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Chapters 16-21 Nursing Assessment
Potter & Perry
Terms in this set (379)
The nursing process is the fundamental
Blueprint for how to care for patients. Is also a standard of practice.
The nursing process allows professional nurses to?
Allows professional nurses to apply the best available evidence to care giving and promoting human functions and responses to health and illness.
The gathering and analysis of information about the patients health status
After assessment what do you do?
Make clinical judgements from the assessment to identify the patients response to health problems in the form of nursing diagnoses.
Once you define appropiate nursing diagnoses you?
Create a plan of care
A plan of care includes
Setting goals and expected outcomes for your care and selecting interventions
individualized to each patients nursing diagnoses
Performing the planned interventions
The nursing process is central to your ability to provide
timely and appropriate care to your patients.
Nursing process allows you to conduct your practice in a systematic way
Assessment includes two steps
1. Collection of information from a primary source and secondary source
2. The interpretation and validation of data to ensure a complete database.
Family members, health professionals and medical records
What is the purpose of assessment?
To establish a database about the patients needs, health problems, and responses to the problems.
Data also reveal?
related experiences, health practices, goals, values, and expectations about the health care system
Once you know the nature and source of a patients specific health problem you are able to?
Provide interventions that will restore, maintain, or improve the patient health.
Critical thinking is a big part of assessment how?
Critical thinking allows you to see the big picture when you form conclusions or make decisions about a patient health condition.
While gathering data about a patient?
You synthesize relevant knowledge, recall prior clinical experiences, apply critical thinking standards and attitudes, and use standards of practice to direct your assessment in a meaningful and purposeful way.
Your knowledge from the physical, biological, and social sciences allow
You to ask relevant questions and collect relevant history and physical assessment data related to the patients presenting health care needs.
Data collection comes from
The patient ( Primary)
Family member ( Secondary)
Other members of health care team (Secondary)
Medical Record information ( Secondary)
Scientific literature or evidence bout assessment techniques and standards ( Secondary)
Information that you obtain through use of the senses
Your judgement or interpretation of cues
Example of cue and inference put together is
A patient crying is a cue that implies fear or sadness.
Assessment is dynamic meaning?
Assessment allows you to freely explore relevant patient problems as you discover them
What are the two approaches to a comprehensive assessment?
Gordons 11 functional health problems ( More structured)
Problem focused ( focuses on problematic area such as incisional pain)
Gordons functional health problems ( STRUCTURED)
Go from general to specific
ex) Health perception- health management pattern: describes frequency of health care provider visits; adherence to therapies at home; knowledge of preventive health practices
Problem focused ( PROBLEM FOCUSED)
Go from specific to general. Focus on patients presenting situation and ask questions to clarify and expand your assessment so you can understand the full nature of the problem. Later your physical exam confirms your findings.
ex) Incision pain
The complete assessment of the 11 functional health patterns represents the interaction of the patient and the environment which Gordon calls
What are two primary sources of data
Subjective and objective data
Patient verbal descriptions of their health problems. Subjective data usually include feelings, perceptions, and self report of symptoms.
Observations or measurement of a patients health status. The measurement of objective data is based on an accepted standard such as Farenheit or Celsius. When you collect objective data apply critical thinking intellectual standards.
Your best source of information is?
Rewuire more time than someone younger and often multiple visits are required to father a complete database
Patients are less likely to full reveal the nature of their health care problems when ?
Nurse show little interest or are easily distracted by activites around them
Primary sources for infants and children; critically ill adults; and patient who are mentally handicapped, disoriented, or unconscious are
Family members and significant others
You must obtain a patients agreement to include
family members or friends
Family and friends make important observations about the patients needs that can affect the way care is delivered
Example: How a patient eats a meal or how he or she makes choices.
When communicating with other health caer team members in gathering information about patients researchers have discovered that bedside handover
Promote patient centered care.
What happens during bedside rounds
The nurse who is completing care for a shift, the patient, and the nurse assuming care for a shift SHARE INFORMATION about the patients condition, status of problems, and treatment plan for the next shift
In regards to medical records HIPAA
Health Insurance Portability and Accountability Act has a privacy rule that came into effect April 14, 2003 to set standards for the protection of health information. The privacy rule allows health care provides to share protected information as long as they use reasonable safeguards
If a patient received services at a community health center or different hospital, you need?
Written permission from the patient or guardian to access the records.
The HIPAA regulations protect access to patients
Reviewing nursing, medical, and pharmacological literature about a patients illness
completes your assessment
When collecting data as a nurse by
Using patient centered interviews
Conducting health history
Performing physical examination
Viewing diagnostic test to collect data
These steps complete a database
Patient centered care
Empowers a patient, promotes mutual decision making with the nurse, and ensures continuity of care.
Think about getting a job
Collect available information about the person before starting the interview.
A good interview environment
Is free of distractions, unnecessary noise, and interruptions
Set aside 10-15 minutes and ensure privacy to obtain more information. Also remember to let the patient decide whether or not to involve family in the interview
An intial patient centered interview involves
Setting the stage
Setting an Agenda
Collecting the assessment or nursing health history
Terminating the interview
Setting the stage
Greet the patient using his or her full name, introduce yourself and explain your role ( If it is the first time you have met) remove and barriers to privacy by closing a room or curtain or shutting a door
Have patient sign an authorization before you collect personal health data
Setting an Agenda
The best clinical interview focuses on the patient, not your agenda. Let the patient know your purpose and what you will be doing. ( Collecting assessment or nursing history)
The professionalism and the competence you show when interviewing patients strengthens
The nurse patient relationship
Collect the assessment or nursing health history
Use attentive listening and other therapeutic communication techniques that encourage a patient to tell his or her story. DO NOT RUSH but stay orderly and focused
Terminating the interview
Giving the patient a clue that the interview is coming to an end by saying something like
" I have just two more questions"
Some interviews are
Focused and others are comprehensive. Because a patient report includes subjective information, validate data from the interview later with objective data.
Example of validating subjective data with objective data
If a patient reports difficulty breathing ( ROS Subjective information) validate data from the interview later with objective data ( Physical examination.
During an interview obtain information about
A patients physical, developmental emotions, intellectual, social, and spiritual dimensions
Open ended questions allow the patient to elicit their story
Tell me how you are feeling
Tell me how your health has been
Describe how your wife has been helping you
Give me an example of how you get relief from your pain at home.
Close ended questions
Limit answers to one or two words
Do you think the medication is helping you?
Who helps you at home?
Do you understand why you are having the x-ray examination?
Are you having pain now?
On a scale of 0 to 10, how would you rate your pain.
How do you reinforce your interest in what the patient has to say?
Use back channeling
Includes active listening prompts such as " all right, go on, or uh huh"
Used open ended questions. Encourages a full description without trying to control the direction the story takes.
Example: Is their anything else you can tell me?
Cultural considerations in Assessment
Avoid making stereotypes; the assumptions tied to stereotypes an lead you to collect inaccurate information.
Nursing health history
Is conducted during initial or early contact with a patient. Most health history's are structured
Nursing health history components
Reason for seeking health care
Present illness or health concerns
Age, address, occupations and working status, marital status, source of health care, type of insurance
Reason for seeking care ( Chief Complaint)
You record the patients response in quotations to indicate the subjective response
It is important to assess the patients understand of why he or she is seeking health care
Present illness or health concerns
Experiencing symptoms along with primary symptoms. For example does nausea accompany pain?
Includes a description of the patients lifestyle patterns. Any drugs, medications, allergies?
Provides information about family structure, interaction, support, and function that often is useful in planing care.
Provides information about a persons home and working environment
Reveals patients support system which includes spouses, children, family members, and close friends
Remember that " Life experiences and events shape a persons spirituality"
Review of systems
A systematic approach for collecting the patient self reported data on all body systems. During the ROS ask the patient about the normal functioning of each body system and any noted changes.
What is a physical examination
An investigation of the body to determine its state of health. Involves Inspection, Palpation, percussion, and auscultation.
Diagnostic and Laboratory data
Provide further explanation of alterations or problems identified during the nursing heath history or physical examination. Basically your blood work.
Determining the presence of abnormal finding, recognizing that further observations are needed to clarify information and begin to identify the patients health problems.
Comparison of data with another source to determine data accuracy. Validate findings from the physical examination and observation of patient behavior by comparing data in the medical record and consulting with other nurses or health care team members.
The Nurse practice acts and the American Nurses Association Nursings social policy statement
Require accurate data collection and recording as independent functions essential to the role of the professional nurse.
Through concept mapping you obtain
A holistic perspective of your patients health care needs, which ultimately leads you to make better clinical decisions.
Clinical judgement based on information
Problems TREATED primarily by nurses
Requiring several disciplines
The identification of a disease condition based on a specific evaluation of physical signs, symptoms, the patients medical history and the results of diagnostic test and procedures.
Are physicians licensed to treat diseases?
Physicians are licensed to treat disease and conditions described in medical diagnosis statements
Acute pain or nausea. A clinical judgement about individual, family, or coMmunity responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat.
An actual or potential physiological complication that nurses MONITOR to detect the onset of changes in a patient status.
Examples of collaborative problems
Things nurses must monitor
Hemorrhage, infection, and paralysis using medical, nursing, and allied health.
Nursing diagnosis were first introduced in nursing literature by
McFarland and McFarlane (1950)
Patient education and symptom relief
Driven by physicians orders such as medication administration and intravenous fluids
North American Nursing Diagnosis Association International
ANA's scope of nursing practice
Defined nursing as the diagnosis and treatment of human responses to health and illness
NANDA has several purposes
Provides a precise definition of a patients problems that gives nurses and other members of the health care team a cocommon language for understanding the needs of the patient
Allows nurses to communicate ( written and electronic) what they do among themselves with other health care professional and the public
Distinguishes the nurses role from that of the physician or other health care provider
Helps focus on the scope of nursing practice
Promotes creation of practice guidelines that reflect the essence of nursing.
Sources of information about nursing diagnoses include
Faculty, advanced practice nurses, documentation systems, and in some setting practice guidelines and protocols
Steps of diagnosis include
Data clustering, identifying patient health problems, and formulating the diagnosis
A set of signs or symptoms gathered during assessment that you group together.
Things that are observable and verifiable. Defining characteristics that support identification of a nursing diagnostic label.
Objective or subjective sign, symptoms, or risk factors that when analyzed with other criteria lead to a diagnostic conclusion
Usually from assessment to diagnosis you move from
General to specific
Defining characteristics often
Apply to more than one diagnosis
Always examine the defining characteristics
To support or eliminate a nursing diagnosis
Is a condition, historical factor, or etiology that gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis.
While focusing on patterns of defining characteristics
Compare a patients pattern of data with data that are consistent with normal, healthful pattern
NANDA-I identifies three types of nursing diagnoses
Health promotion diagnoses
Actual Nursing diagnosis
Describes human responses to health condition or life process THAT EXISTS in an individual, family, or community
Ex) Acute pain, Wandering, Impaired social interaction, stress urinary incontinence
Human responses to health conditions that MAY DEVELOP in a vulnerable individual, family, or community
Ex) risk for loneliness
Risk for acute confusion
Health promotion nursing diagnosis
Focuses on readiness to increase well being and actualize human health potential as expressed in their readiness to enhance 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 personal readiness is supported by defining characterisitics. Examples of health promotion include
Readiness for enhanced family coping
Readiness for enhanced nutrition
The name of the nursing diagnosis as approved by NANDA international. Describes the essence of a patients response to health conditions in as few words as possible.
Risk diagnosis havent occured yet. Patient has a " risk"
Risk diagnosis have two parts---> Diagnostic label and Related to factors
Actual Diagnosis have three parts
E- Etiology or related to
S- AEB/ defining characteristics
Etiology ( Related factors)
Nursing interventions do not change a medical diagnosis. YOU DIRECT NURSING INTERVENTIONS AT BEHAVIORS YOU ARE ABLE TO TREAT OR MANAGE
Order of diagnostic labels
It is important to consider your own cultural competence so you are more sensitive to a patients health care
A concept map
Diagrams the critical thinking associated with making accurate diagnoses. It makes connections between concepts. A concept map promotes critical thinking because you identify, graphically display, and link key concepts by organizing and analyzing information
Errors may our during data
Collection, interpretation, clustering, and labeling.
Error in interpretation
Review data to validate that measurable objective physical findings support subjective data.
Inaccurate interpretation of cues
Failure to consider conflicting cues
Using an insufficient number of cues
Using unreliable or invalid cues
Failure to consider CULTURAL INFLUENCES or DEVELOPMENTAL STAGE
Errors in data clustering
Incorrect clustering occurs when you try to make a nursing diagnosis fit the signs and symptoms obtained. Always identify the nursing diagnosis from the data, not the reverse
Error in labeling
Wrong diagnostic label selected
Evidence that another diagnosis is more likely
Condition a collaborative problem
Failure to validate nursing diagnosis with patient
Failure to seek guidance
Identify the patients response, not the medical diagnosis
Ex) change the diagnosis Acute pain related to prostatectomy to acute pain related to trauma of an incision.
The nursing diagnostic process is unique from that of medical diagnosis in that
Patient become involved in the diagnostic process when possible
Accurate diagnosis of patient problems ensure
the selection of more effective and efficient nursing interventions
One purpose of nursing diagnosis is that
It provides a precise definition of a patient problem that gives nurses and other members of the health care team a common language for understanding the patients needs
The nursing diagnostic process includes
Data clustering, identifying patient needs or problems, and formulation the nursing diagnosis or collaborative problems.
are subjective and objective clinical citeria that form clusters leading to a diagnostic conclusion
When as assessment reveals defining characterirics that apply to more than one nursing diagnosis
gather more information to clarify your interpretation
Absence of defining characteristics suggest that
you reject a proposed diagnosis
The "related to" factor of the diagnostic statement helps you to
Individualize a patient nursing diagnoses and provides direction for your selection of appropiate interventions
Risk factors serve as
Serve as cues to indicate that indicate a risk nursing diagnosis applies to a patients condition
A concept map
Is a visual representation of a patients nursing diagnoses and their relationship with one another
Nursing diagnostic errors occur by
Errors in data collection, clustering, interpretation and analysis of data, or the diagnostic statement
Collaboration with the patient is critical for a plan of care to be successful
identifying patient centered goals and expected outcomes
Prescribing individualized nursing interventions
Planning requires critical thinking applied through
deliberate decision making and problem solving
Planning also requires
Working closely with patients, their families, and the health care team through communication and ongoing consultation
A plan of care is dynamic meaning that
It changes as the patients needs change
Using determinations of urgency and/or importance to establish a preferential order for nursing actions. You should attend to each patient most important needs and better organize ongoing care activities.
Airway status, circulation, safety, and pain are
Highest priority problems. Consider Maslow's hierarchy of needs
Deficient knowledge and impaired physical mobility are both
Each time you begin a sequence of care such as at the beginning of a hospital shift or a patient clinic visit, it is important to reorder priorities. Priority setting begins at a holistic level when you identify and prioritize a patients main diagnosis or problems.
Involves patients in priority setting whenever possible. Patient centered care requires you to know a patients preferences, values, and expressed needs.
Work from your plan of care and use your patients priorities to organize the order for delivering interventions and organizing documentation of care
Goals and expected outcomes are
Specific statements of patient behavior or physiological responses that you set to resolve a nursing diagnosis or collaborative problem
A broad statement that describes a desired change in a patients condition or behavior
ex) she hopes to achieve pain relief
A measurable criterion to evaluate goal achievement
Planning nursing care requires
Critical thinking. Critically evaluate the identified nursing diagnosis, the urgency or priority of the problems, and the resources of the patient and the health care delivery system. You apply knowledge from the medical, socio-behavioral, and nursing sciences to plan patient care
Patient centered goal
Reflects a patients highest possible level of wellness and independence in function. It is realistic and based on patients needs and resources.
How sick or how involved is your patient.
A patient with a lower acuity
Is more capable of independent care
A patient with a higher acutiy
non capable of independent care.
ex) patients on ventilators
Depends on the nature of the problem, etiology, overall condition of the patient and treatment setting
Short term goal
Objective behavior or reponse that an patient can achieve in a short amount of time, usually less than a week
Long term goal
Objective behavior or response that an patient can achieve over a longer period of time usually several days, weeks, or months
Mutual goal setting includes
The patient and family( when appropriate) in prioritizing the goals of care and developing a plan of action. Unless goals are mutually set and there is a clear plan of action, 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 heath or prevent deterioration when possible
Expected outcomes are
Measurable with a time frame
Ex) Patient WILL report pain of 3 or less on a 0-10 scale within 6 hours
Always write expected outcomes sequentially with time frames
Nursing sensitive patient outcome
Is a measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing intervention
For each NANDA international nursing diagnosis
There are multiple NOC suggested outcomes
Goals vs. Expected Outcomes
Goal: Patient will ambulate independently in 3 days
Expected outcome:Patient will ambulate in the hall 3 times a day by 4/22
Each goal and outcome should
Address only ONE behavior or response
Correct:Patient will ambulate independently in 3 days
Incorrect: Patient will will ambulate and perform bowel movements, and perform fishing activities in 3 days
Clear to auscultate
Observable changes occur
In physiological findings and in the patients knowledge, perceptions, and behavior
The outcome statement " Patient will appear less anxious, is not correct because there is no specific behavior observable for " Will appear "A more correct outcome is " Patient will show better eye contact during conversations"
Examples such as " Body temperature will remain 98.6 F, and " Apical impulse will remain between 60 and 100 beat per minute, allow you to objectively measure changes in the patients status. DO NOT USE VAGUE QUALIFIERS SUCH AS NORMAL, ACCEPTABLE, OR STABLE in a expected outcome statement
The time frame for each goal and expected outcome indicates when you expect the response to occur. Time frames help you and the patient to determine if the patient is making progress at a reasonable rate. Time frames also promote accountability in delivering and managing nursing care.
Mutual goal setting increases the patients motivation and cooperation
Realistic goals provide patients a sense of hope that increases motivation and cooperation. To establish realistic goals, assess the resources of the patient, health care facility, and family. Be aware of the patients physiological, emotional, cognitive, and socicultural potential and economic cost and resources available to reach expected outcomes in a timely manner
Choosing suitable nursing interventions involves critical thinking and your ability to be competent in three areas
1) Knowing the scientific rationale for the intervention
2) Possessing the necessary psychomotor and interpersonal skills
3) Being able to function within a particular setting to use the available health care resources effectively
What are three types of nursing interventions
Independent nursing interventions
Dependent nursing interventions
Independent nursing interventions
Actions that a nurse initiates; You act independently on a patient behalf and are autonomous; Nurse initiated interventions require no supervision or direction from others
ex) Elevating an edematous extremity, instructing patients in side effects of medications, re positioning a patient to achieve pain relief
Dependent nursing interventions
Physician initiated interventions or actions that require an order from a physician or another health care professional
ex) Administering a medication, implementing an invasive procedure ( Foley catheter, starting an intravenous IV fusion, changing a dressing, and preparing a patient for diagnostic test
Interdependent interventions ( therapies) that require the combined knowledge, skills, and expertise of multiple health care professionals.
Clarifying an order is
Competent nursing practice, and it protects the patient and members of the health care team.
When considering interventions consider six things
S- Is it Specific?
M- Is it Measurable?
A- Is it attainable/ achievable?
R- Is it relevant to the matter at hand?
T- Time, some sort of denotation to the issue at hand?
When choosing an nursing intervention check for?
The characteristics of the nursing diagnosis
Acceptability to the patient
Capability of nurse
Capable of being done or carried out
Nursing care plan
Includes nursing diagnoses, goals and expected outcomes, specific nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patient clinical needs and situation. A nursing care plan is a guideline for coordinating nursing care, promoting continuity of care, and listing outcome criteria to be used later in evaluation
Interdisciplinary care plans
Include contributions from all disciplines involved in patient care
Hospitals have EHR's
Electronic health records for showing care plans
A care plan
Includes a patients long term needs thus it is beneficial to involve the family in planning care if the patient is agreeable
Nursing intervention classification
1. Physiological: Basic
2. Physiological: complex
6. Health system
Change of shift report ( Handoff)
The standard practice used for offgoing nurses leaving a shift to communicate information about the patients plan of care to oncoming patient care personnel
In some agencies the nursing handoff process occurs during walking round when nurses exchange information about patients at the bedside, giving patients the opportunity to also ask questions and confirm information
Six column care plan for students
The following questions help you design a care plan
What is the intervention
When should each intervention be implemented
How should the intervention be performed for this specific patient
Who should be involved in each aspect of intervention
Each scientific rationale that you use to support a nursing intervention needs to include
A reference whenever possible to document the source from the scientific literature
Common omissions that nurses make in writing nursing interventions include
action, frequency, quantity, method, or person to perform them.
Use the evaluation column to
document whether plan requires revision or when outcomes are met, thus indicating when a particular nursing diagnosis is no longer relevant to the patients plan of care.
When designing care plans for family members
Educate the patient family about the necessary care techniques and precautions
Teach the patient family how to integrate care within family activities
guide the patient family on how to assume a greater percentage of care over time.
Critical pathways are?
Patient care management plans that provide the health care team with the activities and task to be put into practice sequentially. There main purpose is to deliver timely care at each phase of the care process for a specific type of patient.
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 efficient as possible
Type of errors when writing nursing interventions
Failure to completely indicate nursing actions
Failure to indicate frequency
Failure to indicate quantity
Failure to indicate method
Critical pathways improve the continuity of care because
They clearly define the responsibility of each health care discipline. Well developed pathways include evidence based interventions and therapies
A concept map
Offers you a visual representation of all patient nursing diagnosis and allows you to diagram interventions for each
The 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 the planning and implementation of therapies. Consultation is based on the problem solving approach and the consultant is the stimulus for change
Nurses get consulted for
clinical expertise, patient education skills, or staff education skills
Consultation occurs when?
You identify a problem that you are unable to solve using personal knowledge, skills, and resources. Consultation requires good intrapersonal and interprofessional collaboration.
Tips for making phone consultations
Have the information you need before making the call
Asses the patient yourself before making the call
Understand why you are calling for consultation and think through some possible solution
Be prepared to summarize what you think the problem is
Steps to consultation
1) Identify the general problem area.
2) direct the consultation to the right professional such as another nurse or social worker
3) provide consultant relevant information about the problem area
4) Do not prejudice or influence consultants
5) Incorporate the consultants recommendations into the care plan
During planning determine
Patient goals, set priorities, develop expected outcomes of nursing care, and select interventions for the nursing care plan
Priorities help you anticipate and sequence
nursing interventions when a patient has multiple nursing diagnosis and collaborative problems
Goals and expected outcomes
Provide clear direction for the selection and use of nursing interventions and the evaluation of the effectiveness of the interventions
In setting goals the time frame depends
On the nature of the problem, etiology, overall condition of the patient, and treatment setting
A patient centered goal is?
Singular, observable, measurable, time limited, mutual, and realistic
An expected outcome is an
Objective criterion for goal achievement
Nurse initated interventions ?
Do not require any order, supervisions, or direction from others.
Physician initiated interventions?
Require specific nursing responsibilities and technical nursing knowledge
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
A concept map
Provides a visually graphic way to show the relationship between patient nursing diagnoses and interventions
The NIC taxonomy
Provides a standardization to help nurses select suitable interventions for patients problems
Correctly written nursing interventions include
actions, frequency, quantity, method, and the person to perform them
When making a consultation
First identify the general problems, direct the consultation to the right professional, and provide the consultant with relevant information about the problem.
Implementation is circular like all steps of the nursing process. this means that the patients situation is vulnerable to change but you must reassess the status of existing nursing diagnoses, confirm that these diagnoses are still appropriate, evaluate the patients responses to planned intervention and continue to deliver intervention in a timely and competent manner
Any treatment based on patients outcomes. Ideally nursing interventions are evidence based providing the most current up to date and effective approaches for managing patient problems
Direct care interventions
Treatments performed through interactions with patients
ex) A patient receives direct care in the form of medication administration, insertion of an IV infusion, or counseling during a time of grief
Indirect care interventions
Treatments performed away from the patient but on behalf of the patient or group of patients
ex) Safety and infection control
Indirect care interventions include actions for managing the patients environment, documentation, and interdisciplinary collaboration
Indirect care intervention of consultation is a
Who defined the domains of nursing practice?
Domains of nursing practice
The helping role
The teaching coaching function
The diagnostic and patient monitoring function
Effective management of rapidly changing situations
Administering and monitoring therapeutic intervention and regimens
Monitoring and ensuring the quality of health care practices
Organizational and work role competencies
The focus of implementations is and will always be
Before implementing interventions
Exercise good judgement and decision making
Review the set of all possible nursing interventions for the patients problems
Review all possible consequences associated with each possible nursing action
Determine the probability of all possible consequences
Make a judgement of the value of the consequence to the patient
Using simple, clear explanations and repeated instructions
Confidence in performing interventions build trusts
Nurse and physician initiated standardized interventions are available in the form of
Clinical guidelines or protocols, preprinted ( standing) orders
Clinical Practice Guidelines
Is a set of statements that help nurses, physicians and other health care providers make decisions about specific clinical situations. Guidelines are now seen as key tools for improving the quality of health care and bridging the gap between the growth of research finding and actual clinical practice
Set of rules that explain a correct procedure
In acute care settings it is common to find
clinical protocols that outline nursing interventions
A pre-printed document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems.
Licensed prescribing health care provides approve and sign standing orders
An example of a standing order
One specifying certain medication such as lidocaine or propranolol for irregular heart rhythm.
The physicians initial standing order
Covers the nurses action
During the initial phase of implementation
Reassess the patient. The reassessment focused on one primary nursing diagnosis, or one dimension of the patient such as level of comfort, or one system such as the cardiovascular system
Review and revise
After reassessing the patient review the care plan and compare assessment data to validate the nursing diagnoses and determine whether the nursing intervention remain the most appropriate for the clinical situation
Review and modification enable you to
Provide timely nursing interventions to best meet the patient needs
Modification of a care plan incldudes four steps
Revise nursing diagnosses/ revise related factors and patients goal
Revise specific interventions
Choose method of evaluation for determining whether you achieved patient outcomes
Keep extra supplies available in case of error or mishaps, but do not open them unless you need them. this controls health care cost
A primary nurse is accountable for the nursing care that a patient recieves during his or her length of stay or course of visits. A team nurse is accountable for the care that a patient recieves for a specific shift in the which the nurse works.
Remember that patient safety is always your first concern. Rearrange furniture and equipment when ambulating a patient, or make sure that the water temperature is not too warm before a bath. When you need to expose body parts do so privately by closing room doors and curtains to ensure privacy
Make sure that the patient is as physically and psychologically comfortable as possible. For example symptoms such as nausea, dizziness, fatigue, or pain frequently interfere with a patients full concentration and ability to cooperate
Start any intervention by controlling environmental factors, taking care of physical needs, avoiding interruptions, and positioning the patient correctly. Also consider the patients level of endurance and plan only the amount of activity that he or she is able to tolerate
Before beginning care
Review the plan to determine the needs for assistance and the type required
When you are asked to administer a new medication, operate a new piece of equipment, or administer a procedure with which you are familiar you should...
Seek information you need to be informed about
Collect all equipment necessary for the procedure
Have another nurse who has completed the proceudre correctly and safely provide assistance and guidance
Nursing practic includes
Cognitive, Interpersonal, and psychomotor ( technical skills)
Know the rationale for therapeutic interventions and understand normal and abnormal physiological and psychological responses.
Develop a trusting relationship. Good interpersonal commuication is critical for keeping patients informed, providing individualized patient teaching and effectively supporting patients with challenging emotional needs,
Require the integration of cognitive and motor activities. For example when giving an injection you understand anatomy and pharmacology ( cognitive) and use good coordination and precision to administer the injection correctly ( Motor)
Activities of daily living
Activities usually performed in the course of a normal day such as dressing, bathing, and grooming.
A persons need for assistance is
temporary, permanent, or rehabilitative
A patient with impaired physcial mobility because of bilateral arm casts has a TEMPORARY need for assistance
A patient with an irreversible injury to the cervical spinal cord is paralyzed and has a PERMANENT need for assistance.
Restore ADL function
Instrumental activities of daily living (IADL's)
For patients with an illness or disabiltiy. Include skills such as shopping, preparing meals, house cleaning, writing checks, banking, and taking medications. Nurses within the home care and community health setting frequently help patient adapt ways to perform IADL's
Before conducting a new procedure
always assess the situation and your personal competencies to determine if you need assistance, new knowledge, or new skills
Life saving measure
Physical care technique used when a patient psychological or physiological state is threatened. The purpose of lifesaving measures is to restore physiological or psychological homeostasis. Such measures include administering emergency medications, instituting cardiopulmonary resuscitation, intervening to protect a confused or violent patient, and obtaining immediate conuseling from a criss center
DIRECT CARE METHOD that helps a patient use a problem solve process to recognize and manage stress and facilitate interpersonal relationship. Examples include patients who are facing terminal illness or chronic disease. Counseling involved emotional, intellectual, spiritual, and psychological support
A key to patient centered care
As a nurse you are accountable for the quality of education you deliver
A harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention
Preventive nursing actions
Promote health and prevent illness to avoid the need for acute or rehabilitative health care
Indirect care measures
Include nurse actions aimed at management of the patient care environment and interdisciplinary collaborative actions that support the effectiveness of direct care interventions
Delegation of care to NAP is an example of
Indirect care activites
Delegation of acre activites to nursing assistive personnel
Medical order transcription
Environmental safety management
change of shift report
collecting, labeling, and transporting specimens
Anything that doesnt have to do with direct contact with patient is?
Indirect patient care
Intersciplinary care plans
Represent the contributions of all disciplines caring for a patient
Care activities you delegate to NAP
Skin care, ambulation, grooming, vital signs on stable patients, hygiene measures
Means that patients AND FAMILIES invest time in carrying our required treatments.
You are responsible for delivering interventions in a way that reflects your understand of a patients health beleifs, culture, lifestyle pattern, and patterns of wellness
When you delegate aspects of a patients care
You are responsible for ensuring that each task is assigned appropiately and completed according the standard of care
To complete any nursing procedure you need to know the
Procedure, its frequency steps, and expected outcomes
Evaluations involves two components
An examination of a condition or situation and a judgement as to whether change has occured.
The final step of the nursing process is crucial to determine whether after application of the nursing process, the patients contion or well being improves. You apply all that you know about a patient and his or her condition and your experiences with previous patients to evaluate whether nursing care was effective
Why do you conduct evaluative measures
To determine if your patient met outcomes, not if nursing interventions were completed.
Physical stress such as bending and lifting strains a suture line
Gather objective and subjective data
Reflect on previous clinical experiences
Apply critical thinking attitudes
Apply intellectual standards
Review expected outcomes
Were outcome met?
An ongoing process
Once you deliver an intervention
You gather subjective and objective data from the patient, family, and health care team members. You also review knowledge regarding the patient current condition, treatment, resources available for recovery, and expected outcomes
By referring to previous experiences caring for similar patients
You are in a better position to know how to evaluate your patient
Positive evaluations occur when
The patient meets desired outcome which lead you to conclude that the nursing intervention were effective
Unmet or undesirable outcomes such as incomplete knowledge indicate
That interventions are not effective in minimizing or resolving the actual problem or avoiding an at risk problem
Evaluation is dynamic meaning that
It is ever changing, depending on the patients nursing dianoses and condition. As problems change so do expected outcomes. A patient whose health state continuously changes requires more frequent evaluation
Nursing care helps
Patient resolve actual health problems, prevent the occurrence of potential problems, and maintain a healthy state
Defines standards of professional nursing practice
The competencies for evaluation include being
Systematic and using criterion based evaluation, collaborating with patients and other professional, using ongoing assessment data to revise the plan, and communicating results to patients and families.
The expected behavior or response that indicate resolution of a nursing diagnosis or maintenance of a healthy state. It is a summary statement of what will be accomplished when the patient has met all expected outcomes. Goals are also based on standards of care or guidelines established for minimal safe practice
When a nurse cares for a patient with a peripheral IV line, a possible goal is
" The IV site will remain free of phlebitis"
An end result that is measurable, desirable, and observable and translates into observable patient behavior. It is a measure that tells you if the intervention applied in patient care led to a successful goal achievement
When nurses apply the nursing process
A nursing sensitive outcome is a measurable patient or family state, behavior, or perception largely influences by and sensitive to nursing interventions
Nursing sensitive outcome examples
Reduction in pain frequency, incidence of pressure ulcers, and incidence of falls
Medical outcomes are largely influences by
Example: Patient mortality, surgical wound infection, hospital readmissions
When you achieve outcomes
The related factors ( Cause) for a nursing diagnosis usually no longer exist
What is evaluation and what isn't
Evaluation is not a description of the achievement of an intervention
Evaluation does involve observation of the patients behavior in response to an intervention.
An important aspect of patient centered care and evaluation is
The nurse must respect
The patient and family as a core member of the health care team meaning that the patient and family must be actively involved in the evaluation process
Members of the health care team who contribute to the patients care also gather
Assessment skills and techniques
Evaluative measures are the same as assessment measures but you perform them at the point of care when you make decisions about the patients status and progress.
What is intent of evaluation
To determine if the known problems have remained the same, improved, worsened or otherwise changed.
For example over a period of 2 days is te pressure ulcer gradually decreasing in size, is the amount of drainage declining and is the redness of inflammation resolving.
When you evaluate the effect of interventions
You interpret or learn to recognize relevant evidence about a patients condition, even evidence that sometimes does not match clinical expectations
Critical thinking skills promote
Accurate evaluation which leads to the appropiate revision of ineffective care plans and discontinuation of therapy that has successful resolved a problem
Match the results of evaluative measures
With expected outcomes to determine whether or not a patient status is improving
If evaluatiion determines that the expected outcomes were not met or only partially met you begin
Reassessment and revision of the care plan
In settings in which the same nurse will not be providing care throughout a patients state it become very important to have
Consistent, thorough documentation of the patients progress toward expected outcomes
Each time you evaluate a patient you determine if
the plan of care continues or whether revisions are necessary
An important step in critical thinking is knowing
How to patient is progressing and how problems either resolve or worsen
After you determine that expected outcomes and goals have been met
Confirm this evaluation with the patient when possible. If you and the patient agree you discontinue that portion of the care plan. Documentation of a discontinued plan ensures that other nurses will not unnecessarily continue interventions for that portion of the plan of care.
Reassessment ensures that
the database is accurate and current
Standard of care
The minimum level of care accepted to ensure high quality of care to patients.
What measure did you use to determine if the intervention was effective . Inspection, Palpation, Percussion, Auscultation
A standard by which something may be judged
Evaluation is a step of the nursing process that includes two components
Examination of a condition or situation and a judgement as to whether change has occured
occur when you meet desired outcomes and they lead you to conclude that your intervention were effective
Assessment skills or techniques that you use to collect data for determining if outcome were met
It sometimes become necessary to collect
Evaluative measures over time to determine if a pattern of change exists
When interpreting findings
Compare the patients behavioral responses and physiological signs and symptoms that you expect to see with those actually seen from your evaluation and judge the degree of agreement
Documentation of evaluative findings
Allows all members of the health care team to know whether or not a patient is progressing
Evaluations examines two factors
The appropiateness of the interventions selected and the correct application of the intervention.
The national counsil of state boards of nursing identified competencies
that registered nurses and licensed practical vocational nurses need on entry to practice
A strong nursing team
Works together to achieve the best outcomes for patients
Empowered nursing team begins with
The nurse executive who is often vice president or director of nursing. The nurse executive is both a clinical and business leader who is concerned with maximizing quality of care and cost effectiveness while maintaining relationships and professional satisfaction of the staff
The most important responsibility of the nurse executive is to
establish a philosophy for nursing that enables managers and staff to provide quality nursing care. In this environment staff members have high levels of productivity and make contributions to the success of the organization
FA philosophy adresses
the purpose of the nursing unit, how staff works with patients and families, and the standards of care for the work unit. Selection of a nursing care delivery model and a management structure that support professional nursing practice are essential to the philosophy of nursing care
One way of creating an empowering work environment is through
The magnet recognition program
A magnet hospital
Has a transformed culture with a practice environment that is dynamic, autonomous, collaborative, and positive for nurses. Typically a magnet hospital has clinical promotion systems and research and evidence based practice programs
A magnet hospital
Empowers the nursing team to make changes and be innovative. An effective empowerment model leads to a staff that feel valued and has increased autonomy and a work environment that promotes job satisfaction
Characteristics of an effective leader
Is an effective communicator
Is consistent in managing conflict
Is knowledgeable and competent in all aspect of delivery of care
Is a role model for staff
Uses participatory approach in decision making
Delegates work appropriately
Sets objective and guides staff
Displays caring, understanding, and empathy for other
Is proactive and flexible
A care delivery model
Helps nurses achieve desirable outcomes for patients either in the way work is organized or in the way a nurses responsibilities are defined.
Registered RN leads team of other RNs practice nurses and unlicensed assistive personnel
Team members provide direct patient care under supervision
Team leader develops patient care plans, coordinates care among team members and provides care requiring complex nursing skills
Their is hierachical communication from charge nurse to charge nurse to team leader and team leader to team members
Total Patient care
One RN is responsible for all aspects of care for one or more patients during a shift of care
Care can be delegated
RN works directly with patient, family, and health care team members
One primary RN assumes responses for a caseload of patients
When an RN is working, he or she provides care for the same patients during their stay in a facility
RN assesses patient, develops plan of care, and delivers appropriate nursing intervention
Communication is lateral from nurse to nurse and caregiver to caregiver.
Advantages to team nursing
Care is provided through a collaborative style that encourages each member of team to work with and help the other members
Model has a high level of autonomy for the tram leader
Decision making occurs at a clinical level
Nursing care conferences help to solve patient problems
Patient care coordinator has time to manage unit issues
Advantages to total patient care
Patient satisfaction with model is high
RNs plan care
There is a high degree of collaboration with other health care team members
Advantages to primary nursing
Model is flexible and uses a variety of staffing level and mixes
Model has a high level of autonomy and authority
Model promotes collaboration with physician
Model provides continuity of care if facilitated
Model reduces numbers of errors that occur when relaying orders
Care management approach that coordinates and links health care services to patients and their families while streamlining cost and maintaining quality.
Case management is defined as
A collaborative process of assessment, planning, facilitation, and advocacy for options and service to emet an individuals health needs through commnication and available resources to promote quality cost effective outcome
Ex) A case manager coordinates a patients acute care in the hospital and follows up with the patient after discharge
Ongoing communication with team members facilitates
The patients transiton home
A case manager
He or she is advanced practice nurse who through specific intervention helps to improve patient outcomes, optimize patient safety by facilitating care transition, decrase length of stay, and lower health care cost.
When decision making is moved down to the level of staff. Is very common within health care organizations.
Working in a decentralized structure has the potential for
Greater, collaborative effort, increased competency of staff, increased staff motivation, and ultimately a greater sense of professional accomplishment and satisfaction
Refers to the duties and activities that an individual is employed to perform. Nurses meet these responsibilities through participation as members of the nursing unit. Responsibility reflect ownership. A Manager is responsibile for clearly defining the RNs role within the new care delivery model. If decentralized decision making is in place, professional staff have a voice in identifying the new RN role
Evaluate whether plans were successful
Freedom of choice and responsibility for the choice. Autonomy oconsistent with the scope of nursing practice maximizes your effectiveness as a nurse. In work autonomy the nurse makes independent about the work of the unit such as scheduling or unit governance
Refers to legitimate power to give commands make final decision specific to a given position. The primary nurse has the final authority in selecting the best course of action for the patients care
Refers to individuals being answerable for their actions. A primary nurse is accountable for his or her patients outcomes and for ensuring that each patient learns the information necessary to improve self care
A successful decentralized nursing unit supports the four elements of decision making
Responsibility, autonomy, authority, and accountability
When decentralized decision making exists on a nursing unit
All staff members actively participate in unit activities
If the staff learns to value knowledge and contributions of co workers
Better patient care is an outcome. Experiences RNs provide leadership and mentoring on a nursing unit with promoting colloabortive practice
Groups that establish and maintain care standards for nursing practice on thier work unit
Recieve regular reports of committee progress
Nurse physician collaboration improves
Patient safety and outcomes and reduces errors
Decreases mistakes because team members commit to shared knowledge, skills, and attitude
Develops critical thinking skills
An immediate threat to a patients survival or safety such as physiological episode of obstructed airway, loss of consciousness, or a psychological episode of an anxiety attack
Nonemergency non life threatening
Ex) anticipating teaching needs of patients
Often erlated to developmental needs or long term health care needs
ex) a patient at admission who will eventually be discharged and needs teaching for self care in the home.
To identify which patients require assessment first rely
On information from the change of shift report
Effective use of time means
Doing the right things
Efficient use of time
Doing things right
A leader knows his or her limitations and
seeks professional colleagues for guidance and support
Transferring responsibility for the performance of an activity or task while retaining accountability for the outcomes
The five right of delegation
Right direction/ communication
Right supervision/ evaluation
Sets a phiolosophy for a work unit, ensures appropriate staffing, mobilizes staff and institutional resources to achieve objectives, motivates staff members to carry out their work, sets standards of performance, and makes decision to achieve objectives.
Mutual trust, respect, and rapport between a manager and staff members
Empowering staff members
Brings out the best in a manager and allows him or her to concertrate of effective patient care systems, support risk taking and innovation, and focus on results and rewards
An empowered nursing stagg
Has decision making authroity to change how they practice
Nursing care delivery modesl vary according to
the responsibility and autonomy of the RN in coordinating care delivery and roles other staff memebers play in assisting with care.
Critical to the success of decision making
is making staff members aware that they have the responsibility, authority, autonomy, and accountability for the care they give and the decisions they make
A nurse manager encourages
Decentralized decision making by establishing nursing practice committees, supporting nurse physician and interdisciplinary collaboration, setting and implementing quality improvement plans and maintaining timely staff communication
In an enriched professional environment
Each member of a nursing work team is responsible for open, professional communication
Effective delegation requires the use of good
When done correctly delegation
improves job efficiency, productivity, and job enrichment
When delegating nursing care always
According to Gordon's Structured comprehensive assessment
Your assessment identifies functional patterns ( Patient strengths) and dysfunctional pattern (Nursing diagnoses)
In a problem- oriented approach
You focus on the presenting problem, ask follow up questions to clarify and expand your assessment so you can understand the full nature of the problem. Your physical examination further confrims your observations
Who provides subjective data
Only patients. Subjective data usually include feelings, perceptions, and self report of symptoms
Examples of objective data
Describing an observed behavior, measuring blood pressure, inspecting the condition of a surgical wound
Focus on older adults during assessment
Allow for pauses and time for patient to tell the story
Recognize normal changes associated with aging. These changes might be considered abnormal in a younger adult
If patient has limited hearing or visual deficits, use nonverbal communication when conducting a patient centered interview
Nonverbal communication includes: Patient directed eye gaze, affirmative head nodding
If a patient received services at a community health center or different hospital
you need written permission from the patient or guardian to access the records
A physical examination
Involves use of the techniques of inspection, palpation, percussion, auscultation, and smell
A complete physical examination
Includes a patients height, weight, vital signs, and a head to toe examination
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The nurse documents in a client's medical record: "The client is a drug addict and is always asking for more medication than what is necessary." With what might the nurse be charged?
What is the problem oriented record?
A nurse works with a patient to establish outcomes. The nurse believes that one outcome suggested by the patient is not in the patient's best interest. What is the nurse's best action?