Foundations Exam 1

Seven caring behaviors in nursing practice
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Terms in this set (46)
Patients view
-Patients value the affective dimension of nursing care
-Reassuring presence
-Recognizing an individual as unique
-Keeping a close and attentive eye
on the situation

Family view
-Being honest
-Advocating for patient's care preferences
-Giving clear expectations
-Keeping family members informed
-Asking permission before doing
-Providing comfort (warm blanket, back rub)
-Reading to patient (book, cards, mail, religious texts)
-Providing and maintaining privacy
-Assuring the patient that nursing will be available
-Helping patients do as much for themselves as possible
-Teaching the family how to keep the patient comfortable
-Active Listening
-Sharing Observations :say, "I see you haven't eaten" instead of "why haven't you eaten?"
-Sharing Empathy :"This must be very hard for you"
-Sharing Hope
-Sharing Humor
-Sharing Feelings :let them cry
-Using Touch :some touch is acceptable
-Using Silence :sometimes if you are just silent the patient has time to respond
-Providing Information -they have a right to know

-Clarifying :reflect on what they say to make sure you understood correctly
-Paraphrasing :shortening what they have told you
-Asking Relevant:Questions
-Confrontation :saying something like "You said you don't smoke, but I noticed you have cigarettes
-Asking Personal Questions
-Giving Personal Opinions and unwanted advice
-Changing the subject
-Automatic Responses
-False Reassurance
-Asking for Explanations; Using "why" questions

-Approval or Disapproval (using authority/using leading
or biased questions) -"You don't smoke do you?" or using "the doctor said"
-Defensive Responses
-Passive or Aggressive Responses
-Using avoidance language
-Using professional jargon
-Talking too much/interrupting
Nonverbal Skills-Personal appearance -Posture and gait -Facial expressions -Eye contact -Gestures -Sounds -Territoriality and personal spaceAdapting communication to patients with special needs (hearing, older, crying, angry, etc)4 steps of Diagnostic Reasoning (scientific method)The process of analyzing health data and drawing conclusions Four components: -Attending to initially available cues -Formulating diagnostic hypotheses -Gathering data relative to the tentative hypotheses -Evaluating each hypothesis with the new data collected, thus arriving at a final diagnosisAttending to initially available cuesA cue is a piece of information. Cues in nursing: Signs and symptoms Symptom - information the patient states therefore it is __subjective___ Sign - information that you obtain through physical examination or from the patient's record (lab test, diagnostic test, vital signs, etc.) therefore it is __objective___Formulating diagnostic hypothesesCluster or group signs and symptoms that are related Previous example - "I've been vomiting for three days" 350ml of dark green emesis C/O abdominal pain Hyperactive bowel sounds **All related to gastrointestinal problems** A nurse is looking for patterns that are consistent with previous experiences and uses that information to guide careGathering data relative to the tentative hypothesesNeed additional information? Look for gaps Symptom analysis - use this process OLDCARTEvaluating each hypothesis with the new data collected, thus arriving at a final diagnosisDoes your data support your original thinking? Did you have to go into another direction? Validate data Make sure it is accurate No assumptions Novice nurse AKA Student nurse - you may need to ask a more experienced nurse or your clinical instructor to help validate data. Novice nurses tend to rely on analytic reasoning. Expert nurses draw from a variety of reasoning patterns—analytic, intuitive, and narrative.5 steps of Nursing ProcessAssessment - Surprise, Surprise! Diagnosis Planning Implementation Evaluation **Nurses can move back and forth within the steps of the Nursing ProcessCritical Thinking Skills (4 specifically presented in class) including prioritizing-Moving from novice to expert..... -Critical thinking is the means by which we learn to assess and modify, if indicated, before acting. -Focus on critical thinking skills -An expert can apply them in rapid interactive way. -There will not by any one protocol you can memorize that will apply to every situation: unique and patient centeredDifferentiate Subjective and Objective Data (signs and symptoms)Expected values for each VS for adultsTemp: 98.6 & 37C range=96.8-100.4 36-38C Expected values for each VS for adults Temp (98.6-100.4 F, 36-38 C) Pulse (60-100 beats/min) Resp (12-20 breath/min) BP (120/80 mmHg) Sp02 (95-100%) Pain (0-10)OLD CARTO = Onset L = Location D = Duration C = Characteristics A = Associated Symptoms R = Relieving or Aggravating Factors T = TreatmentsFactors that influence or alter VSInfluencing factors for Temp- Age, Exercise, Hormonal Level, Circadian Rhythm, Environment, Temperature Alterations Pulse- patient status, illness, infection, recovery, effectiveness of medications Resp- Exercise, Pain, Anxiety, Smoking, Body Position, Medications, Neurological Injury, Hemoglobin function BP- Age, Ethnicity, Stress, Gender, Daily Variation, Medications, Activity/Weight, Smoking, thickening of artery walls/loss of elasticity, family history, loos of blood volume, positionRecognize unexpected VS findingsStandard precautions-Standard precautions prevent and control infection and its spread. -Apply to contact with blood, body fluid, nonintact skin, and mucous membranes from all patients. -Hand hygiene includes using an instant alcohol hand antiseptic before and after providing patient care, washing hands with soap and water when they are visibly soiled, and performing a surgical scrub. -Handwashing is the act of washing hands with soap and water, followed by rinsing under a stream of water for 15 seconds.Types of isolation and the precautions/PPE required for each-standard : Hand hygiene -airborne: Hand hygiene & Mask/Respirator -droplet: Hand hygiene & Mask -contact: Hand Hygiene, Gown, & gloves -contact (enteric): Hand hygiene, gown, gloves, & soap & water hygiene -protective environment: Hand hygiene, gown, mask, gloves, eye protection, & soap & water hygieneDifferentiate Medical Asepsis vs Surgical AsepsisMedical asepsis, or clean technique, includes procedures for reducing the number of organisms present and preventing the transfer of organisms. Surgical asepsis or sterile technique prevents contamination of an open wound, serves to isolate the operative area from the unsterile environment, and maintains a sterile field for surgery.Principles of Sterile Technique1. A sterile object remains sterile only when touched by another sterile object. 2. Only sterile objects may be placed on a sterile field. 3. A sterile object or field out of the range of vision or an object held below a person's waist is contaminated. 4. A sterile object or field becomes contaminated by prolonged exposure to air. 5. When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action. 6. Fluid flows in the direction of gravity. 7. The edges of a sterile field or container are considered to be contaminated.HAI (risk factors and common types of infections in hospitals)Hospital Acquired Conditions (HAC) - 10 Foreign object retained after surgery Air embolism Blood incompatibility Pressure ulcers stage III & IV Falls and trauma Catheter-associated urinary tract infection Vascular catheter-associated infection Manifestations of poor glycemic control Surgical Site Infections - CAGB, Orthopedic, Bariatric, Cardiac implantable devices DVT/PE - Orthopedic procedures Pneumothorax with Venous CatheterizationSigns and symptoms of inflammation vs infectionDriving forces behind safety and quality and the challengesWhat is a Sentinel Event? Safety culture?Sentinel Event- An unexpected occurrence involving death or serious physical injury, or the risk thereof. Safety Culture- Making sure people are not harmed is how we do things around here.Common hospital safety concerns/HACsBe familiar with the 2016 National Patient Safety Goals-identify patients correctly -improve staff communication -use meds safely -use alarms safely -prevent infection -identify patient safety risk -prevent mistakes in surgery Designed to spotlight areas of highest priority to patient safety and quality care. Established in 2002. Updated annually by The Joint Commission (TJC).What is nurse's role in safety and quality?Nurses are Leaders in Quality and Safety Initiatives: Nurses are able to recognize, interrupt, evaluate and correct healthcare errors more than any other health professional.What is your role as student? What can you do to prevent safety issues?Steps of the Nursing Process and what a nurse does in each stepAssessment: Gathered patient care data through observation, interviews, and physical assessment. Diagnosis: Analyze, validate, and cluster patient data to identify patient problems. Planning: Prioritize the nursing diagnoses and identifies short- and long-term goals that are realistic, measurable, and patient focused, with specific outcome identification for evaluation purposes. Implementation: Initiate specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. Evaluation: Determine whether the patient's goals are met, examine the effectiveness of interventions, and decide whether the plan of care should be discontinued, continued, or revised.Assessment/Data collection (Subjective and ObjectivePrimary Data: -Patient interview Secondary data Subjective data: -Symptoms -Health history Objective data: -signs -Physical exam -lab results -diagnostic testData- signs and symptoms) and data clusteringWhy use Nursing Diagnosis?Differentiate Nursing Diagnosis vs Medical Diagnosis-nursing diagnosis would be ineffective airway clearance -medical diagnosis would be asthma Nursing diagnosis is basically describing the symptoms, not diagnosing what it is.Parts of Nursing Diagnosis statement (Actual vs. Potential/"Risk for") and how to correctly formulate a diagnosisActual Nursing Diagnoses: 3 parts (PES) (1) The patient's identified need or problem (2) The etiology or underlying cause (3) Signs and symptoms Risk Nursing Diagnoses: 2 parts (1) The patient's identified need or problem (2) Factors indicating vulnerabilityRecognize a correctly written goal (broad)Goal - Broad statement Should clearly reflect a relationship to the diagnosis. If pain is the problem, then the goal is to have less pain. If activity intolerance is the problem, then the goal is to tolerate activity.Recognize appropriately written expected outcome (SMART)Expected Outcomes are SMART -Specific -Measurable (Observable) -Achievable or Attainable -Realistic -Timed -Patient CenteredNursing interventions- recognize appropriately written interventions-Should address the "AEB portion." If the activity intolerance is related to pain, then addressing the pain should make the activity intolerance better. -Should be specific, clear, detailed, timed -This is like the babysitters list or a recipe. If you are not there, the person with this plan should know EXACTLY what you want them to do for the patient. -Should be individualized to the patient. Intervention example Expected Outcome: Patient will ambulate the distance of the hall three times daily by discharge Interventions (3 types): Assessment, Therapeutic, Education Assessment: Assess pain rating every hour using 1-10 pain rating scale Therapeutic: Administer Hydrocodone pain medication 30 minutes prior to ambulating Education: Teach to splint incision when repositioning and ambulatingEvaluation- how to evaluate and why?Evaluation focuses on the patient and the patient's response to nursing interventions and goal or outcome attainment. "To determine whether after application of the nursing process, the clients condition improves" Refer back to goal and expected outcomes Collect data (Reassess) Interpret evaluation data Evaluation example Expected Outcome: Pt will ambulate three times daily the distance of the hall by discharge Interventions: Assess pain rating every1h and notify MD if relief not achieved, Teach Sally to splint incision when repositioning and ambulating, Assist Sally to ambulate Sally in progressively increasing distance three times a day (i.e. to bathroom first), Medicate Sally 30 minutes prior to ambulation. Evaluation: 01/27/16 1100 Sally unable to walk the distance of the hall once. Reports pain rating 6 on 0-10 scale. Unmet. Revise the plan.