Exam 2
Describe the information contained in a comprehensive plan of care.
(1) basic needs and ADLs, (2) medical and collaborative therapies, (3) nursing diagnoses and collaborative problems, and (4) special teaching and/or discharge needs Process of patient care plan 1. Making a working problem list. 2. Decide which problems can be managed with standards care plans or critical pathways. 3. Individualize the standardized plan as needed. 4. Transcribe medical order to appropriate documents 5. Write ADLs and basic care needs in special sections. 6. Develop individualized care plans for problems not addressed by standardized documents.
Apply state mandatory reporting laws to client care situations.
-report communicable diseases -report physical, sexual, or emotional abuse or neglect of vulnerable individuals ( children, older adult, and mentally ill) suspect or have actual evidence - protects you when reporting -Fail to report = criminal misdemeanor or to be subject to discplinary challenges -report over comes HIPAA -vary from state to state
Compare and contrast independent, dependent, and interdependent (collaborative) nursing interventions.
1. Independent Interventions- nurses are licensed to prescribe 2. Dependent Interventions- one prescribed by a physician or advanced practice nurse by carried out by bedside nurse. 3. Interdependent interventions- one that is carried out in collaborative interventions.
Identify 3 basic levels of communication.
1. Intrapersonal Communication- self talk. 2. Interpersonal Communication- between two or more people. 3. Group Communication- interaction that occurs among several people.
Use assessment skills to gather data during a nursing assessment.
1. Perform assessment Initial Assessment Ongoing Assessment Comprehensive Assessment Focused Assessment Special Needs Assessment Discharge planning 2.Collect and Validate Date -Subjective, interview -Objective, physical -Primary source -Secondary source 3.Documenting 4. Organizing Assessment involves data collection, use of a systematic and ongoing process, categorizing of data, and recording of data.
Therapeutic Communication-Phases of Therapeutic Relationship (i.e. pre-interaction, working, orientation, termination. Know these terms).
1. Pre-interaction Phase; Gathering information about the client, no direct communication, when client identified the need for healthcare. 2. Orientation Phase; when you meet the client, form rapport (when patients are more likely to express their concerns openly seek emotional support) and trust. Ends when the relationship is defined. 3. Working Phase; active part of relationship, goal is to assist the client to clarify concerns and feelings. Professional relationship is developed by active listening. 4. Termination Phase; conclusion of the relationship, end of shift or end of discharge. If the communication phase is effective the termination phase prepares the nurse and client for further interactions. Unsuccessful communication may affect the clients health outcome.
Identify and describe the "five rights" of delegation in addition to understanding tasks and treatment that can be delegated to a UAP as compared to an LPN.
1. Right task. 2.Right circumstance 3.Right person 4.Right communication 5. Right supervision. UAP- basic interventions bathing, stable pt, vital signs, change linens, assisting its with meals. LPN- Adminiter some med, starting an IV and administering plain IV solutions, and assisting with identification of blood units for transfusion.
Analyze factors that influence the communication process.
1.Environment-quiet, private, free of unpleasant smell, a comfortable temperature, idea places are chapel foyers or activity rooms. 2.Life span variations -Infants and toddlers;limited language communication, response combination of verbal and non-verbal (ex. 1 year old cries) - Older toddlers and preschoolers; more verbal ability, like to have parents around -School-aged children; comfortable interacting verbally, use words and phrase a child would understand -Children reach adolescence, most can process abstract concepts,usually able to understand disease process, children with disease has more knowledge than you know. -Older adult; may be affected by secondary alterations, such as hearing loss or vision changes. 3.Gender; Women- form connections and relationships Male- goals, task, independence ex: I feel lousy today women:want to talk male: want pain medication 4.Personal space -Intimate Distance:"private space", 18 inches, people can sense each others smell and body heat and can hear each other speak at low volume. nurse breach when assessments are performed -personal distance: 18 inches to 4 ft. distance of personal thoughts and good for communication -Social distance: 4-12feet. more formal interaction or when communicating with a group of people. impersonal. -Public distance; beyond 12 feet, requires loud and clear enunciation for communication. 5.Territoriality; space and thing that individual defines a belonging to themselves. Patients may be offended if you move there items, to establish trust- ask for permission. 6.Sociocultural factors; Culture and socioeconmic status strongly influence communication. social distance, patient ask questions to nurse not physicians. 7.Roles and relationships; Role and relationships of sender affects the word choice.
Define the following terms: goal, outcome, expected outcome, nursing-sensitive outcome. What is the ultimate outcome of the nursing process?
1.Goals-expected outcomes, desired outcomes, or predicted outcomes, describes the changes in patient health status that you hope to achieve. 2. Outcomes ( expected outcomes), mores specific observable responses you would use to judge whether the goals has been met. 3. Nursing-sensitive outcome-are those that can be influenced by nursing interventions.
Discuss the elements of the communication process.
1.Message: words, gesture, letter 2.Sender: initiates content delivery, source encoder. 3.Channel: face-to-face, written, audiovisual, telephone, e-mail (additional examples?) 4.Receiver: interprets (decodes) the message 5.Feedback
Differentiate between short-term and long-term goals. What is the purpose for setting a time frame for goals?
1.Short-term goals, hours/days 2. Longe-term goal, week, months, or longer. Importance of goals 1. Provide a guide 2. Motivate nurses and patient 3. Form criteria.
Identify appropriate goals for actual nursing diagnoses. I.e. what are the specific components of a goal statement?
A goal statement should include a subject, an action verb, a performance criterion, a target time, and special conditions if needed.
Identify strategies to minimize liability in nursing practice (Informed Consent, Incident Reports).
Always explain procedure and obtain consent before anything Incident report- standard of care breached or an unusual incident occurs, for quality improvement to prevent incidents from reoccurring .date, time, patient, and location. Informed consent- permission for any and all types of care given by the patient with full knowledge of risks, benefits, costs, and alternatives., signed by the patient or legal personal. 1. Completeness: patient fully educated 2. Clarity and comprehension: pt should be able to describe in his own words 3. Voluntariness: free to accept or reject treatment. 4.Competence: the person must have the ability to understand the information and make a choice about particular situation. (spouse, parents, siblings) Nurse- determine valid inform consent is in place, communicate the patient's needs for more information to the care provider, and provide feedback if patient wished to change her consent. coming to agency consents are for vital signs and injections patient object, education benefits, still objects record and report to doctor.
Describe the role of communication in each of the four phases of the therapeutic relationship.
Caring, relationship, connectedness, and involvement are the foundation of a meaningful communication. Therapeutic relationships focuses on improving the health of the client. Therapeutic communication is client centers communication directed in achieving client goals. It is used to develop therapeutic relationships to provide and obtain healthcare information, express interest, concern and caring for the client and family.
Identify a correctly written measurable client outcome.
Components of an NOC outcome 1. Outcome label- neutral label, allow for positive and negative or no change in patient health status. (linked to NANDA) 2. Indicator- observable behaviors that states you can use to evaluate patient status. 3.Measurement Scale- describing patient status for each indicator.
Describe the process for prioritizing clients who need a comprehensive, formal discharge plan.
Discharge planning- the process of planning for self-care and continuity of care after the patient leaves the hospital setting. Nurses need to plan and coordinate services. 1. Notify the patient and family- try in advance A day or two before discharge 2. Make or confirm necessary arrangements 3. communicate and provide teaching to patient and caregivers. educate about medication, ask family to bring clothes Day of Discharge 4. Make and document final assessment 5. Bring wheelchair or other transport. 6 Make final notifications. 7. Gather prescriptions and instruction sheet. 8. Gather and pack the patients personal items. 9. Prepare patient's medication 10. Review discharge instructions 11. Address any questions or concerns 12. Give new prescriptions and reminder cards. 13. Document your final nursing note and complete the discharge summary. 14. Accompany the patient off the unit. 15. Notify the admissions department. 16. Ensure that patients records are sent.
Explain disciplinary actions for unacceptable nursing decisions or actions (impaired nurses).
Disciplinary actions 1.Complaint from an individual , employer, or professional organization that the nurse was engaged in unprofessional conduct. 2. Complaint sets to investigator to determine legitimacy -violated, need to gather more information, witness, review documents and reports 3. Case is heard by the board of nursing to determine if there was a violation / punishment, Provide you Notice Evidence A hearing 4. Can appeal in private court 5. Every stage have a right for attorney (how many of case were in the area of administrate law and how many times have you represent clients in front of profession boards. *allowed to return back to work after rehabilitation
Compare and contrast techniques that enhance communication to techniques that hinder communication (i.e. what are therapeutic techniques or communicating with your client; what do you say to a client who is crying uncontrollably).
Enhancing therapeutic communication 1.Listen actively. "tell me more", "when you say.. what do you mean?", make eye contact and focus on conversation. not listening= ^ pt anxiety 2.Establish trust. (pt won't let you touch them, unless you build trust) facilitates trust disclosure and honesty, greet by name and answer honestly. 3. Be assertive. -convey their needs and concerns, without care of being judged. 1. Get person attention 2. Express your concern 3. State the problem 4. Propose an action. 5. Reach a decision. 4.Restate, clarify, and validate message. 5.Interpret body language. Connect body language with words, if they don't connect voice concern with pt. 6.Share your observations to clarify. 7.Use open-ended questions. 8.Use silence., especially when someone is emotionally upset. 9.Summarize the conversation. -At the end of the conversation summarize what you heard, demonstrates active listening. 10. Process recordings- two people converse and while three records. Barriers to Therapeutic Communication 1. Asking too many questions ( don't ask so many closed questions, yes/ no) 2. Asking Why 3. Fire-Hosing Information- overwhelm family with tons of information. 4.Changing the subject inappropriately- seems uninterested 5. Failing to probe- incomplete assessment. try to gather more information. 6. Expressing approval or disapproval- consider offering recommendations and allowing patients to choose. ex. I decide to get the survey, nurse response- tell me more. Nurse empowered patient to make there own discussion. 7. Offering Advice- if patients ask what should they do, provide them options and inform them about choices 8. Providing false reassurance- don't say everything is going to be okay. 9. Stereotyping- don't expect, patient to be claim, assume patient understands whats going on, expecting patients with same surgery or diagnosis to experience similar response. 10. Using Patronizing Languages - don't say "you better know better" don't say are we ready for or bed bath? sounds like you are talking to a child. Use Mr. Ms. Dr. and then asked how would they like to be address.
Identify laws and regulations that guide nursing practice (i.e. differences among federal versus state laws).
Federal -HIPAA -EMTALA -Patient self- determination act (PSDA) -Americans with Disabilities Act (ADA) State( law varies) -Mandatory reporting law -good samaritan law -Nurse Practice Acts -Medical Malpractice Statues: death, injury or other loss to person being treated. Other guidelines for Practice -Institutional Policies and Procedures : care appropriate for and expected for specific facility, should not conflict with NPA or other laws. -American Nursing Association Code of Ethnics: not a law. safe, compassionate, nondiscriminatory and quality care. Patient rights to dignity, privacy, and safety. -Patient Care Partnership (PCP), not legal binding explain to patients what they should expect from care : HQ, clean, involvement, protection of privacy, help leaving and billing. - American Nursing Association Nurses Bills of Rights : 7 conditions nurses should expect - American Nurses Association Standards of Practice: 3 components, 1. Professional standards of care, professional performance standards, and practice guidelines.
Write realistic specific, concrete and observable goals that do not conflict with the medical plan of care and are stated in terms of a client.
Goals should be concrete, specific, and observable; they should be valued by the patient/family; and they should not conflict with the medical treatment plan.
Identify nursing interventions for a client experiencing impaired communication.
Impaired condition or consciousness. Make effort to communicate whether or not the client understand you. 1. Always try to communicate 2.Don't use in-room intercom to speak 3. Don't rush the client 4. Reduce environment distractions 5. Approach the patient directly; make eye contact.
Describe how the nurse would communicate with clients with impaired hearing, speech, or cognition.
Impaired speech 1. nonverbal communication. 2.use hand gestures or picture boards. 3.Use family members. 4.provide conformable environment for patient to practice speaking. 5. continue to speak and explain procedure. 6. refer to speech therapist if necessary. Visually impaired 1. Introduce when you enter the room 2.call client by her name 3. describe the room, layout, and activities occurring. 4. explain unfamiliar sound on systems. 5. limited vision- place yourself in field of vision. 6. speak before touch. 7. don't speak loudly unless pt has impaired hearing. 8. let the client know your leaving the room 9. use works look and see. 10. avoid "over there" or "right here" Hearing Impaired Clients -Assess pt method of receiving speech 1.hearing aid -turn on 2. read lips? -only 1/3 could be understood 3. arrange a hearing evaluation and construct any required hearing aids. -Position yourself and minimize noise 1. don't chew gum or eat while talking, many use lip reading 2. Clearly visible to the client 3. Face client directly; hand away from your mouth 4. move to better ear -Send the message 1. speak slowly and clearly, don't shout 2. Don't drop your voice at the end of a sentence 3. Use simple, plain, but longer phrases, ex " would you like me to get you a drink of water?" instead of "do you want a drink?" 4. use gestures 5. use paper, pencil, or computer communication when necessary . -Interpret the client's response 1. observe the clients verbal response, facial expression, and body language. 2. be aware some people may no yes, even though they do not understand what is being said. 3.Confirm client understood what you said by repeating. 4.Pt don't understand rephrase, older adults use low pitched voice.
Discuss common causes of malpractice litigation.
Malpractice- failure of professional person to act in a reasonable and prudent manner. Plaintiff-suer 1. Duty- (relationship)when patient is assigned to nurse or seeks treatment from nurse, or when the nurse observes another person doing something that can harm the patient 2.Breach of Duty- nurse fail to met standards of care. Attorney looks at what another nurse would do in the same situation. Expert witness-educate judge on whether or not the nursing action was acceptable. 3. Causation-nursing action caused injury to patient. 4. Damages: Remedy for harm is money Captain of the ship- surgical situations, physician is held liable. Borrowed Servant Doctrine- borrower is no responsible for actions of employee Respondent Superiors - "let the master answer". Employer is responsible for action of the nurse. Common causes of Malpractice 1.Failure to respond: not intervening to care for the patients specific symptoms or expressed request for care. 2. Failure to Educate: not answering questions, or teaching, or explaining. 3. Failure to follow standards of car and institutional polices and procedure: medical errors, failure to follow providers orders, usually when hospital is understaffed. 4. Failure to communicate: nurse fails to seek medical authorization for treatment or failure to notify physician. 5. Failure to Document: allergies, injuries, medication administration, progress, orders, and telephone conversations with physicians. 6. Failure to act as an advocate: - Medical and discharger orders:ex: nurse needs to question incomplete or illegible orders, just not questioning - Impaired nurses: report nurses coming to work under the influence. -Family and significant other: failure to report neglect and intentional injuries.
Describe major ethical principles that are used in reasoning about healthcare (focus on nonmaleficence, veracity, beneficence and fidelity).
Nonmaleficence- An ethical principle that refers to preventing harm, avoiding actions that cause harm to a client, or removing a client from harm. Veracity- Truthfulness Beneficence- An ethical principle that addresses the concept that nursing actions should promote good Fidelity- Making only promises or commitments that can be kept.
Describe the process for evaluating a client's health status (outcomes) after interventions.
Outcome evaluation focus on the observable or measurable changes in the patient's health status that results from the care given. -used to evaluate quality of care in an organization.
Relate the impact of the Health Insurance Portability and Accountability Act (HIPAA) to patient rights and protections.
Pass by Congress in 1996 - Protect health insurance benefits for workers who lose or change their jobs - protect coverage to persons with pre-existing medical conditions -establish standards to protect the privacy of personal health information * protect patients rights by not sharing patient information Allows patients to see, make corrections to, and obtain copies of there medical record. -8 days in jail taking graphic photos - Fired after painting an unconscious patient face and taking photos - 33 months for handing attorney face sheets.
Describe how you would communicate with clients whose culture or language is different from yours (i.e what nursing interventions provide effective care for a client whose language is different than yours).
Provide interpreter. Only us family if translator is not available. Be aware of culture, is eye contact aggressive, how much space should you provide the client? -use touch cautiously -smile to be polite, don't be overly friendly.
Identify laws and regulations that guide nursing practice (EMTALA)
Requires healthcare facilities to provide emergency health treatment to patients who seek healthcare in the ED, regardless of there ability to pay, legal status, or citizenship. The obligation is for the medical facility to medically screen to determine whether or not an emergency exits before transfering.
Identify characteristics of verbal and nonverbal communication.
Verbal- use words Non-verbal, body language
