objectives chapter 10 & 8 Essentials for Nursing

when describing behaviors or moods of clients, the nurse must choose to?

chart behaviors that are measurable, observable, or stated

acuity level

classification used to compare one or more patients with another group of patients. An acuity system classifies patients from 1 (independent in all but one or two aspects of care; almost ready for discharge) to 5 (totally dependent in all aspects of care; requiring intensive care). Using this system, a patient returning from surgery requiring frequent monitoring and extensive care has an acuity level of 3 compared with another patient awaiting discharge after a successful recovery from surgery who has an acuity level of 1. Accurate acuity ratings justify the number and qualifications of staff needed to safely care for patients. The patient-to-staff ratios established for a unit depend on a composite gathering of 24-hour acuity data for all patients receiving care.

password

collection of alphanumeric characters and symbols that a user types into a computer sign-on screen before accessing a program after the entry and acceptance of an access code or user name. Strong passwords use combinations of letters, numbers, and symbols that are difficult to guess. When using a health care agency computer system, it is essential that you do not share your computer password with anyone under any circumstances.

firewall

combination of hardware and software that protects private network resources (e.g., the information system of the hospital) from outside hackers, network damage, and theft or misuse of information.

incident report

completed whenever an incident occurs. Incident reports are an important part of the quality improvement program of a unit or agency; however, they are not part of the health care record. Incident reports contain confidential information; distribution of the report is limited to the individuals responsible for reviewing the forms

identify the level of critical thinking demonstrated by each of the following-analyzing and examining problems more independently

complex

Examples of critical thinking attitudes: preforming a skill safely and effectively

confidence

EHR and EMR are frequently used interchangeable

contains patient data gathered in a health care setting at a specific time and place and is part of the EHR. The EHR is a digital version of patient data found in traditional paper records. The term EHR is increasingly used to refer to a longitudinal (lifetime) record of all health care encounters for an individual patient. To meet agreed-on standards, EHRs are expected to have the following attributes or component

the nurse on a medical unit in an acute care facility are meeting to select a documentation format to use. they recognize that less fragmentation of patient data will occur if they implement

critical pathways

Curiosity.

critical thinker's favorite question is "Why?" As you care for a patient, you learn a lot of information. As you analyze this patient information, data patterns begin to emerge. Patterns may be unclear, new to you, or very unusual. Curiosity motivates you to question further, investigate the clinical situation in all possible directions, and obtain all the information needed to make a decision.

What does DAR stand for?

data, action, response

Specific Critical Thinking Competencies Diagnostic Reasoning and Inference

depends on your state of readiness to apply critical thinking (Levett-Jones et al., 2010). You must be committed to doing diagnostic reasoning well. It is influenced by your attitudes, philosophical perspective, and preconceptions about nursing.As you collect information about a patient in a clinical situation, diagnostic reasoning begins. It is the analytical process for determining a patient's health problems. You must accurately recognize a patient's health problems before you choose solutions and implement actions.

acuity ratings

determine the hours of care and number of staff required for a given group of patients every shift or every 24 hours. A patient's acuity level, usually determined by assessment data an RN enters into a computer program, is based on the type and number of nursing interventions (e.g., IV therapy, wound care, or ambulation assistance) required by that patient over a 24-hour period.

The nurse identifies in the acronym method, Discharge planning guide the d stands for?

diet instructions

Flow sheets (graphic records)

document routine activities such as daily hygiene care, vital signs, and pain assessments. You need to describe these data in greater detail when they are relevant such as when a change in functional ability or status occurs.

Patient Care Summary

document that you review and sometimes print for each patient at the beginning and/or end of each shift to use as a worksheet for organizing care and in giving hand-off report. The document automatically updates and provides the most current information that was entered into the EHR

charting by exception (CBE)

early 1980s, and although the philosophy behind the method has consistently raised professional concern (Kerr, 2013), many computerized nursing documentation systems currently use a CBE design. Exception-based documentation systems incorporate standards of care and interventions and use clearly defined criteria for nursing assessment and documentation of "normal" findings. These predefined statements used to document nursing assessment of body systems are called "within defined limits" (WDL) or "within normal limits" (WNL) definitions. They consist of written criteria for a "normal" assessment for each body system. Automated documentation within a computerized documentation system allows nurses to select a WDL statement or to choose other statements from a drop-down menu that allow description of any unexpected assessment findings or assessment findings that deviate from the WDL definition

Discharge Summary Forms

ensure cost-effective care and appropriate reimbursement by preparing patients for a safe, effective, and timely discharge from a health care institution. Developing a comprehensive plan for a safe discharge relies on interprofessional discharge planning. This process includes the identification of key clinical outcomes and appropriate timelines for reaching them, the appropriate level of care for discharge, and all necessary resources. Ideally discharge planning begins at admission. Involve the patient and family in the discharge planning process so they have the necessary information and resources to return home or move to the next level of care. Discharge documentation includes medications, diet, community resources, follow-up care, and the name of a person to contact for questions or in case of an emergency. All this information is included in a discharge summary document that is printed out and given to the patient on discharge.

Documentation of Telephone Reports, Telephone Orders, and Verbal Orders

every phone call you make to a health care provider. Your documentation needs to include when the call was made, the number called, who made the call (if you did not make the call), who was called, to whom information was given, what information was given, and what information was received.

Standardized Care Plans

facilitates safe and consistent care for an identified problem by describing or listing institutional standards and evidence-based guidelines that are easily accessed and included in a patient's EHR. After completing a nursing assessment, the nurse identifies and selects the standardized plans that are appropriate for the patient and are to be included in an individualized plan of care within the EHR. Most computer documentation systems allow these care plans to be modified by creating individualized interventions, goals, and outcomes for each patient.

a nurse believes that substance abuse is a serious problem with negative consequences for patients and families. the nurse however provides excellent care to a patient who is admitted with this problem the nurse is displaying the critical thinking attitude of

fairness

incident or occurrence reports should be documented in the patients medical record in the nurse narrative notes section

false

narrative documentation

format traditionally used by nurses and health care providers to record patient assessment, clinical decisions, and care provided. It simply uses a story-like format to document information. In an electronic nursing information system, this is accomplished through use of free text entry or menu selections (Hebda and Czar, 2013). Narrative documentation sometimes is time-consuming and repetitious. It requires the reader to sort through information to locate desired data. However, some nurses believe that in certain situations use of this method provides better detail of individual patient assessment findings and/or complex patient situations

Being disciplined and thorough in gathering information

helps you identify problems more accurately and select the most appropriate nursing interventions. Disciplined thinking does not lessen your creativity but rather ensures that your decision making is systematic, accurate, and comprehensive.

PHI includes health information

identifies the individual such as demographic data; facts that relate to an individual's past, present, or future physical or mental health condition; provision of care; and payment for the provision of care

which of the following are the correct nursing actions for a telephone order?

identifying the mr. j is in room 212 checking that 40 mg of the drug is the amount that should be given identifying "TO" telephone order in the nurse's notes having MR. J doctor cosign the order within 24 hrs.

Documentation is important

if you didn't document it, you didn't do it

having worked for a number of years in the acute care environment, a nurse achieved the ability to use a complex level of critical thinking. The nurse

implements creative and innovative options

meaningful use of health information technology (HIT)

improve the quality and value of health care (HITECH, 2017). Although the goal set by ARRA that all health care records would be kept electronically by 2014 has not yet been fully met, the adoption of EHRs has accelerated rapidly since the passage of HITECH

clinical information system (CIS)

includes monitoring systems; order entry systems; and laboratory, radiology, and pharmacy systems. A monitoring system includes devices that automatically monitor and record biometric measurements (e.g., vital signs, oxygen saturation, cardiac index, stroke volume) in acute care, critical care, and specialty care areas. Some of these devices electronically send measurements directly to a nursing documentation system, decreasing nursing workload.

Intuition

inner sensing that something is so

in employing critical thinking, the first step that the nurse should take is:

interpretation

Focus Charting

involves the use of DAR notes: • D: Data (both subjective and objective) • A: Action or nursing intervention • R: Response of the patient (i.e., evaluation of effectiveness). • DAR notes address patient concerns such as a sign or symptom, condition, nursing diagnosis, behavior, significant event, or change in a patient's condition. • Example of focus charting note: • D: Patient stated, "My leg is so swollen. I'm worried about this blood clot. Do you know how they are going to treat it?" • A: Provided brochure on anticoagulation therapy for DVT. Explained rationale for bed rest and daily blood tests to check anticoagulation levels. Explained that heparin infusion will be stopped when PT/INR is therapeutic on warfarin. • R: Able to teach back and verbalized that heparin infusion will be stopped when his PT/INR reaches therapeutic levels on warfarin and that he can expect to take warfarin for approximately 6 months after discharge until DVT is fully resolved.

clinical judgement

is a conclusion about a patient's needs, concerns, or health problems and/or the decisions to take or avoid action, use or modify standard approaches, or improvise new approaches based on the patient's response (Tanner, 2006)

critical thinking

is a continuous process characterized by open-mindedness, continual inquiry, and perseverance combined with a willingness to look at each unique patient situation and identify the assumptions that are true and relevant. Critical thinking includes recognizing an issue (e.g., patient problem), analyzing information related to the issue (e.g., clinical and historical data about the patient), evaluating information (including assumptions and evidence), and drawing conclusions. An effective nurse engages in critical thinking by fully assessing a patient's health condition (see Chapter 9), meaning that a nurse learns as much as possible about the patient from many sources to form a clear holistic view of a patient's problems and the approaches for resolving them. Critical thinking allows you to focus on the important issues at hand in any clinical situation and make decisions that produce desired outcomes

interprofessional plan of care

is the means of achieving consensus on desired patient and/or population health outcomes

Documentation in Home Care Settings

laptop and tablet computers makes it possible for home health care records to be available in multiple locations (i.e., the patient's home and the home care agency), improving accessibility to information and facilitating interprofessional collaboration. Medicare has specific guidelines to establish eligibility for home care reimbursement. Information used for reimbursement is gathered from documentation of care provided in the home care setting. Documentation is both the quality control and the justification for reimbursement from Medicare, Medicaid, or private insurance companies. Information in the home care health care record includes patient assessment, referral and intake forms, the interprofessional plan of care, a list of medications, and reports to third-party payers. Nurses must document all their services for payment (e.g., direct skilled care, patient teaching, skilled observation, and evaluation visits) (TJC, 2017).

clinical inferences

learn to draw conclusions from related pieces of patient data and previous experience with similar evidence. An inference is a conclusion the nurse draws from data before making a nursing diagnosis

a nurse is working in a facility that uses computerized documentation of patient information. to maintain patient confidentially with the use of computerized documentation the nurse should

log off the file or computer when not using the terminal

Creativity

means you find solutions outside of the standard routines of care while still following standards of practice. Creativity helps you think of new options and approaches. A patient's clinical problems, living environment, and social support systems are just a few factors that can make the simplest nursing procedure more complicated.

accreditation standards

minimize liability. Health care organizations usually incorporate accreditation standards into policies and revise documentation systems and forms to suit these standards. Current documentation standards require that all patients admitted to a health care agency be assessed for physical, psychosocial, environmental, self-care, spiritual, cultural, knowledge level, and discharge planning needs. Your documentation needs to demonstrate application of the nursing process, describe clinical decision making, and include evidence of patient and family teaching and discharge planning (TJC, 2017). In addition to HIPAA standards, health care documentation is affected by standards from state and federal regulatory agencies, the Department of Justice, and CMS.

case management

model of delivering care incorporates an interprofessional approach to documenting patient care.

Quality nursing documentation

necessary to enhance efficient, individualized patient care and has five important characteristics: factual, accurate, current, organized, and complete. According to Beach and Oates (2014), it is easier to maintain these characteristics in your documentation if you continually seek to express ideas clearly and succinctly by doing the following: • Stick to the facts • Write in short sentences • Use simple, short words • Avoid the use of jargon or abbreviations

Telephone Reports.

needs to include clear, accurate, and concise information. TJC reported that in 2011 verbal and written communication among staff and with patients was listed as one of the 10 most frequently identified root causes of medical errors, also called sentinel events (TJC, 2012). To improve communication, some institutions use SBAR (Situation-Background-Assessment-Recommendation), a communication strategy designed to improve patient safety (see Chapter 11). SBAR standardizes telephone communication of significant events or changes in the patient's condition.

confident is to feel secure in your ability

not confident in performing a nursing skill, you become anxious. This anxiety prevents you from attending to a patient, and this anxiety can be perceived by your patient. Always be aware of the extent and limits of your knowledge. If you have a question about a procedure, discuss it with your nursing instructor or preceptor first before performing the procedure on a patient. Patient safety is always the top priority.

Critical Thinking Model

nursing judgment that is relevant to nursing problems in a variety of health care settings. The model includes five elements of critical thinking in nursing judgment: competence (e.g., problem-solving and clinical decision-making ability), knowledge, experience, attitudes, and standards (intellectual and professional). The five model elements combine to guide nurses in making clinical decisions leading to safe, effective nursing care

Telephone Orders

occur when a health care provider gives therapeutic orders over the phone to an RN.

Verbal orders (VOs)

occur when a health care provider gives therapeutic orders to an RN while they are standing in proximity to one another. Use of VOs is discouraged except in urgent or emergent situations. TOs and VOs usually occur at night or during emergencies; they should be used only when absolutely necessary and not for the sake of convenience. In some situations, it is wise to have a second person listen to TOs; some agency policies require it. Check your agency's policy.

Omaha System clinical assessments consists

of three components, Problem Classification Scheme, Intervention Scheme, and Problem Rating Scale for Outcomes, and provides a useful model for comprehensive evaluation of nursing care and evaluates the quality of nursing care provided in the home care setting (Allender et al., 2014).

Clinical Decision Making.

or reasoning is a problem-solving activity that involves diagnostic reasoning as well as deciding on the appropriate therapeutic actions specific to a patient's situation and wishes. requires problem solving and reasoning so you can choose the options that produce the best patient outcomes based on a patient's condition and priority of the problem.

Reports

oral, written, or audiotaped exchanges of information between members of the health care team. A report reflects a summary of activities or observations seen, performed, or heard by the health care provider. Common reports given by nurses include hand-off reports, change-of-shift reports, and transfer reports.

which goal is written correctly?

patient will use IS 3x hour

Documentation in Long-Term Care Settings

patients receive 24-hour-a-day care including housing, meals, specialized (skilled) nursing care, and treatment services, and long-term care facilities, in which patients with chronic conditions receive 24-hour-a-day care including housing, meals, personal care, and basic nursing care. Requirements for documentation in these facilities are governed by individual state regulations, TJC, and CMS. CMS mandates use of the Resident Assessment Instrument (RAI), which includes the Minimum Data Set (MDS) and the Care Area Assessment (CAA) to document data in long-term care facilities. MDS assessment forms are completed on admission and then periodically within specific guidelines and time frames for all residents in certified nursing homes

the medical record serves primarily as a?

permanent account of a pt's health problemscare, and progress

a problem oriented medical record includes which of the following

progress notes database problem list care plan

abbreviations carefully to avoid misinterpretation

promote patient safety. TJC (2015) developed a list of "do not use" abbreviations that is used by all health care providers to promote patient safety. In addition, TJC requires that health care institutions develop a list of standard abbreviations, symbols, and acronyms to be used by all members of the health care team when documenting or communicating patient care and treatment. To minimize errors, spell out abbreviations in their entirety when they become confusing.

Integrity.

question and test their own knowledge and beliefs against the knowledge and beliefs of others (Papathanasiou et al., 2014). This shows a willingness to admit and understand inconsistencies between one's own beliefs and the beliefs of other colleagues. Your integrity as a nurse builds trust in you from your co-workers. Nurses face many dilemmas in everyday clinical practice (e.g., organizing care for multiple patients, choosing the correct size of a urinary catheter for a patient, being unable to respond to a patient's nurse call system while changing a different patient's wound dressing). Everyone occasionally makes a mistake or omits care activities. A person of integrity is honest and willing to admit to any mistakes or inconsistencies in his or her performance, behavior, and beliefs. A professional always tries to follow the highest standards of nursing practice.

Critical thinking is a reasoning process

reflect on and analyze your own thoughts, actions, and knowledge and use this information to make decisions about patient care. To be a good critical thinker, you must know patients and have the dedication and desire to grow intellectually. As a beginning nurse, you must learn the steps of the nursing process and combine them with the elements of critical thinking (Fig. 8.3). These two processes go hand in hand in making clinical decisions.

in using the critical thinking skill of self-regulation a nurse will

reflect on his or her own experience and improve performance

Assessment using the Outcome and Assessment Information Set (OASIS) clinical assessments care home care

required for all patients age 18 years and older (with the exception of prenatal or postnatal patients) who are receiving skilled care through a home health agency that is reimbursed by Medicare or Medicaid (Shang et al., 2015). OASIS includes a comprehensive admission assessment and calculates clinical, functional, and service scores to provide justification for reimbursement of services (Allender et al., 2014).

Responsibility and Accountability.

responsible for correctly performing nursing care activities consistent with standards of practice. Standards of practice are the minimum acceptable level of performance needed to ensure high-quality care. For example, you do not take shortcuts or workarounds when you administer medications to a patient (e.g., failing to identify a patient or preparing medication doses for multiple patients at the same time). You are responsible for following the "six rights" of medication administration

orientation for new nurses begins. The instructor assembled information on critical thinking and nursing approaches. The instructor recognizes that critical thinkers in nursing

review data in a organized manner

a nurse has an extremely large patient assignment this evening and begins to feel overwhelmed. of the following, what is the nurse's priority activity

reviewing the overall assignment to get his or her bearings

which of the following statements are accurate regarding critical thinking attitudes?

risk-taking is not desirable in patient care personal feeling should not be allowed to influence delivery of care all sides of each situation should be considered

a nurse caring for a patient who is experiencing a respiratory disorder. intuition is a part of the critical thinking process for the nurse. while caring for the patient the nurse demonstrates intuition by

sensing that the patient is not doing as well as this morning

a nurse is caring for a patient who is experiencing a respiratory disorder. Intuition is a part of the critical thinking and nursing approaches. The instructor recognizes that critical thinkers in nursing

sensing that the patient is not doing as well as this morning

Diagnostic reasoning

series of clinical judgments that result in informal of formal diagnoses

POMR (problem oriented medical record)

system of organizing documentation that places primary focus on patients' individual problems. Data are organized by problem or diagnosis. Ideally each member of the health care team contributes to one interprofessional list of identified patient problems, which coordinates a common plan of care. Some EHR systems are organized using POMR components. The POMR has the following major sections: database, problem list, care plan, and progress notes.

Decision Making.

the endpoint of critical thinking that leads to problem resolution. Decision-making focuses on resolving a problem. Following a set of criteria helps you make a thorough and thoughtful decision. The criteria may be personal, may be based on an organizational policy, or, in the case of nursing, may be based on a professional standard. This process leads to informed conclusions that are supported by evidence and reason. Decision-making goes hand in hand with problem-solving.

for a written report to be accurate, a nurse recognizes it must include which of the following?

the nurse's objective observation

which of the following are correct statements regarding standardized care plan?

they facilitate safe and consistent care for an identified problem evidence-based guidelines are able to be accessed institutional standards may be described

electronic health record (EHR)

traceable through user log-in information. It is unethical to view medical records of other patients, and breaches of confidentiality will lead to disciplinary action by employers and potentially dismissal from work or nursing school. To protect patient confidentiality, you must ensure that any electronic or written materials you use in your student clinical practice do not include patient identifiers (e.g., name, room number, date of birth, demographic information). Never print material from an EHR for personal use; any information printed must be for professional use only and should not include identifiable information.

Professional Standards.

tries to achieve are the standards cited in Nurse Practice Acts, institutional practice guidelines, and standards of practice of professional organizations (e.g., the ANA Scope and Standards of Practice [http://www.nursingworld.org/scopeandstandardsofpractice]). These standards raise the bar for the responsibilities and accountabilities that nurses assume in guaranteeing quality health care to the public.

HIPAA requires providers to notify patients of privacy policies

true

patients have the right to request copies of their medical records and read the information

true

poor written and verbal communication has been one of the top 10 reasons for sentinel events

true

during the process of reflection what is the most appropriate question for a nurse to ask himself or herself?

what could I have done differently

Variances

when the activities on the critical pathway are not completed as predicted or a patient does not meet the expected outcomes. Variances sometimes result from a change in a patient's health or because of other health complications not associated with the primary reason for which a patient requires care. Once you identify a variance, you modify the patient's care to meet the needs associated with the variance. A positive variance occurs when a patient makes progress faster than expected (e.g., use of a Foley catheter is discontinued a day earlier than anticipated). An example of a negative variance is when a patient develops pulmonary complications after surgery, requiring oxygen therapy and monitoring with pulse oximetry. All variances to expected outcomes are documented on the critical pathway document

medical record

which may be electronic, paper, or a combination of both formats. The information you enter into the medical record communicates the type and frequency of patient care provided, and provides accountability for the care provided by each member of the health care team. It is necessary to document all the nursing care you provide for each patient including assessment data, interventions, and patient responses in the medical record.

a nurse has diverse patient assignment this evening. When reviewing the patients condition the nurse determines that the first individual that should be seen is the patient

who is hypotensive

Risk taking is desirable, particularly when the result can be a positive outcome.

willingness to take risks comes from experience with similar problems. In nursing, risk taking often produces innovations in patient care. In the past, nurses have taken risks by trying new approaches to skin care, wound care, and pain management. Some of these attempts produced interventions that are more effective than traditional approaches. When taking a risk, you must consider all options, be knowledgeable of the new intervention, identify any potential danger to a patient, and then act in a well-reasoned, logical, and thoughtful manner. In the end the evaluation of patient outcomes is critical.

PIE

• A PIE note differs from a SOAP note in that it has a specific nursing focus: • P: Identifies a nursing diagnosis • I: Describes interventions that will be used to address the problem • E: Describes the nursing evaluation • Example of PIE note: • P: Knowledge Deficit related to lack of knowledge about how deep vein thrombosis (DVT) is treated. • I: Provide brochure on anticoagulation therapy for DVT. Explain rationale for bed rest and daily blood tests to check anticoagulation levels. Explain that heparin infusion will be stopped when PT/INR reaches therapeutic levels on warfarin and that he will need to continue taking warfarin for approximately 6 months after discharge until DVT is fully resolved. • E: Stated "My leg is so swollen. I'm worried about this blood clot, but I understand how it is being treated." Able to teach back and verbalized that the heparin infusion will be stopped when PT/INR is therapeutic on warfarin and that he can expect to take warfarin for approximately 6 months after discharge until clot in his leg is fully resolved.

patient care summary document includes

• Basic demographic data (e.g., age, religion) • Health care provider's name • Primary medical diagnosis • Medical and surgical history • Current orders from the health care provider (e.g., dressing changes, ambulation, glucose monitoring) • Nursing care plan • Nursing orders (e.g., education needed, symptom relief measures, counseling) • Scheduled tests and procedures • Safety precautions used in a patient's care • Factors that affect patient independence with activities of daily living • Nearest relative/guardian or person designated as a patient's health care power of attorney to contact in an emergency • Emergency code status (e.g., indication of do not resuscitate order) • Allergies

Following are some steps to take to enhance fax security

• Confirm fax numbers are correct before sending a fax to be sure that you direct information to the proper individual or agency. • Use a cover sheet for all faxes containing health care information. This eliminates the need for the recipient to read the information to determine to whom a fax needs to be delivered. This is especially important if a fax machine serves a number of different users. • Authenticate at both ends before transmitting data to verify that source and destination are correct. Use the cover sheet to list intended recipients, the sender, and the phone and fax numbers. Verify the fax number on the transmittal confirmation sheet. • Use preprogrammed speed-dial keys to eliminate the chance of a dialing error and misdirected information. • Utilize the encryption feature on the fax machine. Encoding transmissions makes it impossible to read confidential information without the encryption key. • Place fax machines in a secure area, and limit machine access to designated individuals. • Log fax transmissions. This feature is often available electronically on the machine.

Application to Nursing Practice hand off

• Face-to-face hand-off at the bedside is believed to be an effective method for increasing patient safety during the patient hand-off between nurses and other caregivers (Mardis et al., 2016). • Multiple mnemonics, such as SBAR (Situation-Background-Assessment-Recommendation) and I PASS the BATON (Introduction, Patient, Assessment, Situation, Safety concerns, Background, Actions, Timing, Ownership, and Next) help nurses provide an organized hand-off report (see Box 11.4) (Mardis et al., 2016). • Use of electronic tools within the electronic medical record to facilitate completion of bedside report shows promise as one way to increase patient safety by improving the quality of patient hand-off (Johnson et al., 2016).

Guidelines for Telephone and Verbal Orders

• Only authorized staff (who are identified in a written policy by each agency) receive and record telephone and verbal orders. • Clearly identify the patient's name, room number, and diagnosis. • Use clarification questions to avoid misunderstandings. • Write TO (telephone order) or VO (verbal order), date and time received, name of patient, the complete order transcribed exactly as stated, and the name of physician or health care provider and nurse. • Read back all telephone and verbal orders to physician or health care provider (TJC, 2015). • Follow agency policies; some institutions require telephone and verbal orders to be reviewed and signed by two nurses. • The health care provider cosigns each telephone and verbal order within the time frame required by each agency (usually 24 hours).

To meet agreed-on standards, EHRs are expected to have the following attributes or components

• Provide a longitudinal or lifetime patient record by linking all patient data from previous health care encounters. • Contain a problem list that indicates current clinical problems for each health care encounter, the number of occurrences associated with all past and current problems, and the current status of each problem. • Use of accepted, standardized measures to evaluate and record health status and functional levels. • Provide a method for documenting the clinical reasoning or rationale for diagnoses and conclusions that allows clinical decision making to be tracked by all providers who access the record. • Support confidentiality, privacy, and audit trails. • Provide continuous access to authorized users at any time, and allow multiple health care providers access to customized views of patient data at the same time. • Support links to local or remote information resources such as databases using the Internet or intranet resources based within an organization. • Support the use of decision analysis tools. • Support direct entry of patient data by physicians. • Include mechanisms for measuring the cost and quality of care. • Support existing and evolving clinical needs by being flexible and expandable.

soap

• The acronym SOAP stands for: • S: Subjective data (patient statements) • O: Objective data (data that are measured and observed) • A: Assessment (nursing diagnosis or problem based on the data) • P: Plan (what the caregiver plans to do) • Example of SOAP note: • S: "My leg is so swollen. I'm worried about this blood clot." • O: Asking questions about medications and treatment plan. • A: Knowledge Deficit related to lack of knowledge about how DVT is treated. • P: Provide brochure on anticoagulation therapy for DVT. Explain rationale for bed rest and daily blood tests to check anticoagulation levels. Explain that heparin infusion will be stopped when PT/INR is therapeutic on warfarin and that he will need to continue taking warfarin for approximately 6 months after discharge until clot in his leg is fully resolved.

Document the following activities or findings at the time of occurrence:

• Vital signs • Pain assessment • Administration of medications and treatments • Preparation for diagnostic tests or surgery including preoperative checklist • Change in patient's status and who was notified (e.g., health care provider, manager, patient's family) • Admission, transfer, discharge, or death of a patient • Treatment for sudden change in a patient's status • Patient's response to treatment or intervention

critical pathways

(also known as clinical pathways, practice guidelines, or CareMap tools) are interprofessional care plans that identify patient problems, key interventions, and expected outcomes within an established time frame (American Health Consultants, 2015). Critical pathway documents facilitate integration of care because all members of the health care team use the same document to monitor a patient's progress during each shift or, in the case of home care, every visit. Many organizations summarize the standardized plan of care into a critical pathway for a specific disease or condition. Evidence-based critical pathways can improve patient outcomes.

Intellectual Standards-14

1. Clear: Plain and understandable (e.g., clear communication) 2. Precise: Exact and specific (e.g., focusing on a problem and possible solution) 3. Specific: To mention, describe, or define in detail 4. Accurate: True and free from error; getting to the facts (objective and subjective) 5. Relevant: Essential and crucial to a situation (e.g., a patient's situation) 6. Plausible: Reasonable or probable 7. Consistent: Expressing consistent beliefs or values 8. Logical: Engaging in correct reasoning by moving from what one believes in a given instance to the conclusions that follow 9. Deep: Containing complexities and multiple relationships 10. Broad: Covering multiple viewpoints 11. Complete: Thorough thinking and evaluation 12. Significant: Focusing on what is important and not trivial 13. Adequate (for purpose): Satisfactory in quality or amount 14. Fair: Open-minded and impartial

Professional Standards

1. Ethical criteria for nursing judgment 2. Criteria for evaluation 3. Professional responsibility

the nurse needs to administer medication at 6 pm. What is the military time.

1800

what information is usually available to nurses on a clinical information system CIS

A clinical information system (CIS) includes monitoring systems; order entry systems; and laboratory, radiology, and pharmacy systems

concept map

A concept map is a visual representation of meaningful relationships between concepts (e.g., patient problems or nursing diagnoses and interventions), which then form propositions. Concept maps are visual road maps that highlight the meanings of these relationships (Hunter Revell, 2012). The maps encourage students to comprehensively observe their patients and

Competence

A second element of the critical thinking model is a nurse's knowledge base. A nurse's knowledge base varies according to his or her educational experience (e.g., type of basic nursing education, continuing education courses, and additional college education and degrees). In addition, a nurse builds knowledge by reading nursing literature (especially research-based literature) to maintain current knowledge of nursing science. Knowledge prepares a nurse to better anticipate and identify patient problems by understanding their origin and nature

identify what is wrong with the following notations and how they can be corrected: a. ate some breakfast b. voided an adequate amount c. provided wound care qd

All of the notations are vague and should include more specific information. For example: a. Identification of the specific intake, such as: Consumed 8 ounces of hot cereal, 6 ounces of orange juice, and an 8-ounce cup of coffee for breakfast. b. Notation of an accurate output, such as: Voided 200 mL of clear, amber urine. c. Description of care, such as 10 a.m. cleansed wound to left lower leg with normal saline and applied dry 4 3 4 dressing. "qd" is removed, as it is not an acceptable abbreviation

computer system

An organization of hardware and software designed to accomplish a data processing function.

What is a basic rule for the nurse to utilize when documenting client care?

Be factual in recording observations.

5. Explain the relationship between clinical experience and critical thinking.

Both these terms describe the mental processes nurses use to ensure that they are doing their best thinking and decision making. The practice of nursing requires critical thinking and clinical reasoning. Critical thinking is the process of intentional higher level thinking to define a client's problem, examine the evidence-based practice in caring for the client, and make choices in the delivery of care. Clinical reasoning is the cognitive process that uses thinking strategies to gather and analyze client information, evaluate the relevance of the information, and decide on possible nursing actions to improve the client's physiological and psychosocial outcomes

Nursing Process

COMPONENT PURPOSE STEPS Assessment To gather, verify, and communicate data about a patient so a database can be established Collect nursing health history. Perform physical examination. Collect laboratory data. Validate or confirm that data are correct. Cluster data by common themes or problem areas. Document data. Nursing diagnosis To identify a patient's health care needs in the form of nursing diagnoses Analyze and interpret data. Identify patient problems. Form nursing diagnoses. Document nursing diagnoses. Planning To work with a patient, his or her family, and health care team members, to set priorities of care, identify patient-centered goals and expected outcomes, and prescribe an individualized approach to care Identify and mutually set goals with the patient. Establish expected outcomes. Select nursing interventions. Document a nursing plan of care. Collaborate with other health care providers. Implementation To carry out nursing interventions specified by the plan of care Perform nursing interventions. Reassess patient. Review and modify existing care plan. Evaluation To determine extent to which interventions helped achieve goals of care Compare patient response with expected outcomes. Analyze reasons for results and conclusions. Modify care plan.

CONCEPTS FOR A CRITICAL THINKER

CONCEPT COMPONENT Truth seeking Seek the true meaning of a situation. Be courageous, honest, and objective about asking questions. Case study: Jessica asks Mr. Myers more questions about how he usually deals with pain and the meaning pain has in this particular situation. Open-mindedness Be tolerant of different views and be sure that you clearly know your patients' views. Be aware of your own biases and respect the right of others to have different opinions. Case study: Jessica asks Mr. Myers to tell her the approaches he would like to use to become mobile after surgery. Mr. Myers tells Jessica that he fears walking too soon and hurting his back. Analyticity Be alert to potentially problematic situations; anticipate possible results or consequences (e.g., how should a patient respond to a certain treatment?); value reason; use evidence-based knowledge. Case study: Jessica points out to Mr. Myers that he has had back pain for some time and explains that evidence shows that persistent low back pain leads to exercise intolerance and further loss of functional capacity (Atalay et al., 2012). His ability to regain mobility quickly will reduce the risk of further decline. Systematicity Be organized and focused and work hard in answering your questions. Organize inquiry based on priorities of care. Case study: Jessica focuses on pain assessment and gives Mr. Myers additional analgesia after consulting with Mr. Myers and his surgeon to identify the best medication considering Mr. Myers' previous pain history. Self-confidence Trust your own reasoning processes. Case study: Jessica believes that by managing Mr. Myers' pain well, she will build trust with him as she prepares him for the mobility protocol and use of relaxation techniques. Inquisitiveness Be eager to acquire knowledge and explanations even when applications of the knowledge are not immediately obvious. Value learning for learning's sake. Case study: Jessica decides to take some time and talk with Mr. Myers' wife about her husband's experience with pain and his coping strategies. Maturity Multiple solutions are acceptable. Reflect on your own judgments; develop cognitive maturity. Case study: Jessica consults with a physical therapist who also is willing to talk with Mr. Myers about the importance of early mobility. Jessica and the physical therapist will form a plan for physical therapy and nursing staff to implement an ambulation schedule during Mr. Myers' waking hours.

A client has an increased respiratory rate, moist breath sounds, and labored breathing. The nurse describes these as what type of data?

Cluster of similar signs and symptoms.

identify the level of critical thinking demonstrated by each of the following- making choices without assistance and accepting accountability

Commitment

CRITICAL THINKING ATTITUDES AND APPLICATIONS IN NURSING PRACTICE

Confidence Learn how to introduce yourself to a patient. For example: "Mrs. Tyms, I'm Chuck Lord, your nurse for this shift. I'll be responsible for your nursing care and will work with your doctor to make sure that you're comfortable." Speak with conviction when you begin a treatment or procedure. Do not let a patient think that you are not sure how to perform care safely. Always be prepared (e.g., organize equipment and provide comfort measures) before beginning a nursing activity. Thinking independently Read the nursing literature, especially when there are different opinions on a subject. Ask colleagues and expert staff nurses to share their ideas about nursing interventions. Fairness Listen to both sides in any discussion. If a patient or family member complains about a colleague, listen to the story and then speak with the colleague. Weigh all the facts. Responsibility and accountability Ask for help if you are not sure about how to perform a task. Report any problems immediately. Follow standards of practice in the care you give. Risk taking If your knowledge leads you to question a health care provider's order, speak up. Offer alternative approaches to nursing care when colleagues are having little success with patients. Discipline Be thorough in everything you do. Use established criteria for activities such as assessment and evaluation. Take time to be thorough. Perseverance Be wary of an easy answer. If colleagues give you information about a patient but some information is missing, clarify the facts or talk to the patient directly. If the same problems recur on a nursing division, bring colleagues together, look for a pattern, and find a solution. Creativity Seek different approaches when interventions are not working. For example, a patient may need a different positioning technique or a different instructional approach. Curiosity Always ask "why." A clinical sign or symptom can indicate a variety of problems. Learn more about the patient to help you make the right clinical judgments. Integrity Recognize when your opinions conflict with those of your patient. Review your position and work with the patient to reach agreement on how best to reach a positive outcome. Humility Recognize times when you need more information to make a decision. When you are new to a clinical division and unfamiliar with the patients, ask for an orientation to the area. Ask nurses regularly assigned to the area for assistance. Read professional journals regularly to keep updated on approaches to care.

Examples of critical thinking attitudes: developing a unique way to teach the patient how to change a dressing

Creativity

provide two items that should be included in a discharge summary

Discharge summaries should include the following: Procedures that should be performed and the instructions given, medications prescribed and precautions, signs and symptoms of complications, names and phone numbers of health care providers, names of community resources, follow-up requirements, actual time of discharge, transportation used, and name of person accompanying the discharged patient.

Examples of critical thinking attitudes: performing a systematic and thorough pain assessment

Disciplined

GUIDELINES FOR ELECTRONIC AND WRITTEN DOCUMENTATION RATIONALE CORRECT ACTION

Do not document retaliatory or critical comments about a patient or care provided by another health care professional. Do not enter personal opinions. Statements can be used as evidence for nonprofessional behavior or poor quality of care. Enter only objective and factual observations of a patient's behavior or the actions of another health care professional. Quote all patient statements. Correct all errors promptly. Errors in recording can lead to errors in treatment or may imply an attempt to mislead or hide evidence. Avoid rushing to complete documentation; be sure that information is accurate and complete. Record all facts. Record must be accurate, factual, and objective. Be certain that each entry is factual and thorough. A person reading your documentation needs to be able to determine that a patient received adequate care. Document discussions with providers that you initiate to seek clarification regarding an order that is questioned. If you carry out an order that is written incorrectly, you are just as liable for prosecution as the health care provider. Do not record "provider made error." Instead document that "Dr. Smith was called to clarify order for analgesic." Include the date and time of the phone call, with whom you spoke, and the outcome. Document only for yourself. You are accountable for information that you enter into a patient's record. Never enter documentation for someone else (exception: caregiver has left unit for the day and calls with information that needs to be documented; include date and time of entry and reference specific date and time to which you are referring and name of source of information in entry; include that information was provided via telephone). Avoid using generalized, empty phrases such as "status unchanged" or "had good day." This type of documentation is subjective and does not reflect patient assessment. Use complete, concise descriptions of assessments and care provided so that documentation is objective and factual. Begin each entry with date and time and end with your signature and credentials. This ensures that the correct sequence of events is recorded; signature documents who is accountable for care delivered. Do not wait until the end of shift to record important changes that occurred several hours earlier; sign each entry according to agency policy (e.g., M. Marcus, RN). Protect the security of your password for computer documentation. This maintains security and confidentiality of patient medical records. Once logged into a computer, do not leave computer screen unattended. Log out when you leave the computer. Make sure that a computer screen is not accessible for public viewing. Guidelines Specific to Written Documentation Do not erase, apply correction fluid, or scratch out errors made while recording. Charting becomes illegible: it appears as if you were attempting to hide information or deface a written record. Draw single line through error, write word error above it, and sign your name or initials and date it. Then record note correctly. Do not leave blank spaces or lines in a written nurses' progress note. This allows another person to add incorrect information in open space. Chart consecutively, line by line; if space is left, draw a line horizontally through it and place your signature and credentials at the end.

Documentation

Documentation is a key communication strategy between health care professionals and a vital element of nursing practice

the following are guidelines for written documentation. indicate the correct action to be taken by the nurse for each guideline: do not cross out

Draw a single line through the error, write the word "error" above the line, initial or sign the error, and complete the correct notation. Electronic records may have specific procedures for alterations of records that will indicate a change has been made.

the following are guidelines for written documentation. indicate the correct action to be taken by the nurse for each guideline: never erase entries or use correction fluid, and never use pencil

Draw a single line through the error, write the word "error" above the line, initial or sign the error, and complete the correct notation. Write all entries clearly and in ink.

15. Discuss advantages of computerized documentation.

Electronic records are safeguarded through the use of passwords, firewalls, audit trails, and disaster recovery systems a. Communication: For continuity of care and accurate patient status b. Financial: For reimbursement, DRGs, insurance audits c. Educational: For teaching nursing and medical students d. Research: For statistical data and patient responses e. Auditing/Monitoring: For Joint Commission standards, incidence of patient falls, pain management

identify at least two ways that electronic record are safeguarded for privacy and security:

Electronic records are safeguarded through the use of passwords, firewalls, audit trails, and disaster recovery systems.

Last week during a care conference, you suggest adding a glass of prune juice to a client's daily breakfast tray because of persistent constipation. This has been done for the last week and today, you review the record of this client's bowel movements for the past week. You are using which phase of the nursing process:

Evaluation

pt coughs and deep breaths and the lungs remain clear post-op what phase of NP is this?

Evaluation

Assessment reveals that a client has lost 10 pounds in the last 2 months. Weight loss is one of the three defining characteristics of the nursing diagnosis 'nutrition, imbalanced: less than body requirements. The nurse's next step is to:

Examine the assessment data to see if other signs and symptoms of altered nutrition exist.

identify one example of how critical thinking is used in each of the following steps of the nursing process Assessment: Nursing diagnosis: Planning: Implementation:

Examples of critical thinking throughout the nursing process: a. Assessment: Collecting and analyzing data b. Nursing diagnosis: Identifying the appropriate patient problems c. Planning: Establishing expected outcomes, prioritizing, collaborating, and delegating d. Implementation: Performing nursing interventions safely e. Evaluation: Determining achievement of outcomes, reassessing as indicated

The nurse personally believes that substance abuse is a serious problem with negative consequences for patients and families. The nurse provides excellent care to his/her substance abuse client. This displays the critical thinking attitude of:

Fairness

identify the four concepts included in informatics

Four concepts included in informatics are data, information, knowledge, and wisdom.

the following are guidelines for written documentation. indicate the correct action to be taken by the nurse for each guideline: never record or chart for someone else

Have the other caregiver document the information, unless the individual calls with additional information. Document that the information was provided by another individual

home care documentation is completed both for quality control and as the basis for

Home care documentation is also completed for financial reimbursement.

clinical setting

Hospitals, medical clinics, and therapy clinics

the following are guidelines for written documentation. indicate the correct action to be taken by the nurse for each guideline: do not record physician made error

Identify that the physician was called to clarify an order for the patient.

The nurse understands that the process of carrying out the nursing care plan is:

Implementation.

Examples of critical thinking attitudes: admitting to the nurse manager that a medication was given in error

Integrity

Core critical thinking skills

Interpretation Interpretation is the process of discovering, determining, or assigning meaning. Interpretation skills can be applied to anything (e.g., written messages, charts, diagrams, maps, graphs, memes, and verbal and nonverbal exchanges). People apply their interpretive skills to behaviors, events, and social interactions when deciding what they think something means in a given context. Analysis Analytical skills are used to identify assumptions, reasons, themes, and the evidence used in making arguments or offering explanations. Analytical skills enable us to consider all the key elements in any given situation and to determine how those elements relate to one another. People with strong analytical skills notice important patterns and details. People use analysis to gather the most relevant information from spoken language, documents, signs, charts, graphs, and diagrams. Inference Inference skills enable us to draw conclusions from reasons, evidence, observations, experiences, or our values and beliefs. Using Inference, we can predict the most likely consequences of the options we may be considering. Inference enables us to see the logical consequences of the assumptions we may be making. Sound inferences rely on accurate information. People with strong inference skills draw logical or highly reliable conclusions using all forms of analogical, probabilistic, empirical, and mathematical reasoning. Evaluation Evaluative skills are used to assess the credibility of the claims people make or post, and to assess the quality of the reasoning people display when they make arguments or give explanations. We can also apply our evaluation skills to assess the quality of many other elements that are important for good thinking, such as analyses, interpretations, explanations, inferences, options, opinions, beliefs, hypotheses, proposals, and decisions. People with strong evaluation skills can judge the quality of arguments and the credibility of speakers and writers. Explanation Explanation is the process of justifying what we have decided to do or what we have decided to believe. People with strong explanation skills provide the evidence, methods, and considerations they actually relied on when making their judgment. Explanations can include our assumptions, reasons, values, and beliefs. Strong explanations enable others to understand and to evaluate our decisions. Self-Regulation Self-Regulation in the context of critical thinking relates to monitoring and, if necessary, correcting any mistakes that may have occurred in the process of interpreting, analyzing, inferring, evaluating, or explaining. Self-regulation occurs throughout the critical thinking process; it is not confined to the ending point only. As soon as an individual or a thinking team identifies an error as a result of the process of self-monitoring, that error can be corrected so that the overall process of critical thinking can again begin to move forward toward its culmination, which is the considered judgment about what to believe or what to do in any given context. Self-regulation can focus any of the elements in that process, including how the problem was framed, what was accepted as evidence, what methods were employed, what the guiding theoretical considerations were, and what level of closure was deemed appropriate for regarding the problem as having been solved or the decision as having been made. Self-regulation is the skill which separates critical thinking from un-critical thinking.

ISBAR stands for?

Introduction Situation Background Assessment Recommendation

Levels of Critical Thinking in Nursing

Level 1: Basic-Beginning nursing students are very task oriented, focusing on performing skills and organizing nursing care activities correctly. At the basic level of critical thinking, a student trusts that experts have the right answers for every problem. Thinking is concrete and based on a set of rules or principles Level 2: Complex-begin to rely less on experts in daily care. You learn to analyze data and examine choices more independently. Your thinking abilities and initiative to look beyond expert opinion begin to increase. As your critical thinking skills grow, you learn that you must consider alternative and perhaps even conflicting solutions. Level 3: Commitment-In commitment, you anticipate the need to make choices without assistance from others. You accept accountability for the decisions you make. As a nurse, you do more than just consider the complex alternatives that might resolve a problem. At the commitment level, you choose an action or belief based on the alternatives available and stand by your choice. Sometimes the choice is to avoid or delay acting.

provide an example of a malpractice issue related to charting:

Malpractice issues related to documenting include the following: (1) failing to record pertinent health or drug information, (2) failing to record nursing actions, (3) failing to record medication administration, (4) failing to record drug reactions or changes in patients' conditions, (5) incomplete or illegible records, and (6) failing to document discontinued medications.

Confidentiality of Medical Record and Patient Information

Nurses are legally and ethically obligated to keep information about patients confidential. Only members of the health care team who are directly involved in a patient's care have legitimate access to the medical record. You discuss a patient's diagnosis, treatment, assessment, and any personal conversations only with members of the health care team who are specifically involved in the patient's care. Do not share information with other patients or with health care team members who are not caring for the patient. Patients have the right to request copies of their medical records and read the information.

what are the purposes and advantages of nursing informatics?

Nursing informatics are the retrieval, storage, presentation, and sharing of data, information, and knowledge to provide quality, safe patient care. Nursing informatics facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in decision making in all roles and settings.

The nurse knows that a heart rate of 68, a respiratory rate of 12, and a BP of 130/80 represents:

Objective data.

the following are guidelines for written documentation. indicate the correct action to be taken by the nurse for each guideline: do not speculate or geuss

Only include factual information in the notation.

narrative notes (narrative format)

Patient stated "My leg is so swollen. I'm worried about this blood clot." Is asking questions about medications and treatment plan. Discussed importance of bed rest and the reason for treatment with heparin infusion. Explained need for daily blood tests to check anticoagulation levels. Provided brochure on anticoagulation therapy for DVT. Used teach-back method to validate that patient understands plan of care; he is able to describe that the heparin infusion will be stopped when his PT/INR is therapeutic on warfarin and that he can expect to take warfarin for approximately 6 months after discharge until clot in his leg is fully resolved.

Perseverance

Perseverance is especially important when problems remain unresolved or when they recur. You must learn as much as possible about a particular problem and try various approaches to care. Perseverance also means that you continually look for additional resources until you find a successful approach. A critical thinker who perseveres is not satisfied with minimal effort but constantly tries to achieve high-quality patient care.

Reflection

Process of recalling an event to determine its meaning and purpose-part of critical thinking that involves purposefully reviewing a situation to discover its purpose or meaning. As a nurse, you will reflect on the purpose and meaning of each patient's situation as well as the purpose and meaning of your actions in that situation.

Scientific Method

Process that moves from observable facts from an experience to a reasonable explanation of those facts. The scientific method has five steps: 1. Identifying the problem 2. Collecting data 3. Forming a question or hypothesis 4. Testing the question or hypothesis 5. Evaluating results of the test or study The scientific method is one formal way to approach a problem, plan a solution, test the solution, and come to a conclusion. Table 8.3 gives an example of a nursing practice issue solved by application of the scientific method in a research study.

The student nurse understands that the primary purpose of the nursing care plan is to:

Promote consistency among nursing staff.

Model for Reflection REFLECT: This model can be used individually or as a process shared with others.

R Recall the events: Review the facts about a situation, and describe what happened. E Examine your responses: Think about or discuss your thoughts and actions at the time of the situation. F Acknowledge Feelings: Identify any feelings you had during the situation. L Learn from the experience: Review and highlight what you learned from the situation, for example, your patient's responses and your actions. E Explore options: Think about or discuss your options for similar situations in the future. C Create a plan of action: Create a plan for action in future similar situations. T Set a Timescale: Set a time by which your plan of action will be completed.

The stated expected outcome is heart rate will be below 90 bpm by 10/6. On 10/6 the nurse identifies a heart rate of 120 bpm. The nurse needs to first:

Reassess the patient to verify the finding.

the following are guidelines for written documentation. indicate the correct action to be taken by the nurse for each guideline: do not wait until the end of shift to record important information

Record pertinent information throughout the shift, signing each entry.

provide an example of how reflection could be used by the nurse in this scenario: the patient has had a colostomy and will need to learn self-care. The nurse has had many patients with new colostomies, some who have done well and others who have struggled to learn the care.

Reflection allows the nurse to look back and learn from an experience and identify opportunities for improvement. b. Language must be used clearly and precisely in order to communicate effectively with patients, families, and other members of the health care team. c. Learning is a continuous process and necessary for nurses as the profession grows. With experience and learning, nurses get better at forming assumptions, presenting ideas, and making valid conclusions about patient care.

for telephone reports, identify what the SBAR acronym represents and give an example of each area

SBAR: Situation Example: "Dr. Green, this is Ms. Nurse on the surgical unit. Mr. X is scheduled for surgery tomorrow, but his temperature is elevated and I want to clarify the preoperative status and orders with you." B: Background Example: "Mr. X was admitted to the unit this morning and has had all of his tests completed." A: Assessment Example: "Mr. X has an oral and tympanic temperature of 102°F and his skin is very warm to the touch." R: Recommendation Example: "I think that the anesthesiologist should be notified and we need an order for an antipyretic."

protected health information (PHI)

Sometimes nurses use health care records for data gathering, research, or continuing education. This is permitted as long as you use a record as specified and permission is granted.

standards for health care agencies and documentation are set by the

Standards are set by The Joint Commission (TJC) and National Committee for Quality Assurance (NCQA).

demonstrate how a student nurse should sign a written patient record

Student nurses should sign their names, followed by either SN or NS and the school affiliation.

Document the following activities or findings at the time of occurrence: CRITERIA FOR DOCUMENTATION AND REPORTING

Subjective assessment data Patient's description of episode in quotation marks, for example: "I feel like an elephant is sitting on my chest, and I can't catch my breath." Describe in patient's own words onset, location, and description of condition (severity; duration; frequency, precipitating, aggravating, and relieving factors), for example: "The pain in my left knee started last week after I knelt on the ground. Every time I bend my knee I have a shooting pain on the inside of the knee." Objective assessment data (e.g., rash, tenderness, breath sounds) or descriptions of patient behavior (e.g., anxiety, confusion, hostility) Onset, location, description of condition, for example: 1100: 2-cm raised pale red area noted on back of left hand. Onset, precipitating factors, behaviors exhibited (e.g., pacing in room, avoiding eye contact with nurse), patient statements, for example: repeatedly stating "I have to go home now." Nursing interventions, treatments, and evaluation (e.g., enema, bath, dressing change) Time administered, equipment used, patient's response (subjective and objective response) compared with previous treatment, for example: denied incisional pain during abdominal dressing change, ambulated 300 feet in hallway without assistance. Medication administration At time of administration when using a computerized bar-code medication administration program (or immediately after administration), document time medication given, medication name, dose, route, preliminary assessment (e.g., pain level, vital signs), patient response or effect of medication; for example: 1500: Reports "throbbing headache all over my head." Rates pain at 6 (0-to-10 scale). Acetaminophen 650 mg given PO. 1530: Patient reports pain level 2 (0-to-10 scale) and states "the throbbing has stopped." Patient and/or family teaching Information presented, method of instruction (e.g., discussion, demonstration, videotape, booklet), and patient response, including questions and evidence of understanding such as teach-back, return demonstration, or change in behavior. Discharge planning Measurable patient goals or expected outcomes, progress toward goals, need for referrals.

Subjective Statements are made by the patient are best documented by

Subjective statements by the patient should be quoted and may be supported with objective findings.

The nurse completes an incident report on a client who fell while walking in the hallway. The primary purpose of this documentation is to:

Support quality improvement in care delivery at the facility.

Experience

Textbook approaches and simulation exercises lay an important foundation for practice, but you must adapt your practice to each setting, the unique qualities of each patient, and the experiences you gain from caring for previous patients. Benner (1984) noted that an expert nurse understands the context of a clinical situation, recognizes signs suggesting patterns, and interprets them as relevant or irrelevant.

A client is suffering from SOB. A correctly stated expected outcome the nurse would write is:

The client will have a respiratory rate of 14 to 18 breaths per minute by the end of the shift.

Discuss and interpret critical thinking skills used in nursing practice.

The elements of the critical thinking model are competence (e.g., problem-solving and clinical decision making ability), knowledge, experience, attitudes, and standards (intellectual and professional)

indicate the elements of the critical thinking model

The elements of the critical thinking model are competence (e.g., problem-solving and clinical decision making ability), knowledge, experience, attitudes, and standards (intellectual and professional)

identify the errors in the following documentation example: patient says she feels ok. 140/82, 88, 14. gained a little weight. complained about her doctor. says she didn't eat much breakfast today.

The errors are: • The word "patient" is usually not included • Vital signs should be identified as BP, Pulse, and Respirations • The amount of weight gained should be specified • The complaint about her doctor should not be included • The specific amount of breakfast consumed should be identified.

identify the five characteristics of quality documentation

The five characteristics of quality documentation are factual, accurate, complete, current, and organized.

completion of narrative notes only when there are abnormal findings is part of the concept of

The process of completing narrative notes only when abnormalities exist is part of "charting by exception."

Attitudes for Critical Thinking

There are 11 attitudes that define a critical thinker and his or her success in approaching a problem (Paul, 1993; Papathanasiou et al., 2014). To become a critical thinker, you must be motivated to develop the attitudes and dispositions of a fair-minded thinker. For example, when a patient complains of anxiety before a diagnostic procedure, a curious nurse seeks information and an explanation by asking several questions to learn what the patient does not know and the nature of the patient's concerns (Kaddoura, 2013). The nurse shows discipline in forming questions and performing a thorough assessment to learn the source of the patient's anxiety.

Examples of critical thinking attitudes: questioning an order that appears incorrect

Thinking independently

the patient is admitted to the medical center with a stage IV pressure ulcer the nurse recognizes the implantation of this finding this specific finding is classified as a _______ what does the nurse need to document?

This is classified as a preventable error or "never event." The nurse needs to document the pressure ulcer and indicate that it was present upon admission.

Fairness.

This means that bias or prejudice does not enter into a decision. For example, regardless of what you think about illicit drug use, you do not allow your attitudes to affect the way you deliver care to patients who abuse drugs. Fairness requires that you look at each situation objectively and consider all viewpoints to understand the situation completely before making a decision.

what are two useful tools for developing critical thinking skills

Two useful tools for developing critical thinking skills are reflective journaling and concept mapping.

the following are guidelines for written documentation. indicate the correct action to be taken by the nurse for each guideline: avoid using generalized, empty phrases

Use complete, concise descriptions of patient interactions.

the following are guidelines for written documentation. indicate the correct action to be taken by the nurse for each guideline: do not leave blank spaces

Use consecutive lines for charting and do not leave margins. Draw lines through unused space and sign your name at the end of the notation

the following are guidelines for written documentation. indicate the correct action to be taken by the nurse for each guideline: do not write retaliatory or critical comments about the patients

Use only objective descriptions of the patient and use quotes for patient comments.

pt says "i'm burning up, and have a temp. "VS taken, assess flushing, feels skin, Nurse is?

Validating subjective data

walk arounds

Walking reports given in person or during rounds allow you to obtain immediate feedback when questions arise about a patient's care. When you make rounds, the patient and family members can participate in any discussions and care decisions. However, be careful about mentioning information that the patient should not hear (e.g., new laboratory or diagnostic reports not yet explained by the health care provider).

as a student nurse, what information should be left off written materials that are prepared for class?

Written materials for class that are prepared based on clinical experiences should not have any patient identifiers on them, such as the patient's last name and room number, date of birth, medical record number, or other identifiable demographic information.

clinical decision support system (CDSS)

a computerized program used within the health care setting to aid and support clinical decision making. The knowledge base within a CDSS contains rules and logic statements that link information required for clinical decisions to generate tailored recommendations for individual patients, which are presented to health care providers as alerts, warnings, or other information for consideration (Lee, 2013). For example, an effective CDSS notifies health care providers of patient allergies before entering a medication order using CPOE to increase patient safety during the medication ordering process.

Thinking Independently.

a critical thinker does not accept another person's ideas without question. When thinking independently, you challenge the ways others think and look for rational and logical answers to problems. An independent thinker applies evidence-based practices (see Chapter 7) when facing clinical decisions. You must be willing to seek answers to difficult questions as well as obvious ones.

health care information system (HIS)

a group of systems used within a health care organization to support and enhance health care. An HIS consists of two major types of information systems: a clinical information system (CIS) and an administrative information system. Together the two systems operate to make the entry and communication of data and information more efficient.

which of the following require occurrence/incident reports

a patients visitors is hit by a portable x-ray machine the patient falls out of bed a nurse sticks herself with a needle an inaccurate medication dosage is administered

Problem Solving

a problem arises, you obtain information, combine it with what you already know, and develop a solution. Patients routinely present problems in practice. A traditional approach for solving problems is to clarify the problem, identify possible causes, assess and identify alternatives, choose one, implement it, and evaluate whether the problem was solved.

what is Kardex/cardex?

a short summarized version of the current daily basic care plan

Change-of-Shift Report

a type of hand-off report that occurs at the end of each shift. This report provides the transfer of relevant information from nurses who have completed a shift of care to nurses about to begin a shift of care. Shift reports occur in a variety of ways.

3. List the basic components of a critical thinking model.

a. Assessment: Collecting and analyzing data b. Nursing diagnosis: Identifying the appropriate patient problems c. Planning: Establishing expected outcomes, prioritizing, collaborating, and delegating d. Implementation: Performing nursing interventions safely e. Evaluation: Determining achievement of outcomes, reassessing as indicated

for each of the following identify an example of how patients record is used a. communication b.finance c.education d. research e. auditing/monitoring

a. Communication: For continuity of care and accurate patient status b. Financial: For reimbursement, DRGs, insurance audits c. Educational: For teaching nursing and medical students d. Research: For statistical data and patient responses e. Auditing/Monitoring: For Joint Commission standards, incidence of patient falls, pain management

what is the priority nursing diagnosis?

activity intol. r/t obesity m/b SOB, diaphoresis, tachypnea

Humility.

admit the limits in your knowledge and skill. Critical thinkers admit their knowledge gaps and try to find the knowledge they need to make proper decisions. A nurse is often an expert in one area of clinical practice (e.g., general surgery) but a novice in another area (e.g., orthopedics). You put a patient's safety and welfare at risk if you cannot admit your inability to solve a practice problem. You must rethink a situation, seek additional knowledge (e.g., literature, clinical experts), and use the information to form an opinion and draw a conclusion.

computerized provider order entry (CPOE)

allows health care providers to directly enter orders for patient care into a medical record from any computer in the hospital information system. Advanced CPOE systems have built-in reminders and alerts to help a health care provider select the most appropriate medication or diagnostic test. The direct entry of orders by providers eliminates safety issues related to illegible handwriting and transcription errors. In addition, a CPOE system potentially speeds the implementation of ordered diagnostic tests and treatments, which contributes to quality care and better patient outcomes. Use of a CPOE system has been shown to improve productivity and cost-effectiveness in the communication and implementation of health care provider orders. More importantly, most CPOE systems have significant potential to reduce medication errors associated with illegibility and inappropriate drug use and dosing

decision support system

an interactive, flexible, computerized information system that enables managers to obtain and manipulate information as they are making decisions

transfer reports

another type of hand-off report that involves the nurse on the sending unit communicating information about a patient to the nurse on the receiving unit. Nurses usually give transfer reports by phone or in person. When giving a transfer report, include the following information: 1. Patient's name, age, date of birth, health care provider(s), and medical diagnosis 2. Summary of medical progress up to the time of transfer 3. Current health status (physical and psychosocial) 4. Allergies 5. Emergency code status 6. Family support 7. Current nursing diagnoses or problems and care plan 8. Any critical assessments or interventions to be completed shortly after transfer (helps receiving nurse establish priorities of care) 9. Up-to-date reconciled medication list (TJC, 2017, 2018) 10. Need for any special equipment such as isolation equipment, suction equipment, or traction

hand-off report

any time one health care provider transfers care of a patient to another health care provider. The purpose of hand-off reports is to provide better continuity and individualized care for patients (Anderson et al., 2015). A hand-off is the process of transferring responsibility for patient care from one provider to another. For example, if you find that a patient breathes better in a certain position, you relay that information to the next nurse caring for the patient Standardizing communication during hand-off reports helps ensure patient safety. Face-to-face hand-off communication includes up-to-date information about a patient's condition, required care, treatments, medications, services, and any recent or anticipated changes. In addition, these reports reduce patient care errors

Nursing Process-5 steps

application of the five-step nursing process (Fig. 8.2): assessment, diagnosis, planning, implementation, and evaluation (see Chapter 9). The purpose of the nursing process is to diagnose and treat human responses (e.g., patient symptoms, need for knowledge, or emotional stress) to actual or potential health problems competency when delivering patient care The nursing process requires a nurse to use the general and specific critical thinking competencies described earlier in this chapter to focus on a specific patient's unique needs.

. Diagnosis-related groups (DRGs)

are classifications based on a hospitalized patient's primary and secondary medical diagnoses that are used as the basis for establishing Medicare reimbursement for patient care. Hospitals are reimbursed a predetermined dollar amount by Medicare for each DRG. Private insurance carriers and auditors from federal agencies review records to determine the reimbursement that a patient or a health care agency receives

clinical care experience have recently begun fro a student nurse. When beginning to work with patients, the student nurse implements critical thinking in practice by

asking for assistance if uncertain

entering a room at 2:00 am a nurse notes that the patient is not in bed; the patient is sitting in the chair and states that she is having difficulty sleeping. Employing critical thinking, the nurse responds by

asking more about the patient's sleep problem

identify the level of critical thinking demonstrated by each of the following -trusting experts to have the right answers for every problem

basic

in applying the concept of critical thinking the nurse demonstrates systematicity by

being organized and focused and working hard

Nursing informatics

broadly defined as the "use of information and computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research" (Hebda and Czar, 2013). Nursing informatics is also recognized as a specialty area of nursing practice at the graduate level. Nurses who specialize in informatics have advanced knowledge in information management and demonstrate proficiency with informatics to support all areas of nursing practice including quality improvement, research, project management, and system design