NUS 110 - Communication, EBP, & Nursing Process

What does SBAR stand for?

Situation

Background

Assessment

Recommendation

I am (name) a nurse from (hospital/clinic)

I am calling about (patient/ room #)

I am calling because I am concerned that ...

(ex: temperature is 103, painful urination)

Is an example of what nursing communication?

SBAR - S (situation)

Patient (X) was admitted on (date) with (diagnosis)

Patient (X) has a past medical history of ...

Patient's condition has changed in last (xx mins)

Their last set of vitals were ...

Is an example of what nursing communication?

SBAR - B (Background)

I think the problem is ...

OR

I am not sure what the problem is but patient is not doing well and I am concerned

Is an example of what nursing communication?

SBAR - A (Assessment)

I request that you (enter what you want done)

ex: come see patient, order labs, antibiotics

If there is a change to treatment, ask, "How often would you like vitals" or "If patient does not improve, would you like us to call back again?"

Is an example of what nursing communication?

SBAR - R (Recommendation)

When is SBAR used?

When nurses need to communicate with other health care physicians or nurses

Why is SBAR used?

It tells the physician exactly why you are calling about the patient

Physiological needs according to Maslow are ?

breathing, food, water, sex, sleep, homeostasis, excretion

What are the 5 steps of basic human needs according to maslow? starting at the bottom

Physiological needs

safety

love/belonging

self esteem

self actualization

The nursing process is a ________ method, meaning?

Systemic method - meaning theres a way of doing things (APPIE)

Why do nurses use APPIE?

its a systemic method used for nurses to work through getting the patient the help they need

What does the A stand for in APPIE?

Assessment (What type of care they need)

What does the first P in APPIE stand for?

Identifying the PROBLEM/ nurse diagnosis

What does the second P in APPIE stand for?

Planning - "the patient will"

What does the I in APPIE stand for?

Interventions (always starts with a verb) - what nurse will do with patient

What does the E in APPIE stand for?

Evaluation - outcomes. If the patient did or did not meet their plan for that shift

Collection of Data can be both ?

Subjective (only seen or felt by patient)

Objective (what can be measured; temp, BP, RR)

Info perceived only by the infected person is known as

Subjective data - "I have a headache"

Info that can be measured, felt, observed by someone other than the patient is known as

Objective data - patients skin is hot and red, patient has a temp of 102 F

What 4 factors are used when assessing a patient?

1. Collection of date (subjective and objective are both documented)

2. Analysis of data

3. Validation of data - if a patient has alot of subjective data and not much objective data - you need to look at validation

4. Communication of data - how to help the patient (SBAR)

The term ADL means

Activity daily living

T/F - Nurses can NOT diagnosis patients - but can identify & interpret medical diagnosis

True

T/F - A nurse can say "patient has risk of hypoglycemia" but can not say "patient has diabetes"

True

How to correctly write an APPIE

Patient problem (activity intolerance) RELATED TO clinical manifestation (sedentary lifestyle) AS EVIDENCE BY dyspnea - shortness of breath

EBP is

recommendation for the patient guided by evidence (nurse problem solving approach to make clinical decisions)

Nurses use _____ as a problem solving approach to make clinical decisions

Evidence Based Practices (EBP)

What are the 7 Steps to EBP

1. develop a sense of inquiry

2. Ask questions

3. Search for answers in professional/literature journals

4. Assess the evidence

5. Implements the best evidence into clinical practice

6. Evaluate the outcomes of the changes to your practice

7. Share the outcomes with healthcare team

What is nursing informatics

the way nurses use technology to take care of patients (evidence)

What kind of communication do nurses use?

therapeutic communication - facilitates coordination of care for patient

When communicating with the patient, the nurse should ask

open ended questions

Healthy People 2020, 2030, 2040, etc focuses on

what conditions/diseases they are working on as a country

What 3 levels are used for health promotion

- Primary

- Secondary

- Teritary

Disease prevention (before the patient is sick) is known as what type of health prevention

Primary prevention

Getting a screening test for a patient at risk is what type of health prevention (someone with a history of that disease)

Secondary prevention (breast screening for someone with family history of breast cancer)

After patient is diagnosed, what type of health prevention is used

Teritary prevention - to keep patient from getting worse

When communicating with a patient, is it OK to communicate through family members?

No, patient must understand (ex: get translator)

When does re-registration happen for RN

every 2 years RN has to be re-registered & child abuse

T/F - every state has their own policy

True

________ entails the procedures and processes by which one party justifies and takes responsibility for its activities.

accountability

______ is the protection and support of another's rights.

advocacy

As bridges between vulnerable patients and the resources they need to secure health outcomes, nurses have always been strong patient ______

advocates

the principle of doing good is known as

beneficence

Implicating beneficence as a nurse is to

Commit yourself to actively promoting the patient's BENEFIT (health and well-being or good dying). Be sensitive to the fact that individuals (patients, family members, and professional caregivers) may identify benefits and harms differently. A benefit to one may be a burden to another.

process by which a person who has met certain criteria established by a nongovernmental association is granted recognition

certification

What are the 6 steps in dealing with conflict (resolution) (ACCCCS)

- Avoiding

- Collaborating

- Competing

- Compromising

- Cooperating/Accommodating

- Smoothing

One of the ways to deal with conflict (conflict resolution) is by: There is awareness of the conflict situation, but the parties involved decide to ignore, or postpone its resolution. The conflict has not been resolved and may resurface later in an exaggerated form.

Avoiding

One of the ways to deal with conflict (conflict resolution) is by: a joint effort to resolve the conflict with a win-win solution. All parties set aside previously determined goals, determine a priority common goal, and accept mutual responsibility for achieving this goal. This focus on problem solving is based on mutual respect, honest communication, and shared decision making.

Collaborating

One of the ways to deal with conflict (conflict resolution) is by: This approach results in a win for one party at the expense of the other group. This win-lose confrontation can leave the loser frustrated, with a desire to "get even" in the future. This strategy may be used when one party has more knowledge regarding the situation, or when resistance is appropriate because of ethical concerns or unsafe patient care practices.

Competing

For this goal in conflict resolution to be effective, both parties must be willing to relinquish something of equal value. If that does not occur, either or both parties may feel that they have lost the conflict and given up more than the other group.

Compromising

This type of conflict resolution One party makes a conscious decision to let the other group win and may collect an "IOU" for use in the future. This party's original loss may result in a more positive outcome in the future.

Cooperating/Accommodating

This type of conflict resolution results in an effort to compliment the other party and focus on agreement rather than disagreement, thus reducing the emotion in the conflict. The original conflict is rarely resolved with this technique.

Smoothing

The person's family, ______ , community, and society also influence this personal perception of health.

culture

DNR means

do not resuscitate

As you begin clinical practice, remember that while the ANA Code of Ethics for Nurses reminds us that our primary duty is to the ______

patient

______ is a systematic study of principles of right and wrong conduct, virtue and vice, and good and evil as they relate to conduct and human flourishing

ethics

what are the 5 principles of bioethics

autonomy (self-determination)

nonmaleficence

beneficence

justice

fidelity

______ which is a subset of bioethics, is the formal study of ethical issues that arise in the practice of nursing and of the analysis used by nurses to make and evaluate ethical judgments.

nursing ethics

What is the moral rule for justice (bioethics) ?

Give each his or her due; act fairly.

Implications of nursing practice for justice (bioethics) include

Always seek to distribute the benefits, risks, and costs of nursing care justly. This may involve recognizing subtle instances of bias and discrimination.

What is the moral rule for nonmaleficence (bioethics)?

Avoid causing harm.

The implications of nursing practice for nonmaleficence (bioethics) include

Seek not to inflict harm; seek to prevent harm or risk of harm whenever possible.

The moral rule for fidelity is to

Keep promises.

Be faithful to the promise you made to the public to be competent and to be willing to use your competence to benefit the patients entrusted to your care. Never abandon a patient entrusted to your care without first providing for the patient's needs falls under which bioethics

fidelity

nursing care provided that is supported by sound scientific rationale

evidence based practice (EBP)

ability to read, understand, and act on health information

health literacy

process of lawsuit is known as

litigation

performing an act that a reasonably prudent person under similar circumstances would not do, or failing to perform an act that a reasonably prudent person under similar circumstances would do

negligence

If you leave a patients room and keep the bed raised high instead of lowering it, that is considered

negligence

________ are laws established in each state in the United States to regulate the practice of nursing.

Nurse Practice Act

T/F- The license, which must be renewed at specified intervals, is valid during the life of the holder and is registered in the state

True

T/F- The license and the right to practice nursing can be denied, revoked, or suspended for professional misconduct (e.g., incompetence, negligence, chemical impairment, or criminal actions

True

Four broad aims of nursing practice can be identified in the definitions of nursing:

To promote health

To prevent illness

To restore health

To facilitate coping with disability or death

To meet these aims, the nurse uses four blended competencies:

cognitive, technical, interpersonal, and ethical/legal.

Its primary mission is to advance the profession of nursing to improve health for all

ANA

The _____ is the professional organization for RNs in the United States

ANA

process by which an educational program is evaluated and then recognized as having met certain predetermined standards of education

accreditation

The registered nurse collects pertinent data and information relative to the health care consumer's health or the situation.

assessment

_______ is the failure to meet the standard of care.

breach of duty

Failure to note and report that an older adult patient assessed as alert on admission is exhibiting periods of confusion

• Failure to execute and document use of appropriate safety measures (e.g., upper and lower bedside rails, use of restraints if necessary, assisted ambulation)

are examples of

breach of duty

_______ involves four elements that must be established to prove that malpractice or negligence has occurred: duty, breach of duty, causation, and damages.

Liability

Liability involves four elements that must be established to prove that malpractice or negligence has occurred, they are:

duty, breach of duty, causation, and damages

______ are the actual harm or injury resulting to the patient.

damages

Fractured left hip, pain and suffering, lengthened hospital stay, and need for rehabilitation are examples of ________

damages

"the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations

The ANA definition of nursing

The central focus in all definitions of nursing is ______

the patient (the person receiving care),

Nursing's concepts and definitions have expanded to include the

prevention of illness and the promotion and maintenance of health for people, families, groups, and communities.

Nurses promote health by identifying, analyzing, and maximizing each patient's own individual strengths as components of preventing

illness, restoring health, and facilitating coping with disability or death.

Describe factors that influence communication among inter-personal professional health care team members

SBAR

Nurses need to document

everything

During the implementing step of the nursing process, nursing actions planned in the previous step are _______. The purpose of implementation is to help the patient achieve _________

carried out.

valued health outcomes: promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning.

One of nursing's major contributions to the health care team is the role of ________

coordinator.

assess, re-assess, revise, record: Assess patients before _________. Re-assess them to determine __________ Revise your approach _______. Record patient ________

performing nursing actions, their responses after you perform nursing actions, as indicated, responses and any changes you made in the plan of care."

To implement the plan of nursing care, nurses need blended _______ (4) competencies as well as mastery of the Quality and Safety Education for Nurses (QSEN) competencies.

intellectual, interpersonal, technical, and ethical/legal

An important nursing intervention is ongoing __________

data collection

Remembering the legal truth, "___________," each nurse carefully documents all nursing interventions.

It wasn't done if it wasn't documented

Screenings (blood pressure, cholesterol, glaucoma, HIV, skin cancer)

Pap smears

Mammograms

Testicular examinations

Family counseling

are examples of which part of preventative care?

secondary prevention

Weight loss

Diet

Exercise

Smoking cessation

Reduced alcohol consumption

Avoidance of illicit drugs

Farm safety

Seat belts and child safety seats

Immunizations

Water treatment

Safer sex practices

Effective parenting

are examples of which part of preventative care?

primary prevention

Medication

Medical therapy

Surgical treatment

Rehabilitation

Physical therapy

Occupational therapy

Job training

are examples of which part of preventative care?

Tertiary prevention

______ is the behavior of a person who is motivated by a personal desire to increase well-being and health potential.

health promotion

Health promotion and illness prevention activities are traditionally described as occurring on _______

primary, secondary, and tertiary levels