NURS 3110 Test 1 Notes and Study Guide
NURS 3110 Test 1 Notes and Study Guide NURS 3110 01
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3110 Test Two Study Guide Qualities of a nurse as good communicator Types of communication Phases of the helping relationship Purpose of SBARR to be covered next week What each letter of SBARR is referring to be covered next week Nursing diagnoses related to verbal communicationspeech Communicating with a foreign patients Communication with the elderly Therapeutic responses Interventions designed to facilitate communication Communication concerns Appropriate responses from the nurse to criticisms difficult patients Nurse documentation entries into a patient s record Legal charting Chart locations of data Discharge planning for patients community resources Hand offs at shift changes Data entry errors Patient education Assessing teachinglearning Phases of a teaching plan Learning domains Techniques to enhance learning of developmental stages Factors affecting a patient ability to learn Learning readiness assessment Timing of teaching content Evaluation of learning Obtaining informed consent Physical symptoms of stress relaxation therapy Nursing code of ethics Ethical dilemmas Ethical principles Determining quality of life Tuesday January 20 2015 Chapter 1 Nursing Today Test 2 hours for test scantron 7075 questions read the question mostly application not definitions recognize nursing diagnoses asked to give the better answer whatever is more accurate more wholistic best way to study read book notes do questions at end of each chapter big picture test review week following the test after class 40 minutes Historical Perspective Highlights nurses respond to needs of the patient actively participate in policy professional organizations lobby for health care legislation to meed needs of patients esp those underserved respond and adapt to challenges studied and tested new and better ways to help patients ex Florence make clinical judgments and decisions about patients health care needs based on knowledge experience and standards of care sometimes experience can hurt you New eyes are good nursing care is provided according to standards of practice and a code of ethics Florence Nightingale first practicing epidemiologist saw nursing as having quotcharge of somebody39s healthquot organized the first school of nursing Nightingale Training School for Nurses at Thomas39 Hospital in London improved sanitation in battlefield hospitals connected poor sanitation with cholera and dysentery known as quotlady with the lampquot her practices remain a basic part of nursing read summaries in book The 20th Century movement toward scientific researchbased practice defined body of knowledge 1901 army nurse corps established 1906 Mary Adelaide Nutting first professor of nursing at Columbia University insert rest of slide Tuesday January 20 2015 The 21 st Century nursing code of ethics changes in curriculum nursing in multiple care settings advances in technology and informatics end of life care people are living longer Influences on Nursing changes in society lead to changes in nursing health care reform demographic changes where people are living settling medically underserved how do you get the needs out to people who can39t afford it What is their perspective and expectation think of what they can afford how to talk to them you have to try to understand threat of bioterrorism ask yourself quotwhat were they exposed toquot mustard gas unsafe water allergens Same with miners rising health care costs nursing shortage Nursing as a Profession requires an extended education insert slides Scope and Standards of Practice insert slide nursing standards provide the guidelines for implementing and evaluate nursing care 6 Standards assessment diagnosis outcomes ID planning implementation evaluation Code of Ethics a code of ethics is the philosophical ideals of right and wrong that define principles used to provide care it is important for you to incorporate your own values and ethics into your practice Yourself how do my ethics values and practice compare with established standards Nursing Education 2 year associates 4 year bachelors masters ranges from nursing education specialty nurse practitioner doctoral continuing and inservice education Nursing Practice insert slides response to patients has to be practiced it can open the door or you can limit their trust with you Tuesday January 20 2015 advocating is scary but takes courage insert slides Professional Responsibilities nurses are responsible for obtaining and maintaining specific knowledge and skills in the past the provide care and comfort now to provide care and comfort AND to emphasize health promotion and illness prevention Professional Roles Autonomy and Accountability caregiver advocate educator communicator manager Career Development insert slides Professional Nursing Organizations insert slides Quality and Safety Education for Nurses QSEN competency patient centered care teamwork and collaboration evidencebased practice quality improvement safety informatics Additional Nursing Trends genomics public perception of nursing impact of nursing on politics and health policy future trends Tuesday January 20 2015 Chapter2 The Health Care Delivery System Challenges to Health Care reducing health care costs while maintaining highquality care for patients where39s the line improving access and coverage for more people our age group is under insured schoolaged children are also under insured encouraging healthy behaviors ower insurance if you don39t smoke if you39re a member in a gym etc earlier hospital discharges result in more patients needing nursing homes or home care more follow up home visits don39t happen anymore Emphasis on Population Wellness pay attention to this in the reading health services pyramid managing health instead of managing illness its better to take care of yourself than to patch up yourself when you39re sick emphasis on wellness injury prevention programs National Priorities Partnership national priorities patient and family engagement we value your judgement working with the family to help the patient popuation health working with groups students etc safetyeliminating errors as possible care coordination upon admission is when you start thinking about discharge possibilities palliative care for advanced illnesses what do you do when there39s nothing left to do help them die with dignity just get them comfortable overusereducing waste recycle is this equipment necessary Institute of Medicine IOM nurses need to be transformed by practicing to the full extent of their education achieving higher levels of education and training through an improved education system that provides seamless progression becoming full partners with physicians and other leaders in redesigning the health care system by improving data collection and the information the hierarchy view can destroy the system we can39t stand by and let at trouble physician take the fall Healthcare Regulation and Competition insert slides profitability if hospitals don39t profit then they close This affects the community in a great way people lose jobs elderly don39t have somewhere to go etc read PPS section in book Tuesday January 20 2015 Health Care Settings and Services look in book Health Care AccreditationCertification if joint commission gives a hospital a bad report then they will probably close Preventative and Primary Health Care insert slides Secondary and Tertiary Care insert slides highest level of spending Restorative Care insert slides Continuing Care for people who are disabled functionally dependent or suffering a terminal disease assisted living respite care adult day care centers hospice Provide 24hour intermediate and custodial care Nursing rehabilitation diet social recreational and religious services Residents of any age with chronic or debilitating illness Regulated by standards Omnibus Budget Reconciliation Act of 1987 lnterdisciplinary functional assessment is the focus of clinical practice MDS RAls Residence can be temporary or permanent According to the US Census Bureau 5 of those over 65 years of age live in nursing centers or other facilities Nursing facilities succeed when they recognize residents as active participants and decision makers in their care and life in institutional settings Staff must complete the Resident Assessment Instrument RAl on all residents The RAl consists of the Minimum Dataset MDS Resident Assessment Protocols and utilization guidelines of each state Box 2 2 on text p 21 lists major regulatory requirements defined by OBRA 1987 Discuss Box 2 3 on text p 21 describes the minimum data set and resident assessment protocols Discuss Assisted Living offers a long term care setting with a home environment and greater resident autonomy Provides services such as laundry assistance with meals personal care housekeeping and 24 hour overnight Aows residents to live in their own units As one of the fastest growing industries within the United States assisted living offers privacy independence and security Some facilities provide assistance with medication administration although nursing care services are not available directly However this industry has little regulation no fee cap It may not be the most financially sound plan for some individuals Photo is on text p 22 Respite Care The service provides short term relief or quottime offquot for persons providing some care to an ill disabled or frail older adult Setting include home day care or health care institution with overnight care Tuesday January 20 2015 Trained volunteers allow family caregivers to leave the home for errands or social time The family caregiver usually not only has the responsibility for providing care to a loved one but often has to maintain a fulltime job raise a family and manage the routines of daily living as well Adult Day Care Centers Provide a variety of health and social services to specific patient populations who live alone or with family in the community May be associated with a hospital or nursing home or may operate independen y Offer services to patients such as daily physical rehabilitation and counseling Adult day care centers allow patients to retain more independence by living at home which reduces costs of health care Deaf patients are the most lonely Hospice Family centered care that allows patients to live and remain at home Focuses on palliative Not curative care comfort independence and dignity Provides patient and family support during terminal illness and time of death Hospice nurses mostly deal with pain regulation Many hospice programs provide respite care which is important in maintaining the health of primary caregiver and family Hospice care can be provided at home within a homelike setting or within the hospital setting Issues in Health Care Delivery Nursing shortage high shortage in hospicerespite care most go to ER OB etc Competency Box 2 4 on text p 23 presents the lOM s competencies for the twenty first century The health care practitioner competencies are an excellent tool for measuring how well a nurse practices nursing and can serve as a guide for the development of a professional nursing career Evidencebased practice Evidencebased practice involves the conscientious use of current best evidence along with clinical expertise and patient preferences and values in making decisions about patient care See Box 2 6 on text p 24 Nursing Work Environment and Patient Safety Quality and safety in health care Patientcentered care Health care providers define the quality of their services by measuring health care outcomes Ten rules of performance in a redesigned health care system are shown in Box 2 5 on text p 23 Health care organizations are being evaluated on the basis of outcomes such as prevention of complications patients functional outcomes and patient satisfaction Pay for performance programs and public reporting of hospital quality data are designed to promote quality effective safe patient care Tuesday January 20 2015 Box 2 7 on text p 25 reviews Dimensions of PatientCentered Care Discuss By learning early what a patient expects with regard to information comfort and availability of family and friends nurses are able to better plan patient care Magnet Recognition Program The American Nurses Credentialing Center ANCC established the Magnet Recognition Program to recognize health care organizations that achieve excellence in nursing practice See Boxes 2 8 Magnet Model and Forces of Magnetism and 2 9 Nursing Quality Indicators both on text p 26 Nursing informatics and technological advancements Nursing informatics uses information and technology to communicate manage knowledge mitigate error and support decision making Nurses gain or use information when they organize structure or interpret data Knowledge develops when nurses combine and identify relationships between different pieces of information Technological advancements influence where and how nurses provide care to patients and can help nurses improve direct care processes patient outcomes and work environments Ask students what they think of recent technological advancements do they help or hinder the nurse s effectiveness Globalization of health care globalization the increasing connectedness of the world s economy culture and technology is one of the forces reshaping the health care delivery system Children women and older adults are vulnerable populations most threatened by urbanization The Future of Health Care Change opens up opportunities for improvement Health care delivery systems need to address the needs of the uninsured and the underserved Health care organizations are striving to become better prepared to deal with these and other challenges in health care The solutions necessary to improve the quality of health care depend largely on the active participation of nurses Nurses need to remain knowledgeable and proactive about issues in the health care delivery system to provide quality patient care and positively affect health Tuesday January 20 2015 Chapter4 Theoretical Foundations of Nursing Practice insert 4 slides Theones Generate nursing knowledge for use in practice Can direct how to use nursing process Are adaptable to different patients and all care settings The goal of nursing knowledge is to explain the practice of nursing as different and distinct from the practice of medicine psychology and other health care disciplines what if you don39t know your role as a nurse we are the quotcaptain of the shipquot when it comes to patient care if you dive into areas where you are not the main role you39re not protected ex if a doctor orders you to do something that is not in your practice policy don39t do it delegation don39t delegate to people who cannot fill your role Nursing is a practiceoriented discipline Nursing process is not a theory It is a systematic set of steps for the delivery of nursing care not the knowledge component of our discipline Remember that a theory can direct how a nurse uses the nursing process Theory generates nursing knowledge for use in practice thus supporting evidence based practice Integration of theory into practice is the basis for professional nursing Theories from nursing and other disciplines help explain how the roles and actions of nurses fit together in nursing Interdisciplinary Theories Explain systematic views of phenomena specific to the discipline of inquiry basic human needs From developmental psychology you remember the basic human needs Maslow s hierarchy of needs is an interdisciplinary theory Ask students if they can recall the five needs 1 physiological 2 safety and security 3 love and belonging 4 esteem and selfesteem and 5 selfactualization developmental Developmental theories help determine whether patients are adapting during their specific developmental stage in life psychosocial Psychosocial theories help us to predict patient responses to their physiological psychological sociocultural developmental and spiritual needs systems draw picture Selected Nursing Theories Nightingale mid 1800s Environment as the focus of nursing care Tuesday January 20 2015 She was one of the first to develop a nursing theory 1860 that is still in use today Her concept of the environment was the focus of nursing care and her suggestion that nurses need not know all about the disease process differentiated nursing from medicine The focus of nursing is on caring through the environment and helping the patient deal with the symptoms and changes in function related to an illness Nightingale did not view nursing as limited to the administration of medications and treatments but rather it is oriented toward providing fresh air light warmth cleanliness quiet and adequate nutrition Through observation and data collection she linked the patient s health status with environmental factors and initiated improved hygiene and sanitary conditions during the Crimean War Nightingale s descriptive theory provides nurses with a way to think about patients and their environment Peplau 1952 focus on interpersonal relations between nurse patient and patent39s family development of nurseaptiet relationship theory focuses on interpersonal relations between the nurse the patient and the patient s family and developing the nursepatient relationship The patient is an individual with a need and nursing is an interpersonal and therapeutic process In developing a nursepatient relationship the nurse can serve as a resource person counselor and surrogate The patient gains from this relationship by using available services to meet needs and the nurse helps the patient reduce anxiety related to health care problems Peplau s theory is unique The collaborative nursepatient relationship creates a maturing force through which interpersonal effectiveness meets the patient s needs Henderson defines nursing as assisting the individual sick or well in the performance of those activities that will contribute to health recovery or a peaceful death and that the individual would perform unaided if he or she had the necessary strength will or knowledge Henderson organized the theory into 14 basic needs of the whole person and includes phenomena from the following domains of the patient physiological psychological sociocultural spiritual and developmental Framing nursing care around the needs of the individual allows you to use Henderson s theory for a variety of patients across the life span and in multiple settings along the health care continuum Orem 2001 focuses on patient39s selfcare needs because of the nursing shortage goal is for patient to manage hisher health problems defines selfcare as a learned goaloriented activity directed toward the self in the interest of maintaining life health development and wellbeing Nursing care is necessary when the patient is unable to fulfill biological psychological developmental or societal needs The nurse assesses and determines why a patient is unable to meet these needs identifies goals to assist the patient intervenes to help the patient perform selfcare and evaluates how much selfcare the patient is able to perform 9 TuesdayJanuan202015 According to Orem s theory the goal of nursing is to enhance the patient s ability to independently meet these needs Leininger 2010 theory of cultural care diversity and universality considers social structure factors how do you care for people who don39t speak your language have extreme poverty religious differences background in anthropology informed her theory Human caring varies among cultures in its expressions processes and patterns Societal structure factors such as the patient s religion politics culture and traditions are significant forces affecting care and influencing the patient s health and illness patterns The major concept of Leininger s theory is cultural diversity and the goal of nursing care is to provide the patient with culturally specific nursing care To provide care to patients of unique cultures the nurse safely integrates the patient s cultural traditions values and beliefs into the plan of care Leininger s theory recognizes the importance of culture and its influence on everything that involves the patient and providers of nursing care In addition symptom expression differs among cultures Neuman 2010 based on stress and the patient39s reaction to the stressor role of nursing is to stablize the patient or situation In the Neuman model the patient is the individual group family or community The system is composed of five concepts that interact physiological psychological sociocultural developmental and spiritual These concepts interact with both internal and external environmental factors and all levels of prevention primary secondary and tertiary to achieve optimal wellness Neuman considers any internal and external factors as stressors that affect the patient s stability and any or all of the five system concepts When you apply the Neuman systems model you assess the stressor and the patient s response to the stressor identify nursing diagnoses plan patientcentered care implement interventions evaluate the patient s response and determine whether the stressor is resolved Roy 1989 views the patient as an adaptice system when patnt cannot adapt to stressors nursing is needed According to Roy s model the goal of nursing is to help the person adapt to changes in physiological needs selfconcept role function and interdependent relations during health and illness The need for nursing care occurs when the patient cannot adapt to internal and external environmental demands All individuals must adapt to the following demands meeting basic physiological needs developing a positive selfconcept performing social roles and achieving a balance between dependence and independence The nurse determines which demands are causing problems for a patient and assesses how well the patient is adapting to them Nurses direct care at helping the patient adapt to changes Box 42 on text p 46 reviews TheoryBased Practice in the Management of Heart Failure Watson 1996 defines the outscome of nusring activity with regard to the humanistic aspects of life 10 Tuesday January 20 2015 purspose is to understand the interrlationships among health illness and human behavior In Watson s theory nursing is concerned with promoting and restoring health and preventing illness Watson designed the model around the caring process assisting patients in attaining or maintaining health or dying peacefully This caring process requires the nurse to be knowledgeable about human behavior and human responses to actual or potential health problems The nurse also needs to know individual patient needs how to respond to others and strengths and limitations of the patient and family and those of the nurse In addition the nurse comforts and offers compassion and empathy to patients and their families Benner and Wrubel 1989 caring is central not pitysympathy pity and sympathy with change how you treat your patient With Benner and Wrubel s theory caring is central to nursing and creates possibilities for coping enables possibilities for connecting with and concern for others and allows for giving and receiving help Caring means that persons events projects and things matter to people It presents a connection and represents a wide range of involvement This theory sees personal concern as an inherent feature of nursing practice In caring for one s patients nurses help patients recover by noticing interventions that are successful and that guide future caregiving The Link Between Theory and Knowledge Development nursing knowledge is theoretical and practical Nursing theories help direct nursing practice When using theorybased nursing practice you apply the principles of the theory in delivering nursing interventions in your practice Theorybased nursing practice improves nurse satisfaction and patient outcomes The reason for this is that the basic values guiding principles and elements from the foundation of a particular nursing theory give meaning to the practice and influence how patient care is provided the goals of theoretical knowledge are to stimulate thinking and create a braod understanding of the quotscienceAnd practices of the nursing discipline experiential knowledge or the quotartquot of nursing is based on the nurses39 experiences in providing care to patients 11 Tuesday January 20 2015 Chapter 15 Critical Thinking in Nursing Practice Critical thinking is A continuous process characterized by openmindedness continual inquiry and perseverance combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant It is being openminded quotwhat am not consideringquot Look through different angles How are you approaching the situation No labels no personal agendas or opinions don39t let the shift before me change my view of the patient Recognizing that an issue exists analyzing information evaluating information and making conclusions Critical thinking is a continuous process characterized by openmindedness continual inquiry and perseverance combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant Heffner and Rudy 2008 Critical thinking encompasses the following Recognizing that an issue exists analyzing information evaluating information and making conclusions Settersten and Lauer 2004 Nurses who apply critical thinking in their work focus on options for solving problems and making decisions rather than rapidly and carelessly forming quick simple solutions Thinking and learning are related processes Nurses will use observations and judgments to make choices You will always want to ask why and how when caring for patients The use of evidencebased knowledge see Chapter 5 helps you become a critical thinker Clinical Decisions in Nursing Practice Clinical decision making requires critical thinking Clinical decisionmaking skills separate professional nurses from technical and ancillary staff Patients often have problems for which no textbook answers exist Nurses need to seek knowledge act quickly and make sound clinical decisions adapt improv overcome Clinical decision making is judgment that includes critical and reflective thinking and action and application of scientific and practical logic Critical thinking challenges you to think creatively search for the answer collect data make inferences and draw conclusions Critical Thinking Skills Interpretation Be orderly in data collection Look for patterns to categorize data eg nursing diagnoses see Chapter 17 Clarify any data you are uncertain about It isn39t enough to know the facts you have to interpret Analysis Be openminded as you look at information about a patient Do not make careless assumptions Do the data reveal what you believe is true or are there other options Inference Look at the meaning and significance of findings Are there relationships between findings Do the data about the patient help you see that a problem exists 12 Tuesday January 20 2015 Evaluation Look at all situations objectively Use criteria eg expected outcomes pain characteristics learning objectives to determine results of nursing actions Reflect on your own behavior Explanation Support your findings and conclusions Use knowledge and experience to choose strategies to use in the care of patients SelfRegulation Reflect on your experiences Identify ways that you can improve your own performance What will make you believe that you have been successful Thinking and Learning Learning is a lifelong process lntellectual and emotional growth involves learning new knowledge as well as refining the ability to think solve problems and make judgments The science of nursing continues to grow Nurses need to be flexible and open to new information In Chapter 1 we talked about the attributes of a profession One of them was having a knowledge base As you have more clinical experiences and apply the knowledge you acquire you will become better at forming assumptions presenting ideas and making valid conclusions When you care for a patient always think ahead The following questions are questions a nurse should ask when caring for a patient What is the patient s status now How might it change and why Which physiological and emotional responses do I anticipate What do I know to improve the patient s condition In which way will specific therapies affect the patient What should be my first action Do not let your thinking become routine or standardized Instead learn to look beyond the obvious in any clinical situation explore the patient s unique responses to health alterations and recognize which actions are needed to benefit the patient Concepts for a Critical Thinker Truth seeking Seek the true meaning of a situation Be courageous honest and objective about asking questions Openmindedness Be tolerant of different views be sensitive to the possibility of your own prejudices respect the right of others to have different opinions Analytic approach Analyze potentially problematic situations anticipate possible results or consequences value reason use evidencebased knowledge Systematic approach Be organized and focused work hard in any inquiry Selfconfidence Trust in your own reasoning processes lnquisitiveness Be eager to acquire knowledge and learn explanations even when applications of knowledge are not immediately clear Value learning for learning s sake Maturity Multiple solutions are acceptable Reflect on your own judgments have cognitive maturity insert slide Critical thinking competencies are cognitive processes 13 Tuesday January 20 2015 Critical thinking processes are not unique to nursing but are used in everyday life in many situations Critical thinking processes include scientific method problem solving and decision making Specifically in nursing we use diagnostic reasoning and inference clinical decision making and nursing processes In diagnostic reasoning a nurse collects patient data and analyzes them to determine the patient s problems In clinical decision making a nurse identifies a patient s problem and selects a nursing intervention The nursing process is a fivestep clinical decisionmaking approach assessment diagnosis planning implementation and evaluation Let s look at a critical thinking model for nursing judgment This is Fig 151 from text p 194 The model s levels of critical thinking in the pyramid at the top of the model are discussed on this slide The components of critical thinking at the bottom of the model are discussed on the next slide This model presents three levels of critical thinking Level 1 is Basic At the basic level nurses think concretely on the basis of a set of rules or principles following a stepbystep process without deviation from the plan Following a procedure step by step without adjusting to a patient s unique needs is an example of basic critical thinking Level 2 is Complex Complex critical thinking analyzes and examines choices independently Nurses learn to think beyond and synthesize knowledge In complex critical thinking a nurse learns that alternative and perhaps conflicting solutions exist Level 3 is Commitment Commitment is the third level of critical thinking Nurses anticipate needs and make choices without assistance from others Five components of cirtical thinking in above slide Nursing Process the nursing precess is a 5 step assessment diagnosis planning implementation eval Nursing process is a scientific method with five specific steps Nursing process is essentially the process of applying the scientific method to caring for a patient The scientific method has five steps 1 Identifying the problem 2 Collecting data 3 Formulating a question or hypothesis 4 Testing the question or hypothesis 5 Evaluating results of the test or study 14 Tuesday January 20 2015 Attitudes Critical thinking attitudes help you to know when more information is necessary and when it is misleading and to recognize your own knowledge limits A nurse needs 11 attitudes when thinking critically The 11 attitudes a nurse needs are presented in Table 153 on text p 200 These attitudes include confidence independence fairness responsibility risk taking discipline perseverance creativity curiosity integrity and humility Let s discuss the first six attitudes The remaining five are covered in the next slide To acquire and show confidence learn how to introduce yourself to a patient speak with conviction when you begin a treatment or procedure Do not lead a patient to think that you are unable to perform care safely Always be well prepared before performing a nursing activity Encourage a patient to ask questionsyou39re mindful not thinking about other things hink about past times when you did it well To develop independence read the nursing literature especially when different views on the same subject are presented Talk with other nurses and share ideas about nursing interventions bring something to the team To practice and extend fairness listen to both sides in any discussion If a patient or a family member complains about a coworker listen to the story and then speak with the coworker If a staff member labels a patient as uncooperative assume the care of that patient with openness and a desire to meet that patient s needsdo i view patients differently does one deserve something more than another To take on responsibility and authority ask for help if you are uncertain about how to perform a nursing skill Refer to a policy and procedure manual to review steps of a skill Report any problems immediately Follow standards of practice in your care if i screw up admit it To become comfortable with risk taking if your knowledge causes you to question a health care provider s order do so Be willing to recommend alternative approaches to nursing care when colleagues are having little success with patientssometimes you have to fight for a patient and speak up To develop discipline be thorough in whatever you do Use known scientific and practicebased criteria for activities such as assessment and evaluation Take the time to be thorough and manage your time effectively have to be prepared do the work etc To develop perseverance be cautious of an easy answer If coworkers give you information about a patient and some fact seems to be missing clarify the information or talk to the patient directly If problems of the same type continue to occur on a nursing division bring coworkers together look for a pattern and find a solution To employ creativity look for different approaches if interventions are not working for a patient For example a patient in pain may need a different positioning or distraction technique When appropriate involve the patient s family in adapting your approaches to care methods used at home different angles 15 Tuesday January 20 2015 To show curiosity always ask why A clinical sign or symptom often indicates a variety of problems Explore and learn more about the patient so as to make appropriate clinical judgments To develop integrity recognize when your opinions conflict with those of a patient review your position and decide how best to proceed to reach outcomes that will satisfy everyone Do not compromise nursing standards or honesty in delivering nursing care who will i be characterized as will you lie wrong medicine make up numbers To show humility recognize when you need more information to make a decision When you are new to a clinical division ask for an orientation to the area Ask registered nurses RNs regularly assigned to the area for assistance with approaches to care I39m going to mess up what will i do about that Developing Cristical THinking Skills When you use critical thinking you need to connect knowledge and theory This can be done through reflective journaling and concept mapping Reflective journaling Reflective journal writing is a tool for developing critical thought and reflection by clarifying concepts Reflective writing gives you the opportunity to define and express the clinical experience in your own words Di VitoThomas 2005 By keeping a journal of each of your clinical experiences you are able to explore personal perceptions or understanding of each experience and develop the ability to apply theory in practice The use of a journal improves your observation and descriptive skills Writing skills improve through the development of conceptual clarity Concept mapping The primary purpose of concept mapping is to better synthesize relevant data about a patient including assessment data nursing diagnoses health needs nursing interventions and evaluation measures Hill 2006 Through drawing a concept map you learn to organize or connect information in a unique way so the diverse information that you have about a patient begins to form meaningful patterns and concepts You begin to see a more holistic view of a patient When you see the relationship between the various patient diagnoses and the data that support them you better understand a patient s clinical situation Concept maps become more detailed integrated and comprehensive as you learn more about the care of a patient and the care you provide similar patients Ferrario 2004 Critical thinking and delegation Effective communication is needed between registered nurses RNs and nursing assistive personnel NAP for giving feedback and clarifying tasks and patient status When patients clinical conditions change warranting attention by RNs clear directions are necessary to avoid missed care Applying critical thinking can help an RN make the decision about when to appropriately delegate care 16 TuesdayJanuan202015 This slide covers the content of Box 151 on text p 197 Critical Thinking and Delegation which is drawn from the results of two separate studies in which nurses were asked to describe the process of delegation in their clinical practice Nurses synthesize large amounts of information and think through complex and often emergent clinical situations to make decisions about patient care including delegation An important delegation issue is the right circumstances Registered nurses RNs are responsible for making clinical decisions when patients conditions change including determining what and when to delegate When an RN makes the clinical decision to delegate care it is expected that nursing assistive personnel NAP must report significant findings and that the RN must follow up on tasks that have been delegated Delegation is ineffective if RNs fail to carry out proper supervision and evaluation of care When delegation is ineffective often activities such as ambulation feedings and turning are missed by NAP Successful delegation depends on good communication developing a trusting and respectful relationship and showing initiative Caring for Groups of Patients Identify the nursing diagnoses and collaborative problems of each patient Decide which are most urgent Consider the time it will take to care for those patients Consider the resources that you have to manage each problem Consider how to involve the patients as participants in care Decide how to combine activities Decide which nursing care procedures to delegate Discuss complex cases with the health care team Box 152 on text p 197 covers the important issues of clinical decision making for groups of patients ldentify the nursing diagnoses and collaborative problems of each patient see Chapter 17 Analyze patients diagnosesproblems and decide which are most urgent on the basis of basic needs the patients changing or unstable status and problem complexity see Chapter 18 Consider the time it will take to care for patients whose problems are of high priority eg do you have the time to restart a critical intravenous IV line when medication is due for a different patient Consider the resources you have to manage each problem nursing assistive personnel assigned with you other health care providers and patients family members Consider how to involve the patients as decision makers and participants in care Decide how to combine activities to resolve more than one patient problem at a time Decide which if any nursing care procedures to delegate to assistive personnel so you are able to spend your time on activities requiring professional nursing knowledge 17 Tuesday January 20 2015 Discuss complex cases with other members of the health care team to ensure a smooth transition in care requirements Meeting with Colleagues When nurses have a formal means to discuss their experiences such as a staff meeting or a unit practice council the dialogue allows for questions differing viewpoints and sharing of expenences When nurses are able to discuss their practices the process validates good practice and offers challenges and constructive criticism Meeting with colleagues gives you the chance to discuss and examine work expenences Discussing anticipated and unanticipated outcomes in any clinical situation allows you to continually learn and develop your expertise and knowledge Cirocco 2007 Much can be learned by drawing from others experiences and perspectives to promote reflective critical thinking Five Step nursing process model Fig 152 from text p 198 is a model of the fivestep nursing process This model of the fivestep nursing process illustrates that the critical thinking and clinical decision making that you will engage in as nurses are not part of a simple linear process Each step of the process is affected by the step before and will affect the steps that follow The purpose of the nursing process is to diagnose and treat human responses to actual or potential health problems American Nurses Association 2010 Human responses include patient symptoms and physiological reactions to treatment the need for knowledge when health care providers make a new diagnosis or treatment plan and a patient s ability to cope with loss Use of the process allows nurses to help patients meet agreedon outcomes for better health The nursing process requires a nurse to use the general and specific critical thinking competencies that we have reviewed to focus on a particular patient s unique needs Within each step of the nursing process you apply critical thinking to provide the very best professional care to your patients Synthesis of Criical THinking Witht he nursing process competency This is Fig 153 from text p 203 a synthesis of critical thinking with the nursing process competency or the five steps of the nursing process As a beginning nurse it is important to learn the steps of the nursing process and incorporate the elements of critical thinking 18 Tuesday January 20 2015 Critical thinking is a reasoning process by which you reflect on and analyze your own thoughts actions and knowledge To be a good critical thinker requires dedication and a desire to grow intellectually The two processes dedication and the desire to grow intellectually go hand in hand in making quality decisions about patient care Discuss the QSEN Box on text p XXX Building Competency in Quality Improvement Critical Thinking Synthesis Critical thinking is a reasoning process used to reflect on and analyze thoughts actions and knowledge Critical thinking requires a desire to grow intellectually Critical thinking requires the use of nursing process to make nursing care decisions Critical thinking and the nursing process are inseparable As a new nurse you will rely on the nursing process to guide your practice The next five chapters thoroughly discuss nursing process and application to patient care VIDEO 19 Tuesday January 20 2015 Chapter 16 Nursing Assessment Five Step Nursing Process This is Fig 161 from text p 207 The nursing process is central to your ability to provide timely and appropriate care to your patients It begins with the first step assessment the gathering and analysis of information about the patient s health status You then make clinical judgments from the assessment to identify the patient s response to health problems in the form of nursing diagnoses Once you define appropriate nursing diagnoses you create a plan of care Planning includes setting goals and expected outcomes for your care and selecting interventions nursing and collaborative individualized to each of the patient s nursing diagnoses The next step implementation involves performing the planned interventions After performing interventions you evaluate the patient s response and determine whether the interventions were effective Nursing Process The nursing process is a variation of scientific reasoning Practicing the five steps of the nursing process allows you to be organized and to conduct your practice in a systematic way You learn to make inferences about the meaning of a patient s response to a health problem or generalize about the patient s functional state of health Through assessment a pattern begins to form Assessment is the deliberate and systematic collection of information about a patient to determine his or her current and past health and functional status and his or her present and past coping patterns Clearly defining your patients problems provides the basis for planning and implementing nursing interventions and evaluating the outcomes of care Critical Thinking Approach to Assessment patient is best source of info unless they are compromised Assessment involves collecting information from the patient and from secondary sources eg family members along with interpreting and validating the information to form a complete database Two stages of assessment 1 Collection and verification of data First to collect and verify data from the patient primary source and from family health care providers and medical records secondary source 2 Analysis of data The data will be used to develop the nursing diagnosis identify collaborative problems and develop an individualized plan of care You perform assessment to gather information needed to make an accurate judgment about a patient s current condition Experience knowledge standards and attitudes all influence critical thinking in assessment Database 20 Tuesday January 20 2015 The purpose of assessment is to establish a database about the patient s perceived needs health problems and responses to these problems In addition the data reveal related goals experiences health practices values and expectations about the health care system Critical thinking skills help you to synthesize relevant information and use it in a purposeful way Critical thinking is a vital part of assessment It allows you to see the big picture when you form conclusions or make decisions about a patient s health condition Validation of any abnormal assessment findings and personal observation of assessments performed by skilled professionals help you become competent in assessment You also learn to apply standards of practice and accepted standards of normal for physical assessment data when assessing patients Use of critical thinking attitudes such as curiosity perseverance and confidence assists you in completing a comprehensive database See also Fig 162 Critical thinking and the assessment process on text p 208 Data Collection Sources of data Patient interview observation physical examination the best source of information this is when the importance of a good interview comes into play Family and significant others obtain patient s agreement first parents of PEDS is the best info Health care team Medical records Scientific literature Nurse s experience Subjective vs objective data Data can be subjective or objective Ask students if they can differentiate between these two Subjective data Patients verbal descriptions of their own health problems Objective data Observations or measurements that a health care provider obtains As you begin a patient assessment think critically about what to assess for that specific patient When beginning to assess your patients you will use cues and inferences to help you deal with all of the data collected A cue is information that you collect through the use of your senses An inference is your judgment or interpretation of the cues you just gathered Note You will want to discuss the assessment model or tool that you utilize at your college or university Remember a patient does not always want you to question or involve the family You must obtain a patient s agreement to include family members or friends Cues and lnferences looks uncomfortable presents disomfort in surgical area cues lies still with tense arms at side states they haven39t turned in some time rates 710 on pain scale inferences pain is sever pain limits patient39s ability to move and reposition self Comprehensive side Process of Assessment 21 Tuesday January 20 2015 Collect data Cluster cues make inferences and identify patterns and problem areas Critically anticipate Be sure to have supporting cues before making an inference Knowing how to probe and frame questions is a skill that grows with experience Once you ask a patient a question or make an observation patterns form and the information branches to an additional series of questions or observations See Fig 164 on branching logic on text page 210 You learn to decide which questions are relevant to a situation and to attend to accurate interpretations of data During assessment critically anticipate and use an appropriate branching set of questions or observations to collect data and to cluster cues of assessment information to identify emerging patterns and problems Methods of Data Collection Patientcentered interview An organized conversation with the patient Set the stage preparation environment greeting tell them how longhow many questions you39ll ask Set an agendagather information about patient s concerns Collect the assessment or nursing health history assure the patient of confidentiality Terminate the interview cue the end The best clinical interview focuses on the patient not on your own agenda A successful interview requires preparation Collect available information about the patient before starting the interview prepare the interview environment and time the interview to avoid interruptions A good interview environment is free of distractions unnecessary noise and interruptions Remove any barriers to privacy See Box 162 on text p 211 Focus on OlderAdults During the interview you will conduct a nursing health history The history collects information regarding patients current level of wellness as well as a review of body systems family history sociocultural history spiritual health and mental and emotional reactions More discussion of the health history is provided on an upcoming slide Be sure to assure the patient that any information obtained remains confidential and is used only by health care professionals who provide his or her care The Health Insurance Portability and Accountability Act HIPAA regulations require patients to sign an authorization before you collect personal health data As you conclude the interview you summarize your discussion with the patient and check for accuracy of the information collected Give your patient a clue that the interview is coming to an end This helps the patient maintain direct attention without being distracted by wondering when the interview will end and also gives the patient an opportunity to ask additional questions Interview Techniques Openended vs closedended questions Backchanneling Probing quotwhat do you mean by thatquot Because a patient s report includes subjective information validate data from the interview later with objective data 22 Tuesday January 20 2015 Obtain information as appropriate about a patient s physical developmental emotional intellectual social and spiritual dimensions Examples of closedended and openended questions are shown in Box 163 on text p 213 How you conduct the interview is just as important as the questions you ask A skillful interviewer adapts interview strategies based on the patient s responses During the interview you are responsible for directing the flow of the discussion so your patient has the opportunity to freely contribute stories about his or her health problems to enable you to get as much detailed information as possible Always clarify or validate any information about which you are unclear During an assessment interview encourage patients to tell their stories about their illnesses or health care problems Cultural Considerations To conduct an accurate and complete assessment you need to consider a patient s cultural background When cultural differences exist between you and a patient respect the unfamiliar and be sensitive to a patient s uniqueness If you are unsure about what a patient is saying ask for clarification to prevent making the wrong diagnostic conclusion As a professional nurse it is important to conduct all assessments with cultural competence This involves not imposing your own attitudes and beliefs Avoid making stereotypes draw on knowledge from your assessment and ask questions in a constructive and probing way to allow you to truly know who the patient is You must be sure that you grasp exactly what a patient means and know exactly what a patient thinks you mean in words and actions Do not make assumptions about a patient s cultural beliefs and behaviors without validation from the patient Communication and culture are interrelated in the way feelings are expressed verbally and nonverbally If you learn the variations in how people of different cultures communicate you will gather more accurate information from patients Using the right approach with eye contact shows respect for your patient and likely results in the patient sharing more information It is easier to explore cultural differences if you allow time for thoughtful answers and ask your questions in a comfortable order Nursing Health History 23 Nursing health history Data about the patient s current level of wellness When collecting a complete nursing history let the patient s story guide you in fully exploring the components related to his or her problems 1 Biographical information Age address occupations marital status health care insurance 2 Patient expectations Find out what patients expect to happen to them while seeking treatments for their health 3 Reason for seeking health care You learn the patient s chief concerns or problems 4 Present illness or heath concerns Determine when the problems began how severe intensity quality what makes them worse and what makes them better Tuesday January 20 2015 5 Concomitant symptoms Does the patient experience other symptoms along with the primary symptom 6 Health history Provides you with information regarding the patient s past history Has there been a hospitalization A procedure Medication uses Prescription over the counter herbal natural Use of alcohol tobacco caffeine recreational drugs Sleeping patterns Exercise habits Nutritional habits Family history Blood relative health issues Recent losses Religious influences Relationships 7 Environmental history Home environment Workplace environment Exposure to pollutants 8 Psychosocial history Support system Spouse Children Friends Family members Coping mechanisms 9 Spiritual health Religion Religious habits 10 Review of systems A method for collecting data on body systems 11 Documentation Each health care facility has forms to use Refer to your specific health care facility s documentation forms See also Fig 165 Dimensions for gathering data for a health history on text p 215 Next Assessment Step Physical examination An investigation of the body to determine its state of health Observation of patient behavior verbal vs nonverbal Diagnostic and laboratory data lnterpreting and validating assessment data Validation of assessment data consists of comparison of data with another source to determine accuracy of the data You will learn more about physical assessments when we get to Chapter 30 Health Assessment and Physical Examination A physical examination involves the techniques of inspection palpation percussion auscultation and smell A complete examination includes a patient s height weight and vital signs and a head totoe examination of all body systems The data from a handson physical assessment allow you to collect valuable objective information needed to form accurate diagnostic conclusions Always conduct an examination competently using a caring and culturally sensitive approach To accompany the results you obtain from the physical assessment data can be obtained from other sources By observing patients you will be able to get an idea of whether their nonverbal behavior matches what they are saying Observations direct you to gather additional objective information to form accurate conclusions about the patient s condition An important aspect of observation consists of a patient s level of function physical developmental psychological and social aspects of everyday living Diagnostic and laboratory data will provide you with information needed to develop a plan of care 24 Tuesday January 20 2015 Interpreting and validating assessment data will help you when selecting a nursing diagnosis Data analysis involves recognizing patterns or trends in the clustered data and then comparing them with standards See Box 166 for assistance see also Box 164 on text p 217 Recognizing Data Clusters Successful interpretation and validation of assessment data ensure that you have collected a complete database Data Documentation the last ocmpnent of a complete assessment legal and professional responsibility requoires accurate and approved terminology and abbreviations The patient record is a legal document It can be used in a court of law It is reviewed by accreditation agencies It is used by insurance companies to deny or approve patient charges and payments 25 Tuesday January 20 2015 Chapter 17 Nursing Diagnosis Medical diagnosis ID of a disease condition based on specific evaluationf signs and symptoms Nursing diagnosis clinical judgment about the patient in response to an actual potential health problem Collaborative problem actual or potential physiological complication that nurses monitor to detect a change in patient status A medical diagnosis is the identification of a disease condition based on a specific evaluation of physical signs and symptoms the patient s medical history and the results of diagnostic tests and procedures A nursing diagnosis is a clinical judgment about individual family or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat What makes the nursing diagnostic process unique from medical diagnoses is having patients involved when possible in the process Selection of a nursing diagnosis provides the basis for choosing nursing interventions Accurate diagnosis of patient problems ensures the selection of more effective and efficient nursing interventions Nursing diagnoses are listed according to the North American Nursing Diagnosis Association NAN DA Selecting the correct nursing diagnosis on the basis of an assessment involves diagnostic expertise Nursing Diagnostic Process assesssment of patient39s health status patient familyl health care resources insert slides if no additional data re needed proceed interpret and analyze meaning of data data clustering gourp sign and sypmtoms classify and organize book Nursing Diagnostic Statement Provides a precise definition of a patient s problem that gives nurses and other members of the health care team a common language for understanding patients needs Allows nurses to communicate what they do among themselves and with other health care professionals and the public Distinguishes the nurse s role from that of the physician or other health care provider Helps nurses focus on the scope of nursing practice Two additional purposes of nursing diagnosis are that they Foster the development of nursing knowledge Promote creation of practice guidelines that reflect the essence of nursing Critical Thinking and the nursing Diagnostic Process The diagnostic reasoning process involves using the assessment data you gather about a patient to logically explain a clinical judgment or a nursing diagnosis Nursing diagnoses and definitions Defining characteristics Clinical criteria or assessment findings 26 Tuesday January 20 2015 Related factors pertinent to the diagnoses Interventions suited for treating the diagnoses The diagnostic process flows from the assessment process and includes decisionmaking steps Data clustering identifying patient health problems and formulating the diagnosis or collaborative problem Think back to the critical thinking chapter You will use your critical thinking abilities to identify an appropriate nursing diagnosis to individualize patient care In the practice of nursing it is important for you to know nursing diagnoses their definitions and defining characteristics for making diagnoses related factors pertinent to the diagnoses and interventions suited for treating the diagnoses Sources of information about nursing diagnoses include faculty advanced practice nurses documentation systems and in some settings practice guidelines or protocols The application of critical thinking attitudes and standards helps you to be thorough comprehensive and accurate when identifying nursing diagnoses that apply to your patients See Figure 171 on text p 223 which shows how critical thinking interacts with the nursing process Each nursing diagnosis contains a specific set of defining characteristics to support it When you focus on the defining characteristics you also need to compare the patient s pattern of data with normal or expected data Data you will look at include laboratory and diagnostic values professional standards and normal anatomy and physiology Data Clustering A data cluster is a set of signs or symptoms gathered during assessment that you group together in a logical way Data clusters are patterns of data that contain defining characteristics clinical criteria that are observable and verifiable Each clinical criterion is an objective or subjective sign symptom or risk factor that when analyzed with other criteria leads to a diagnostic conclusion Each NANDAl approved nursing diagnosis has an identified set of defining characteristics that support identification of a nursing diagnosis You learn to recognize patterns of defining characteristics from your patient assessments and then readily select the corresponding diagnosis Working with similar patients over a period of time helps you recognize clusters of defining characteristics but remember that each patient is unique and requires an individualized diagnostic approach Defining characteristics are subjective and objective clinical criteria that form clusters leading to a diagnostic conclusion Box 173 Examples of NAN DA International Approved Nursing Diagnoses with Defining Characteristics on text p 227 shows two examples of approved nursing diagnoses and their associated defining characteristics When an assessment reveals defining characteristics that apply to more than one nursing diagnosis gather more information to clarify your interpretation Interpretation lD Health Problems It is critical to select the correct diagnostic label for a patient s need From assessment to diagnosis move from general information to specific 27 TuesdayJanuan202015 Think of the problem identification phase in assessment as the general health care problem and the formulation of the nursing diagnosis as the specific health problem The absence of certain defining characteristics suggests that you reject a diagnosis under consideration While analyzing clusters of data you begin to consider the patient s health problems Your interpretation of the information allows you to select among various diagnoses the ones that apply to your patient Often a patient has defining characteristics that apply to more than one diagnosis Knowing that there are similar diagnoses directs you to gather more information to clarify your interpretation Always examine carefully the defining characteristics in your database to support or eliminate a nursing diagnosis To be more accurate review all characteristics eliminate irrelevant ones and confirm relevant ones Formulating a Nursing Diagnosis 28 A related factor is a condition historical factor or causative event that gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis A related factor allows you to individualize a nursing diagnosis for a specific patient When you are ready to form a plan of care and select nursing interventions a concise nursing diagnosis allows you to select suitable therapies To individualize a nursing diagnosis further you identify the associated related factor Placing a diagnosis into the context of the patient s situation clarifies the nature of the patient s health problem While focusing on patterns of defining characteristics you compare a patient s pattern of data with data that are consistent with normal healthful patterns Use accepted norms as the basis for comparison and judgment This includes using laboratory and diagnostic test values professional standards and normal anatomical or physiological limits When comparing patterns judge whether the grouped signs and symptoms are expected for the patient and whether they are within the range of healthful responses soate any defining characteristics not within healthy norms to allow you to identify a specific problem A nursing diagnosis focuses on a patient s actual or potential response to a health problem rather than on the physiological event complication or disease A nurse cannot independently treat a medical diagnosis Critical thinking is necessary in identifying nursing diagnoses and collaborative problems so you can appropriately individualize care for your patients See also Figure 173 on text p 228 Differentiating nursing diagnoses from collaborative problems Tuesday January 20 2015 Types of Nursing Diagnoses 1 Actual Nursing Diagnosis describes human responses to health condition or life processes 2 Risk Nursing Diagnosis describes human responses to health conditions life processes that may develop 3 Health Promotion Nursing Diagnosis a clinical judgement of motivation desire and readiness to enhance wellbeing and actualize human health potential NANDAI 2012 identifies three types of nursing diagnoses actual diagnoses risk diagnoses and health promotion diagnoses An actual nursing diagnosis describes human responses to health conditions or life processes that exist in an individual family or community The selection of an actual diagnosis indicates that assessment data are sufficient to establish the nursing diagnosis Risk factors serve as cues to indicate that a risk nursing diagnosis applies to a patient s condition A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual family or community These diagnoses do not have defining characteristics because they have not occurred yet Instead a risk diagnosis has risk factors environmental physiological psychological genetic or chemical elements that place a person at risk for a health problem Risk factors are diagnosticrelated factors that help in planning preventive health care measures A health promotion nursing diagnosis is a clinical judgment of a person s family s or community s motivation desire and readiness to enhance wellbeing and actualize human health potential as expressed in their readiness to focus on specific health behaviors such as nutrition and exercise Health promotion diagnoses can be used in any health state and do not require current levels of wellness A person s readiness is supported by defining characteristics Components of a Nursing Diagnosis Related FactorsEtiology treatment related pathophysiological biological or phycological maturational situational environmental or personal PES Format Problem Etiology Symptoms or defining characteristics A common method of developing a nursing diagnosis is to assign a diagnostic label and then note the related or causative factor Table 171 on text p 229 NANDA International TwoPart Nursing Diagnosis Format presents examples The diagnostic label is the name of the nursing diagnosis as approved by NANDA International 29 Tuesday January 20 2015 All NANDAl approved diagnoses also have a definition which describes the characteristics of the human response identified The related factor is identified from the patient s assessment data and is the reason the patient is displaying the nursing diagnosis The related factor is associated with a patient s actual or potential response to the health problem and can change by using specific nursing interventions lnclusion of the related to phrase requires you to use critical thinking to individualize the nursing diagnosis and then select nursing interventions See Table 172 on text p 229 Comparison of Interventions for Nursing Diagnoses with Different Related Factors See also Fig 174 Relationship between a diagnostic label and related factor etiology on text p 229 In the case of a risk nursing diagnosis a risk factor is the related factor Table 173 on text p 230 Developing a Twopart Nursing Diagnosis Label demonstrates the association between a nurse s assessment of a patient the clustering of defining characteristics and the formulation of nursing diagnoses The diagnostic process results in the formation of a total diagnostic label that allows you to develop an appropriate patientcentered plan of care Some agencies prefer a threepart nursing diagnostic label the NANDAl label the related factor and the defining characteristics Athreepart nursing diagnosis using a PES format includes a diagnostic label etiological statement and symptoms or defining characteristics Cultural Relevance of Nursing Dlagnoses 30 Consider patients cultural diversity when selecting a nursing diagnosis Ask questions such as How has this health problem affected you and your family What do you believe will help or fix the problem What worries you most about the problem Which practices within your culture are important to you Cultural awareness and sensitivity improve your accuracy in making nursing diagnoses It is important to consider your own cultural competence so you are more sensitive to a patient s health care problems and the implications Additional examples of questions that contribute to making culturally competent nursing diagnoses are What do you expect from us your nurses to help maintain some of your cultural practices What cultural practices do you do to keep yourself and your family well When you ask questions such as these you use a patientcentered care approach that allows you to see the patient s health situation through his or her eyes When making a diagnosis be sure to also consider how culture influences the related factor for your diagnostic statement Your own culture potentially influences the cues and defining characteristics that you select from your assessment Tuesday January 20 2015 Concept Mapping Nursing Diagnosis a visual representation of a ptietn39s nursing diagnoes and their relationships with one another concept maps promotes problem solving and critical thinking skills by ornaizing omplex patient data analyzing concept relationships and ID interventions A concept map places the central focus on the patient rather than on the patient s disease or health alteration This encourages nursing students to concentrate on patients specific health problems and nursing diagnoses The focus also promotes patient participation with the eventual plan of care A concept map diagrams the critical thinking associated with making accurate diagnoses A concept map promotes critical thinking because you identify graphically display and link key concepts by organizing and analyzing information Patients seldom have only one health problem Your holistic view of a patient heightens the challenge of thinking about all patient needs and problems Therefore a picture of each patient usually consists of several interconnections between sets of data all associated with identified patient problems Data sources include physical psychological and sociocultural domains Concept mapping helps students to display knowledge in a visual format See Figure 175 on text p 231 For each diagnosis you list defining characteristics and begin to see the connections of associations among different diagnostic statements Sources of Diagnostic Error 31 1 data collection 2 data clustering 3 interpretation and analysis of data 4 labeling and diagnosisthe diagnostic statement 5 documentation and informatics Nursing diagnostic errors occur during data collection clustering interpretation and labeling of the diagnosis Box 174 on text p 232 lists Sources of Diagnostic Error You should strive to avoid inaccurate or missing data and to collect data in an organized way It is important to validate the measurable objective physical findings that support subjective data Errors in data collection occur when data are clustered prematurely incorrectly or not at all Begin interpretation by identifying and organizing relevant assessment patterns to support the presence of patient problems Be careful to consider conflicting cues or decide whether cues are insufficient to form a diagnosis To reduce errors you will need to word the diagnostic statement in appropriate concise and precise language using NANDAl terminology Documentation is of paramount importance Always date the diagnosis accurately Refer to your clinical facility for the way to list nursing diagnoses 32 Tuesday January 20 2015 Diagnostic Statement Guidelines ID the pt39s response not he medical diagnosis ID a NANDAl diagnostic statement rathe than the symptom ID a treatable cause or risk factor rather than a clinical sign or chronic problem that is not treatable through nursing intervention ID the problem cause by the treatment or diagnostic study rather than the treatment or study itself ID the pt response to the equipment rather than the equipment itself Be sure that the etiology portion of the diagnostic statement is within the scope of nursing to diagnose and treat Because the medical diagnosis requires medical interventions it is legally inadvisable to include it in the nursing diagnosis ldentify nursing diagnoses from a cluster of defining characteristics not just from a single symptom An accurate etiology allows you to select nursing interventions directed toward correcting the cause of the problem or minimizing the patient s risk Patients experience many responses to diagnostic tests and medical treatments Patients often are unfamiliar with medical technology Tuesday January 20 2015 Chapter 18 Planning Nursing Care Planning constitutes the third step of the nursing process Planning will require the use of your critical thinking skills in which decisionmaking and problemsolving techniques are incorporated After you have identified your patient s nursing diagnosis planning appropriate care comes next Planning involves setting priorities identifying patientcentered goals and expected outcomes and prescribing individualized nursing interventions A plan of care is dynamic and will change as your patient s needs change or as you identify new needs Planning requires working closely with patients their families and the health care team through communication and ongoing consultation Establishing Priorities Ordering of nursing diagnoses or patient problems uses determinations of urgency and or importance to establish a preferential order for nursing actions Helps nurses anticipate and sequence nursing interventions No doubt patients will have multiple nursing diagnoses and problems To care for one patient and groups of patients you will need to rank and deal with individual and aggregate nursing diagnoses so you can recognize those most important problems to organize your day It will be important to classify priorities as high intermediate or low By ranking a patient s nursing diagnoses in order of importance you attend to each patient s most important needs and better organize ongoing care activities Nursing diagnoses that if untreated result in harm to a patient or others have the highest priority and typically revolve around safety adequate oxygenation and circulation However you must always consider each patient s unique situation These priorities can be physiological psychological or related to other basic human needs Together with your patients you select mutually agreedon priorities based on the urgency of the problems the patient s safety and desires the nature of the treatment indicated and the relationship among the diagnoses Classification of priorities 1 High Emergent 2 Intermediate Atask for an intermediatepriority diagnosis involves the nonemergent non life threatening needs of the patient Can someone else do it delegate 3 Low Affect patients future wellbeing The lowpriority nursing diagnosis may not be related to a specific illness or prognosis but may call for an intervention that affects the patient s future wellbeing Many of these deal with the patient39s longterm health care needs The order of priorities changes as a patient s condition changes Priority setting begins at a holistic level when you identify and prioritize a patient s main diagnoses or problems Patientcentered care requires you to know a patient s preferences values and expressed needs Helps you structure your day Have to be clear about what you need to do that day 33 Tuesday January 20 2015 Ethical care is a part of priority setting Each time you begin a sequence of care such as at the beginning of a hospital shift or a patient s clinic visit it is important to reorder priorities You also need to prioritize the specific interventions or strategies that you will use lnvolve patients in priority setting whenever possible Consulting with the patient to learn the patient s concerns does not relieve you of the responsibility to act in a patient s best interests Always assign priorities on the basis of good nursing judgment When ethical issues make priorities less clear it is important to have open dialogue with the patient the family and other health care providers Priorities in Practice picture in slide This model for priority setting is Fig 181 from text p 238 A model for priority setting Modified from Hendry C WalkerA Priority setting in clinical nursing practice J Adv Nurs 47427 2004 Patient acuity how sick a patient is Availability of resources what is at your disposal Can be how many nurses you have on staff lnterruptions are you being paged Nursepatient relationship this effects organization of hospital settings nurses station closet to patients39 rooms Priority setting strategiesframeworks this is where bias comes into play Ethically who really needs your care resources and time Many factors within the health care environment affect your ability to set priorities The same factors that influence your minutebyminute ability to prioritize nursing actions affect your ability to prioritize nursing diagnoses for groups of patients The nature of nursing work challenges your ability to cognitively attend to a given patient s priorities when you care for more than one patient Always work from your plan of care and use your patients priorities to organize the order for delivering interventions and documenting care Critical Thinking in Setting Goals and Expected Outcomes 34 Goal gtA broad statement that describes the desired change in a patient s condition or behavior An aim intent or end Expected outcome gtMeasurable criteria to evaluate goal achievement Once you identify nursing diagnoses for a patient ask yourself What is the best approach to address and resolve each problem What do I plan to achieve Goals and expected outcomes are specific statements of patient behavior or physiological responses that you set to resolve a nursing diagnosis or collaborative problem Having goals and expected outcomes serves two purposes It gives a clear direction for selecting and using nursing interventions and for evaluating the effectiveness of the interventions Tuesday January 20 2015 See Fig 182 on text p 239 Critical thinking and the process of planning care Once an outcome is met you know that a goal has been at least partially achieved Selection of goals expected outcomes and interventions requires consideration of your previous experience with similar patient problems and any established standards for clinical problem management Goals and outcomes need to meet established intellectual standards by being relevant to patient needs specific singular observable measurable and time limited You use critical thinking attitudes in selecting interventions with the greatest likelihood of success Goals of Care insert table A patientcentered goal is realistic and is based on patient needs and resources Patientcentered goals reflect a patient s highest possible level of wellness and independence in function A patient goal represents predicted resolution of a diagnosis or problem evidence of progress toward resolution progress toward improved health status or continued maintenance of good health or function Each goal must be time limited so that the health care team has a common time frame for problem resolution The time frame depends on the nature of the problem its causes the patient s overall condition and the treatment setting A shortterm goal is what you expect the patient to achieve in a short period of time Because hospital stays are shorter than before these goals may last several hours to days Longterm goals are expected to be achieved over a longer period of time Table 181 on text p 240 shows the progression from nursing diagnoses to goals and expected outcomes and their relationship to nursing interventions insert table goals of care ctd Mutual goal setting includes the patient and the family when appropriate in prioritizing the goals of care and developing a plan of action Unless goals are mutually set and a clear plan of action is decided patients fail to fully participate in the plan of care When setting goals act as an advocate or support for the patient to select nursing interventions that promote his or her return to health or prevent further deterioration when possible Expected Outcomes An objective criterion for goal achievement A specific measurable change in a patient s status that you expect in response to nursing care Direct nursing care Determine when a specific patientcentered goal has been met Are written sequentially with time frames Usually several are developed for each nursing diagnosis and goal Outcomes must be measurable Expected outcomes direct nursing care because they are the desired physiological psychological social developmental or spiritual responses that indicate resolution of a patient s health problems 35 Tuesday January 20 2015 Expected outcomes should be written in a sequential time frame The time frames give progressive steps in which a patient moves toward recovery and impose an order on nursing interventions Time frames also set limits for problem resolution A patient s willingness and capability to reach an expected outcome improves his or her likelihood of achieving it A list of the stepbystep expected outcomes gives you practical guidance in planning interventions Nursing Outcomes Classification A nursingsensitive patient outcome is a measurable patient family or community state behavior or perception largely influenced by and sensitive to nursing interventions The Iowa Intervention Project published the Nursing Outcomes Classification NOC and linked the outcomes to NANDA International nursing diagnoses NOC outcomes provide a common nursing language for continuity of care and measuring the success of nursing interventions Much attention in the health care environment is focused on measuring outcomes to gauge the quality of health care If a chosen intervention repeatedly results in desired outcomes that benefit patients it needs to become part of a standardized approach to a patient problem Nursing plays an important role in monitoring and managing patient conditions and diagnosing problems that are amenable to nursing intervention Thus it is important to identify and measure patient outcomes that are influenced by nursing care For the nursing profession to become a full participant in clinical evaluation research policy development and interdisciplinary work nurses need to identify and measure patient outcomes influenced by nursing interventions For each NANDA International nursing diagnosis there are multiple NOCsuggested outcomes These outcomes have labels for describing the focus of nursing care and include indicators to use in evaluating the success of nursing interventions Table 182 on text p 241 shows examples of NANDA International nursing diagnoses and suggested NOC linkages Efforts to measure outcomes and capture changes in the status of patients over time allow nurses to improve patient care quality and add to nursing knowledge The fourth edition of NOC is an excellent resource for use in developing care plans and concept maps Seven Guidelines for Writing Goals Patient centered singular goal or outcome observable measurable time limited realistic mutual factors A patientcentered goal is singular observable measurable time limited mutual and realistic 36 Tuesday January 20 2015 Outcomes and goals reflect patient behaviors and responses expected as a result of nursing interventions Write a goal or outcome to reflect a patient s specific behavior not to reflect your goals or interventions A specific goal or outcome must be defined precisely before a patient response to a nursing action can be evaluated Each goal or outcome addresses only one behavior or response Observable changes occur in physiological findings and in the patient s knowledge perceptions and behavior You will learn how to write goals and expected outcomes that set standards against which to measure the patient39s response to nursing care Do not use vague term or qualifiers such as normal acceptable or stable Instead use terms that can be evaluated precisely for example terms that describe quality quantity frequency length or weight Timelimited time frames for each goal and expected outcomes indicate when nurses expect identified responses to occur Time frames enable nurses to help patients meet goals and make progress at a reasonable rate Mutual factors combine goals and expected outcomes to ensure that the patient and the nurse agree on the direction and time limits of care By setting mutual goals and expected outcomes nurses can increase the patient s motivation and cooperation For the patient to succeed goals and outcomes must be attainable Because lengths of stay are now much shorter this can be problematic When setting goals and outcomes make sure to factor in the patient s physiological emotional cognitive and sociocultural potential as well as the economic costs and resources required to reach these in a timely manner Critical Thinking in Planning Care Nursing interventions are treatments or actions based on clinical judgment and knowledge that nurses perform to meet patient outcomes Nurses need to Know the scientific rationale for the intervention Possess the necessary psychomotor and interpersonal skills Be able to function within a setting to use health care resources effectively Part of the planning process is to select nursing interventions to meet the patient s goals and outcomes Once nursing diagnoses have been identified and goals and outcomes selected you choose interventions individualized for the patient s situation During planning you select interventions designed to help a patient move from the present level of health to the level described in the goal and measured by the expected outcomes Actual implementation of these interventions occurs during the implementation phase of the nursing process 37 Tuesday January 20 2015 Types of Interventions Nurse initiated lndependent Actions that a nurse initiates Physician initiated Dependent Require an order from a physician or other health care professional Collaborative nterdependent Require combined knowledge skill and expertise of multiple health care professionals Nurseinitiated interventions require no order and no supervision or direction from others Nurseinitiated interventions are autonomous actions based on scientific rationale According to the Nurse Practice Acts in a majority of states independent nursing interventions pertain to activities of daily living health education and promotion and counseling The NIC taxonomy provides standardization to help nurses select suitable interventions for patients problems Ask students to identify some independent nursing actions ANSWERS can include elevating an extremity providing patient education showing how to splint Physicianinitiated interventions require specific nursing responsibilities and technical nursing knowledge These interventions are based on the physician s or the health care provider s response to treat or manage a medical diagnosis Each of these interventions requires nursing responsibilities and specific knowledge Advanced practice nurses who work under collaborative agreements with physicians or who are licensed independently by state practice acts are able to write dependent interventions Typically when you plan care for a patient you review the necessary interventions and determine whether the collaboration of other health care disciplines is necessary In a patient care conference the multidisciplinary health care team selects and assigns interdependent nursing interventions Clarifying an Order When preparing for physicianinitiated or collaborative interventions do not automatically implement the therapy but determine whether it is appropriate for the patient The ability to recognize incorrect therapies is particularly important when administering medications or implementing procedures Every nurse faces an inappropriate or incorrect order at some time Clarifying an order is part of competent nursing practice and it protects the patient and members of the health care team When you carry out an incorrect or inappropriate intervention it is as much your error as the person s who wrote or transcribed the original order You are legally responsible for any complications resulting from the error Selection of Interventions Six factors to consider characteristics of nursing diagnosis goals and expected outcome evidence base for interventions 38 Tuesday January 20 2015 feasibility of interventions acceptability to the patent nurse39s competency When selecting interventions review the patient s needs priorities and previous health experiences See Box 181 on text p 243 Choosing Nursing Interventions Correctly written nursing interventions include actions frequency quantity method and the person to perform them Nursing Interventions Classification NIC The Iowa Intervention Project developed a set of nursing interventions that provides a level of standardization to enhance communication of nursing care across health care settings and to compare outcomes The NIC model includes three levels domains classes and interventions for ease of use NC interventions are linked with NANDA International nursing diagnoses If your college or university uses the Nursing Interventions Classification NIC discuss how you incorporate NIC into your plan of care The domains are the highest level level 1 of the model and broad terms are used to organize the more specific classes and interventions See Table 183 on text pp 244245 Nursing Interventions Classification NIC Taxonomy The second level of the model includes 30 classes which offer useful clinical categories The third level of the model includes 542 interventions defined as any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes Each intervention includes a variety of nursing activities from which to choose and which a nurse commonly uses in a plan of care See Boxes 182 and 183 on text p 243 Example of Interventions for Physical Comfort Promotion and Example of an Intervention and Associated Nursing Activities You determine which interventions and activities best suit your patient s individualized needs and situation Systems for Planning Nursing Care 39 Nursing care plan Nursing diagnoses goals and expected outcomes and nursing interventions and a section for evaluation findings so any nurse is able to quickly identify a patient s clinical needs and situation Reduces the risk for incomplete incorrect or inaccurate care Changes as the patient s problems and status change nterdisciplinary care plan Contributions from all disciplines involved in patient care In health care settings nurses are responsible for providing a written nursing plan of care for all patients The plan can take many forms such as Kardex standard care or computerized plan ncreasingly hospitals are adopting electronic health records EHRs and a documentation system that includes software programs for nursing care plans Written care plans can be used for changeofshift reports The nursing care plan helps to ensure continuity of care by all nurses The nursing care plan enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care A care plan includes a patient s longterm needs Tuesday January 20 2015 lncorporating the goals of the care plan into discharge planning is important Change of Shift A critical time when nurses collaborate and share important information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventions Changeofshift report Communicates information from offgoing to oncoming patient care personnel Nurse handoff Focus your reports on the nursing care treatments and expected outcomes documented in the care plans During a nursing handoff nurses collaborate and share important information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventions At the end of a shift you discuss with the next caregivers your patients plans of care and their overall progress Thus all nurses are able to discuss current and relevant information about each patient s plan of care No evidence has been found for one best nursing handoff practice See Box 184 on text p 247 EvidenceBased Practice Nursing HandOffs In some agencies the nursing handoff process occurs during walking rounds when nurses exchange information about patients at the bedside giving patients the opportunity to also ask questions and confirm information Written care plans organize information exchanged by nurses in changeofshift reports Avoid adding personal opinions about the patient because these are not relevant and could unnecessarily influence the oncoming nurse s perception of him or her as an individual Student Care Plans A student care plan Helps you apply knowledge gained from the nursing and medical literature and the classroom to a practice situation ls more elaborate than a care plan used in a hospital or community agency because its purpose is to teach the process of planning care Planning care for patients in communitybased settings involves Educating the patientfamily about care Guiding them to assume more of the care over time Student care plans are useful for learning the problemsolving technique the nursing process skills of written communication and organizational skills needed for nursing care The plan also helps you to apply theory you learned Most commonly a column format is used 40 Tuesday January 20 2015 A sixcolumn format includes from left to right 1 assessment data relevant to corresponding diagnosis 2 goals outcomes identified for the patient implementation for the plan of care a scientific rationale the reason that you chose a specific nursing action based on supporting evidence 6 a section to evaluate your care In the implementation section you select interventions appropriate for the patient 3 4 5 For care plans in communitybased settings you design a plan to 1 educate the patientfamily about necessary care techniques and precautions 2 teach the patientfamily how to integrate care within family activities 3 guide the patientfamily on how to assume a greater percentage of care over time Finally the plan includes nurses and the patient s family s evaluation of expected outcomes Review Table 184 on text p 247 Frequent Errors in Writing Nursin Critical Pathways Critical pathways are patient care plans that provide the multidisciplinary health care team with activities and tasks to be put into practice sequentially The main purpose of critical pathways is to deliver timely care at each phase of the care process for a specific type of patient Care plans and critical pathways increase communication among nurses and facilitate the continuity of care from one nurse to another and from one health care setting to another A critical pathway clearly defines transition points in patient progress and draws a coordinated map of activities by which the health care team can help to make these transitions as efficiently as possible Critical pathways improve continuity of care because they clearly define the responsibility of each health care discipline Welldeveloped pathways include evidencebased interventions and therapies Concept Maps Provide a visually graphic way to show the relationship between patients nursing diagnoses and interventions Group and categorize nursing concepts to give you a holistic view of your patient s health care needs and help you make better clinical decisions in planning care Help you learn the interrelationships among nursing diagnoses to create a unique meaning and organization of information When planning care for each nursing diagnosis analyze the relationships among the diagnoses Draw dotted lines between nursing diagnoses to indicate their relationship to one another See Fig 183 on text p 248 for an example of a concept map showing these relationships Because you care for patients who present with multiple health problems and related nursing diagnoses it is often not realistic to have a written columnar plan developed for each nursing diagnosis 41 Tuesday January 20 2015 It is important for you to make meaningful associations between one concept and another The links need to be accurate meaningful and complete so you can explain why nursing diagnoses are related Critical thinkers learn by organizing and relating cognitive concepts Consulting Other Health Care Professionals Planning involves consultation with members of the health care team Consultation is a process by which you seek the expertise of a specialist such as your nursing instructor a physician or a clinical nurse educator to identify ways to handle problems in patient management or in planning and implementation of therapies Consultation occurs at any step in the nursing process most often during planning and implementation Consultation can occur at any step of the nursing process Consultation increases your knowledge about a patient s problem and helps in learning skills and obtaining the resources needed to solve the problem When making a consultation first identify the general problem direct the consultation to the right professional and provide the consultant with relevant information about the problem may include dietitians respiratory therapists physical therapists wound care specialists diabetic educators and case managers Do not be afraid to ask for a consultation Consultations will increase your knowledge and will help you learn new skills and how to obtain additional resources You consult most often during planning and implementation During these times you are more likely to identify a problem requiring additional knowledge skills or resources This requires you to be aware of your strengths and limitations as a team member Consultation is a process by which you seek the expertise of a specialist such as your nursing instructor a physician or a clinical nurse educator to identify ways to handle problems in patient management or in planning and implementation of therapies The consultation process is important so all health care providers are focused on common patient goals Always be prepared before you make a consult Consultation is based on the problemsolving approach and the consultant is the stimulus for change Often an experienced nurse is a valuable consultant when you face an unfamiliar patient care situation such as a new procedure or a patient presenting a set of symptoms that you cannot identify In clinical nursing consultation helps to solve problems in delivery of nursing care For example a nursing student consults a clinical specialist for wound care techniques or an educator for useful teaching resources Nurses are consulted for their clinical expertise patient education skills or staff education skills Nurses also consult with other members of the health care team such as physical therapists nutritionists and social workers Again the consultation focuses on problems in providing nursing care When and How to Consult When the exact problem remains unclear How begin with your understanding of the patient39s clinical problem 42 43 Tuesday January 20 2015 direct the consultation tot he right professional provide the consultant with relevant info about the problem area summary methods used to date and outcomes do no influence consultants be available to discuss the consultant39s findings incorporate the suggestions See Box 185 Tips for Making Phone Consultations Consultation occurs when you identify a problem that you are unable to solve using personal knowledge skills and resources The process requires good intrapersonal and interprofessional collaboration Consultation with other care providers increases your knowledge about the patient s problems and helps you learn skills and obtain resources An objective consultant enters a clinical situation and more clearly assesses and identifies the nature of a problem whether it is patient personnel or equipment oriented Share information from the patient s medical record conversations with other nurses and the patient s family Consultants are in the clinical setting to help identify and resolve a nursing problem and biasing or prejudicing them blocks problem resolution Avoid bias by not overloading consultants with subjective and emotional conclusions about the patient and the problem When you request a consultation provide a private comfortable atmosphere for the consultant and the patient to meet A common mistake is turning the whole problem over to the consultant The consultant is not there to take over the problem but to help you resolve it When possible request the consultation for a time when both you and the consultant are able to discuss the patient s situation with minimal interruptions or distractions The success of the advice depends on the implementation of the problemsolving techniques Always give the consultant feedback regarding the outcome of the recommendations TuesdayJanuan202015 Chapter 19 Implementing Nursing Care Implementation constitutes the fourth step of the nursing process After the nursing diagnoses have been identified nurses initiate the nursing interventions most likely to achieve the goals and expected outcomes that support or improve the patient s health status Nursing interventions can be direct or indirect Ideally nursing interventions should be evidence based and should use the most upto date approaches to solving patient problems Nursing Intervention A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes nterventions include direct and indirect care measures aimed at individuals families andor the community nterventions include direct and indirect care measures aimed at individuals families andor the community Direct care interventions are treatments performed through interactions with patients Indirect care interventions are treatments performed away from the patient but on behalf of the patient or a group of patients These are discussed further in a later slide See Box 191 Domains of Nursing Practice on text p 253 Critical THinking in Implementation Review the set of all possible nursing interventions Review all possible consequences associated with each possible nursing action Determine the probability of all possible consequences Make a judgment of the value of that consequence to the patient Given the complexity of interventions critical thinking is necessary in choosing which of a number of alternative approaches to use in the time available to act The critical thinking model described in Chapter 15 provides a framework for how to make decisions when implementing nursing care Before nurses proceed with an intervention they need to consider what they know about the purpose of the interventions the steps in performing the interventions correctly and the medical condition of the patient and the patient s expected response See also Fig 191 on text p 255 Critical thinking and the process of implementing care Standard Nursing Interventions Clinical practice guidelines and protocols Standing orders NIC interventions ANA Standards of Professional Practice Standing orders order on a unit Ex patient with high temp when a doctor leaves you with an order So in this case the doctor would leave you an order saying if the patient s temp reaches x degree give them xx medication This way the doctor isn t bothered because he has already spoken on this case 44 TuesdayJanuan202015 Standards of nursing practice offer guidelines for the selection of interventions Clinicians within a health care agency sometimes choose to review the scientific literature and their own standard of practice to develop guidelines and protocols in an effort to improve their standard of care A nursing care plan is unique to the patient Therefore interventions are individualized However patients do have common health care problems and standardized interventions for those health problems make it quicker and easier for you to intervene These interventions are evidence based NC interventions offer a level of standardization to enhance communication of nursing care across settings If your collegeuniversity uses NIC and NOC please spend time explaining how students use this in their plan of care See also Box 192 on text p 256 Purposes of the Nursing Interventions Classification The ANA Standards of Professional Nursing Practice are to be used as evidence of the standard of care that registered nurses provide their patients Protocols and Standing Orders Guidelines and Protocols Systematically developed set of statements that helps nurses physicians and other health care providers make decisions about appropriate health care for specific clinical situations Standing Orders A preprinted document containing orders for the conduct of routine therapies monitoring guidelines andor diagnostic procedures for specific patients with identified clinical problems Guidelines and protocols there to protect you and the patient They are there for a reason A guideline guides interventions for specific health care problems or conditions such as low back pain dizziness or deep vein thrombosis The guideline is developed on the basis of an authoritative examination of current scientific evidence Implementation Process 1 Reassessing the pt 2 reviewing and revising the existing nursing care plan 3 organizing resources and care delivery 4 anticipating and preventing complications You will need to prepare to implement your interventions to provide efficient safe and effective nursing care When you reassess your patient you collect additional data and identify any new patient needs At this point you may need to modify your plan of care To organize resources and deliver care to your patient you need to identify the facility s resources and personnel So an orientation to the facility s physical layout equipment and operations is a necessity Creating a favorable environment for the patient to receive care is another part of organizing resources 45 Tuesday January 20 2015 It is necessary to anticipate and prevent complications that might occur while patients are hospitalized Risks to patients come from both illness and treatment Methods used to ensure that you administer physical care techniques appropriately include protecting yourself and the patient from injury using proper infection control practices staying organized and following applicable practice guidelines Anticipate and Prevent Complications ldentify risks to the patient Everything has a side effectconsequence Adapt interventions to the situation Evaluate the relative benefit of a treatment vs the risk lnitiate risk prevention measures Modification of an Existing Written Care Plan Revise data assessment Revise the nursing diagnoses Revise specific interventions Determine how to evaluate whether you have achieved outcomes After you reassess your patient review the care plan compare assessment data to validate the nursing diagnoses and determine whether the nursing interventions remain the most appropriate for the clinical situation Implementation Skills Cognitive skills Application of critical thinking in the nursing process lnterpersonal skills Developing a trusting relationship expressing a level of caring and communicating clearly with a patient and his or her family Psychomotor skills lntegration of cognitive and motor activities These three skills are needed to implement direct and indirect nursing interventions lnterpersonal skills explain to patient why we are doing what we are doing Never because the doctor ordered it No intervention should be automatic Nurses need to think and anticipate how to individualize care for their patients lnterpersonal skills are used to develop a trusting relationship express a level of caring and communicate clearly with the patient and family Psychomotor skills require the integration of cognitive and motor activities Remember it will take time and practice to acquire a psychomotor skill So make sure to take advantage of your time in the nursing skills lab with human patient simulation with interactive technology and with each other to hone your skills and con dence 46 Tuesday January 20 2015 Direct Care vs Indirect Care Direct Care Treatments performed through interactions with patients Examples Medication administration lnsertion of an intravenous IV infusion Counseling during a time of grief Indirect Care Treatments performed away from the patient but on behalf of the patient or group of patients Managing the patient s environment eg safety and infection control Documentation lnterdisciplinary collaboration Nurses provide a wide variety of direct care measures All direct care measures require competent and therefore safe practice Show a caring approach each time you provide direct care Nurses spend much time in indirect and unit management activities Communication of information about patients eg changeofshift report consultation is critical ensuring that direct care activities are planned coordinated and performed with the proper resources Direct Care Activities of Daily Living ADL lnstrumental Activites of Daily Living lADL39s Physical care techniques lifesaving measures counseling teaching controlling for adverse reactions perventive measure To complete any nursing procedure you need to know the procedure its frequency the steps and the expected outcomes Activities of daily living ADLs are activities usually performed in the course of a normal day including ambulation eating dressing bathing and grooming You will perform these activities of direct care as you carry out the nursing interventions you have selected for your patients You will want to be cognitive of mobility pain confusion and fatigue that patients may be experiencing lADLs These instrumental ADLs include the daytoday activities a person performs such as shopping preparing meals writing checks to pay the bills and taking medications Physical care techniques are the activities that nurses perform while rendering care These including turning positioning and administering care as well as performing tasks such as Foley catheter insertion NG tube insertion IV insertion and administering medications Lifesaving measures are those activities you perform when a patient s physiological or psychological state is threatened They include CPR administering emergency medications and falls prevention 47 Tuesday January 20 2015 Note that when you delegate aspects of a patient s care you are responsible for ensuring that each task is assigned appropriately and is completed according to the standard of care Counseling involves providing emotional intellectual spiritual and psychological support to your patients Box 193 on text p 260 presents examples of counseling strategies DEPENDING ON SETTING school nurse etcc Teaching is a constant part of nursing Teaching occurs formally and informally and involves patients and their family members We will further discuss this in Chapter 25 Patient Education An adverse reaction is a harmful or unintended effect of a medication diagnostic test or therapeutic intervention Before performing any skill or task you need to know the possible adverse effects or reactions that can occur Preventive nursing actions promote health and prevent illness to avoid the need for acute or rehabilitative health care Prevention includes assessment and promotion of the patient s health potential application of prescribed measures health teaching and identification of risk factors for illness andor trauma Shown is Fig 193 from text p 261 Indirect Care Communicating nursing interventions Written or oral Delegating supervising and evaluating the work of other health care team members Need to know what they ultimately got as the answer You are still responsible for that reading Have to delegate according to what they are able to do These measures are actions that support the effectiveness of direct care interventions Many of these measures may be managerial Box 194 on text p 262 presents examples of indirect nursing interventions Communication is imperative to ensure that direct care activities are planned coordinated and performed with the proper resources Many health care agencies use interdisciplinary care plans Most important all interventions must be documented correctly and in the proper time sequence In Chapter 26 documentation will be discussed more thoroughly Staff in many institutions develop interdisciplinary care plans plans that represent the contributions of all disciplines caring for a patient Oftentimes nurses who develop the patient s plan of care do not deliver the care Some activities are performed by other members of the health care team Chapter 21 will present the ten principles of delegation as delineated by the American Nurses Association and the National Council of State Boards of Nursing Achieving Patient Goals 48 Nurses implement care to meet patient goals At times multiple interventions may be needed Priorities help nurses to anticipate and sequence nursing interventions Patient adherence means that patients and families invest time in carrying out required treatments Another way to achieve patient goals is to help patients adhere to their treatment plan When delivering care it will be necessary for you to incorporate your patient s health beliefs culture lifestyle patterns and patterns of wellness Tuesday January 20 2015 Chapter 20 Evaluation Evaluation Did it worknot work why etc Evaluation is the final step of the nursing process In this step you determine if your patient s condition or wellbeing has improved Nurses conduct evaluation measures to determine whether they have met expected patient outcomes not whether their nursing interventions were complete It is important to remember that expected outcomes are the standards against which the nurse judges whether goals have been met and care was successful Evaluation is a step of the nursing process that includes two components examination of a condition or situation and judgment as to whether change has occurred Critical Thinking and Evaluation Evaluation is an ongoing process If outcomes are met patient goals are met Positive evaluations occur when nurses meet desired outcomes Goal was metintervention was effective Positive evaluations lead nurses to conclude that interventions were successful Evaluation the final step of the nursing process is an ongoing process that occurs whenever you have contact with a patient Think about the sequence used during evaluations and the conclusions that can be drawn Positive evaluations occur when desired outcomes occur leading you to conclude that the nursing interventions effectively met the patient s goals Unmet or undesirable outcomes indicate that interventions did not minimize or resolve the actual problem or avoid a potential problem An unmet outcome reveals that the patient has not responded to interventions as planned When expected outcomes do not materialize the nurse needs to change the plan of care by trying different therapies or changing the frequency or approach of existing therapies See Fig 201 on text p 266 Critical thinking and the evaluation process and Fig 202 on text p 267 Critical thinking and evaluation for further discussion Standards for Evaluation 49 Nursing care helps patients resolve actual health problems prevent potential problems maintain a healthy state The evaluation process is an integral step in achieving these goals A nurse must respect the patient and family as core members of the health care team meaning that the patient and family must be actively involved in the evaluation process American Nurses Association ANA Tuesday January 20 2015 Defines standards worksheet Competencies include Being systematic Using criterionbased evaluation Collaborating Using ongoing assessment data to revise care plan Communicating results Ex tell upcoming shift The American Nurses Association ANA defines standards of professional nursing practice which include standards for the evaluation step of the nursing process see Chapter 1 The standards define the duties that all registered nurses are expected to perform competently When evaluating be systematic and use criterionbased evaluative measures Collaborate with patients and other professionals as appropriate Use ongoing assessment data to revise the care plan for the best results Clearly communicate the results of the plan to your patients and their families It is important to ensure that only appropriate interventions are used with each patient CriterionBased Standards the physiological emotional and behavioral responses that are a patent39s goals and expected outcomes Note that criterionbased standards are both goals and expected outcomes They include physiological emotional and behavioral responses Figure out who you are dealing with what makes them tick are they satisfied with their progress am I encouraging or discouraging CriterionBased Evaluation Goal Expected behavior or response that indicates resolution of a nursing diagnosis or maintenance of a healthy state Expected outcome End result that is measurable desirable and observable and translates into observable patient behaviors Nursingsensitive outcome You evaluate nursing care by knowing what to look for as described in the criterion based standards included in a patient s goals and expected outcomes The goals and outcomes help you judge a patient s response to care objectively Goals are often based on standards of care established for safe practice For example the Infusion Nurses Society INS has a standard of care for preventing the IV complication known as phlebitis When a nurse cares for a patient with an IV line the goal is to make sure that the IV site remains free of phlebitis When nurses apply the nursing process a nursingsensitive outcome is a measurable patient or family state behavior or perception largely influenced by and sensitive to nursing interventions What are some examples of nursingsensitive outcomes Examples of nursing sensitive outcomes include reduction in pain frequency incidence of pressure ulcers and incidence of falls See Box 201 on text p 268 EvidenceBased Practice for further discussion 50 TuesdayJanuan202015 A valuable resource for selecting outcomes is the Nursing Outcomes Classification NOC see Chapter 18 See Table 201 on text p 268 Linkages Between Nursing Outcomes Classification and Nursing Diagnoses for further discussion Collaborate and Evaluate Effectiveness of Interventions Collaborate with the patient and family Use evaluative measures lnterpret and summarize findings Document results Revise care plan Determining a patient s response to nursing care requires the use of evaluative measures which are simply assessment skills and techniques See Table 202 on text p 269 Evaluative Measures to Determine the Success of Goals and Expected Outcomes for examples of evaluative findings The intent of evaluation is to determine whether known problems have remained the same improved worsened or in any way changed Next you will need to interpret and summarize the findings More discussion on this step is provided on the next slide Acute changes occur frequently and chronic changes occur over a period of time and can be subtle See also Table 203 on text p 270 Examples of Objective Evaluation of Goal Achievement for further discussion Documentation and reporting are a most important part of the evaluative process It will be important to describe the evaluative measures This can be done via nursing progress notes assessment flow sheets and shift reports At this juncture you will be able to adjust the plan of care or discontinue it Unmet or partially met goals require you to continue the interventions Your choice will be to discontinue or modify the plan of care The question you will ask is Do the goals and expected outcomes or interventions need to be modified mage is Fig 203 on text p 269 Objective Evaluation 1 Examine the outcome criteria 2 Evaluate the patient39s actual response 3 COmpare the established outcome criteria with the actual response 4 Judge the degree of agreement between the outcome criteria an the response 5 If no or only partial agreement what are the barriers The steps are 1 Examine the outcome criteria to identify the exact desired patient behavior or response 2 evaluate the patient s actual behavior or response if they should be in pain but aren t voicing it why are they doing that Could be culture could be fear etc Does it add up 3 compare the established outcome criteria with the actual behavior or response 4 judge the degree of agreement between outcome criteria and the actual behavior or response 51 Tuesday January 20 2015 5 if there is no agreement or only partial agreement between the outcome criteria and the actual behavior or response what isare the barriers Why did they not agree Revising a Care Plan 52 Discontinuing a care plan has the goal been met Each time you evaluate a patient you determine whether the plan of care continues or if revisions are necessary does the patient agree document the discontinued plan Modifying a care plan Reassessment Redefining diagnoses Goals and expected outcomes It sometimes becomes necessary to collect evaluative measures over time to determine whether a pattern of change exists f goals are unmet or are only partially met you should continue the intervention You may need to create a new plan of care and redefine priorities to achieve goals For example if the original goal was to teach the patient to correctly prepare and selfadminister insulin but the patient develops a tremor that makes it impractical for him to administer the medication himself the care plan could be revised so that a family member assumes this task to meet the goal of care When modifying a plan a complete reassessment is necessary Reassessment requires critical thinking An important step in critical thinking is noting how the patient is progressing and how problems are resolving or worsening After reassessment determine which nursing diagnoses are accurate for the situation Then review the goals and expected outcomes for necessary changes Modifying a care plan Interventions Appropriateness of the intervention Based on the standard of care Correct application of the intervention A patient s nursing diagnoses priorities and interventions sometimes change as a result of evaluation The evaluation of interventions examines two factors the appropriateness of the intervention selected and the correct application of the intervention Appropriateness is based on the standard of care for a patient s health problem lncreasing or decreasing the frequency of interventions is another approach to ensure appropriate application of an intervention You adjust interventions on the basis of the patient s actual response to therapy and your previous experience with similar patients During evaluation you may find that some planned interventions are designed for an inappropriate level of nursing care If you need to change the level of care substitute a different action verb such as assist in place of provide or demonstrate in place of instruct Remember that Evaluation is a continuous process Modifying a care plan Unmet patient needs 53 Tuesday January 20 2015 When a goal is not met no matter what the reason repeat the entire nursing process sequence for that nursing diagnosis to identify necessary changes to the plan By consistently incorporating evaluation into practice you minimize errors and ensure that the patient s plan of care is appropriate and relevant Occasionally during evaluation you discover unmet patient needs This is normal The nursing process is a systematic problemsolving approach to individualized patient care but many factors can affect each patient with health care problems For unmet patient needs reassess the patient determine accuracy of the nursing diagnosis establish new goals and expected outcomes and select new interventions Patients with the same health care problem are not treated the same way As a result you sometimes make errors in judgment Determining that each goal and expected outcome is realistic for the problem the cause and the time frame is particularly important Unrealistic expected outcomes and time frames make goal achievement difficult The systematic use of evaluation provides a way for you to catch these errors 54 Tuesday January 20 2015
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