NUR1410 Unit 2

Critical thinking

Purposeful, analytical thinking that results in a reasoned decision

What is the purpose of the nursing process?

To provide care for the patient that is individualized, holistic, effective, safe and efficient

A in ADPIE (nursing process)

Assessment

D in ADPIE (Nursing process)

Diagnosis

P in ADPIE (Nursing process)

Planning (outcome identification, interventions)

I in ADPIE (Nursing process)

Implementation

E in ADPIE (Nursing process)

Evaluation

What does the nursing assessment involve? (Step 1 in the nursing process)

Includes data- collection, validation, organization, interpretation, documentation. The patient should always be considered the primary source of assessment data.

How is assessment data collected from the patient?

Communication techniques, physical examination, observation

What can you find on the electronic medical record?

Past medical records, H&P, Progress notes, Nursing shift reports, consultations, lab and diagnostic results, med lists

Initial assessment

Data related to the person’s reason for seeking care. This is where baseline information comes from.

Ongoing assessment

Identifies new concerns or follows up on initial concerns. Assessment is DYNAMIC

Comprehensive assessment

Holistic information on patient’s overall health status

Focused assessment

Obtain data about an actual, potential or possible problem

Special needs assessment

Information about a particular area of patient functioning

Subjective assessment data

What the patient says. From the patient’s PV and includes information, experience, feelings, perceptions and concerns

Objective assessment data

What the nurse observes (vision, hearing, smell, touch)

Gordon’s functional health pattern

Systemic and standardized approach to data collection, in the nursing process. There are 11 health pattern categories (Health perception/management, nutritional/metabolic, Elimination, activity, cognitive-perceptual, sleep, self-perception, Sexuality etc.)

Why is Gordon’s framework good?

Assessment data is organized into related, manageable groups (think first clinical assignment) It identifies patient strengths and altered functions.

What is the goal of the nurse during assessment? (Interpretation of data)

To develop thoughts, impressions and judgments about what the data means. To prioritize the importance of each piece of data

What is the goal of the nurse during assessment? (documentation of data)

Follow legal and nursing standards of care guidelines. Descriptive, detailed, complete, truthful, by exception

Maslow’s hierarchy of needs

Physiological needs > Safety needs > Love and Belonging > Esteem > Self-actualization

High priority nursing concerns

Cardiac, pulmonary, neurological status, nutrition/elimination, safety, pain, emotional/behavior distress

What are the tasks of the planning phase?

Identify short and long term patient centered goals and specific nursing interventions

When designing goals use SMART

Specific/patient focused (date and time), measurable, achievable, realistic, refined based on progress

What is important about documenting nursing inverventions?

They should be written with specific details so that every nurse knows exactly what to do.

How should nursing interventions change throughout a patient’s stay?

They should change as patient makes progress toward achieving their short and long term goals. Changes based on assessment and evaluation

Independent nurse intervention

The nurse initiates

Dependent intervention

Physician initiated

Collaborative intervention

Nurse works with the health care team to carry out intervention

Examples of independent nurse intervention

Teach patient to cough and deep breathe, monitor BP q30 following increase in HTN meds

Examples of dependent interventions

Increase Lisinipril to 40mg po

Examples of collaborative interventions

Pt eval for muscle strength, gait steadiness/abilities, following med adjustments

What is an important nurse task during implementation?

To continue to assess the patient before, during and after the interventions.

5 rights of delegation

Right task, right person, right circumstance, right communication/direction, right supervision/evaluation

Scope of practice for LPN

Assessment of patient condition (with limits), documenting I/O, patient transfers and ambulation, eating/feeding, bathing, safety, dressing changes, med pass (limited), prep for G feeding, CPR, postmortem care

Scope of practice for CNA/NA

Vitals, measuring I/O, ambulation, bathing, eating/feeding, safety, weighing, simple dressing changes, CPR, postmortem care

Tasks that MAY NOT be delegated

Assessment, interpretation, nursing care plan, evaluation, care for lines/drains/tubes, med pass, NG tubes, Patient education, triage, telephone advice

ISBAR + R for reporting to other professionals

Identify self/patient, situation (concern), Background (relevant clinical information), Assessment, recommendation, response