utilizing in the development of the plan of care?
Research findings
Goals or Outcomes
Short term -Minutes/hours, days Long term -week
Outcome identification & planning
Specification of patient outcomes to prevent, reduce, or resolve the problems identified in the nurisng diagnoses & related nursing identifications
Defining characteristics
Strong body and urine order, unclean hair -identify subjective and objective data that signal existence of problem (cues that reflect existence of problem)
A 30-year-old male patient is postoperative day 2 following a nephrectomy (kidney removal) but has not yet mobilized or dangled at the bedside. Which of the following is the nurse's best intervention in this patient's care?
Teach the patient about the benefits of early mobilization and offer to assist him.
You are a brand new RN. When you orient to a new nursing unit that is currently understaffed, you are told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response?
Tell the charge nurse that you are choosing not to delegate the admission assessment at this time until you can get further clarification from admission.
Implementation of the plan of care is most succesful when:
The nurse includes family members and other healthcare professionals
The American Nurses Association recommends adherence to defined principles when delegating care tasks to unlicensed assistive personnel. According to these principles, who is responsible and accountable for nursing practice?
The registered nurse
Implementation
Therapy, dietary, pharmacy etc.
Goal Setting
Time limited Measurable
Which of the following skills is appropriate for unlicensed assistive personnel to perform?
Transferring the patient from bed to chair
Examples of goals/outcomes -Pain
W/in 8 hours, patient will report pain is absent or diminished
Nursing Interventions Classification (NIC)
a report of research to construct a taxonomy of nursing interventions, each has a level, definition, and set of activities the nurse performs to carry out the intervention, and a short list of background readings
A nursing diagnosis is not
a single sign or symptom (based on pattern of clusters)
nursing intervention
any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes
Implementing step of nursing process
assist patient in achieving valued health outcomes: promote health, prevent disease and illness, restore healht, and facilitate coping with altered function
Implementing -purpose
assist patients to achieve desired outcomes -promote wellness, prevent disease and illness, restore health, and facilitate coping w/ altered functioning
The Joint Commission requires that care
be documented according to the nursing process
Domains of Critical thinking -Point of view
better reasoning when multiple, relevant points of view sought