Integrated Learning - Exam 1 Blueprint

Evidence Searches

- the preferred browser is Google Chrome
- TTUHSC Libraries Website: APA style help, citation tools, School of Nursing Resources Page, Gold Rush (for articles and helpful resources), Interlibrary Loans (books not on campus; Document Delivery), CINAHL Complete (journals), and PEPID (help tool)

Electronic Health Records

give a broader view of the patient's health
- Advantages: enhance communication between clinicians; easy access; accuracy; confidentiality; e-prescribing
- Challenges: learning the system; knowing how to correct errors; maintaining security

HIPPA (1996)

sets rules to limit who may have access to a patient's health information
- any details that can identify a patient must be protected (SSN, name, phone number, etc)
- gives patients the right to access and change their records
- info must be shredded

The Privacy Rule

a part of HIPPA that requires that nurses protect all written and verbal communication about clients

Quality and Safety Education for Nurses (QSEN)

Assists nursing programs in preparing nurses to provide safe, high-quality care

QSEN 6 Competencies

1. Safety: minimization of risk factors
2. Patient-Centered Care
3. Evidence-Based Practice: use of knowledge to base judgements
4. Informatics: the use of IT communication/info
5. Quality Improvement: development and implementation of a plan to improve healthcare services
6. Teamwork and Collaboration
- prepare nurses to provide safe, high-quality care

medicare

A federally funded program of health insurance for persons 65 years of age and older and those who have a permanent disability

medicaid

Federal program that provides medical benefits for low-income persons.
- federally and state funded
- stated determine eligibility

Patient Protection and Affordable Care Act (2010)

1. Increased access to healthcare
2. Decreased healthcare costs
3. Provides opportunities for uninsured people

Private Insurance Plans

- managed care organizations (MCOs)
- preferred provider organizations (PPOs)
- exclusive provider organizations (EPOs)
- long term care insurance

Factors Affecting Healthcare

-Changing Demographics (life expectancy, mortality, smoking rates, obesity, etc)
-Advances in Technology
-Health Literacy: the capacity to obtain, communicate, process, and understand basic health info

Levels of Prevention

Primary Prevention
Secondary Prevention
Tertiary Prevention

Primary Prevention

focuses on health promotion and illness prevention
- attempt to avoid development of disease as much as possible
EX: Healthy People 2020

Secondary Prevention

include the diagnosis and treatment of disease
- attempts to prevent progression of the disease
EX: screenings

Tertiary Prevention

the restoration of health following an illness or accident and includes rehabilitation and palliative services
- decreasing disease-related complications

Levels of Care

Primary Health Care
Secondary Health Care
Tertiary Health Care

Primary Health Care

emphasizes health promotion
- a sustained partnership between clients and providers
EX: office and clinic visits, work and school screenings

Secondary Health Care

the diagnosis and treatment of acute illness and injury
EX: hospital settings; diagnostic centers; urgent and emergency care centers

Tertiary Health Care

the provision of specialized and highly technical care
EX: intensive care; oncology centers; burn centers

Regulatory Agencies

help ensure the quality and quantity of health care and the protection of health care consumers
- FDA, state and local public health agencies, the US Department of Health and Human Services

Nursing Care Delivery Systems

functional nursing
team nursing
primary nursing

Functional Nursing

a task-oriented approach to care delivery
- head nurse delegates tasks to team members
- enables the nursing team to complete many tasks in a short time
-UAPs used heavily
- cost effective

Team Nursing

a registered nurse serves as the team leader and is accountable for care provided to the patients assigned to the team
- team members are assigned tasks based on their ability to perform them
- pod nursing

Primary Nursing

One nurse has 24/7 authority and responsibility for the care of an assigned group of clients
- a relationship-based model of care

the ultimate issue in designing and delivering health care

ensuring the health and welfare of the population

Nurses hold...

...the public's trust

Benner's Novice to Expert Model

development of professionalism
- Novice to Advanced Beginner to Competent to Proficient to Expert

ANA Code of Ethics

integrity

Professional Dress and Demeanor

- No excessive jewelry; no artificial nails; no chewing gum
- Personal cleanliness; avoid strong odors and perfumes
- Clean uniform and clothing
- Avoid loud talking
- Maintain positive attitude
- Avoid gossiping
- Do not use illegal subtances

Unprofessional Behaviors

- Lateral violence: directed towards peers
- Sexual Harassment
- Improper use of authority: no longer following the code of ethics
- Intimidation: bullying, threatening, or forcing

When do nurses start adhering to the professional behaviors?

As soon as they become nursing students

Characteristics of the Nursing Process

Systemic, Cyclic, Dynamic, client-centered, continuous, and problem-solving.

The Nursing Process

Assessment
Diagnosis
Planning
Implementation
Evaluation

Assessing

collecting, organizing, validating, and documenting client data
- subjective and objective data collection
Includes: initial assessments, interviews, medical history, or a physical examination

Diagnosing

analysis of patient data to identify health problems, risks, and strengths
- clustering of assessment data
- formulate diagnostic statements based on nursing judgement, not the medical diagnosis
- health promotion is key

A Nursing Diagnosis

a statement based on the nurses judgement
- describes the human response (what's going on)
- changes when the patient's response changes (not static)
- involves independent nursing functions

Interchangeable Terms

"nursing diagnosis" and "problem statement"

NANDA

North American Nursing Diagnosis Association
- develop and periodically update nursing diagnoses

Basic Two Part Statement

Includes the Problem (P) and Etiology (E)
EX: "Constipation related to prolonged laxative use"

Basic Three Part Statement

Includes the Problem (P), Etiology (E), and Signs/Symptoms (S)
EX: "Low self-esteem related to feelings of rejection as manifested by hypersensitivity to criticism"

A Medical Diagnosis

made by a physician and refers to a disease process
- does not change
- involved dependent nursing functions (orders to provide care)

Planning

the nurse sets priorities, determines client goals and outcomes, and selects specific nursing interventions
- nursing interventions are written based on the plan
- "patient will"
- the Nursing Care Plan is the end product

Short Term Goals

health care required for a short amount of time (acute care setting); range from a few hours to a few days
- we can see, assess, and evaluate

Long Term Goals

long-term care required (chronic care setting); range from 1 week to several months
- patient often goes home with this

Characteristics of a Good Goal

- must be derived from the nursing diagnosis
- must be patient-centered
- one goal for each nursing diagnosis
- starts with "The patient will..."
- does not include assessment data or nursing actions

SMART Goals

S = Specific
M = Measurable
A = Attainable/Achievable
R = Relevant
T = Time-Limited

S in SMART Goals

Specific
- clearly stated specific action; detailed information

M in SMART Goals

Measurable
- measurable observation or result; quantifiable

A in SMART Goals

Attainable/Achievable
- appropriate for the patient; one that the patient can complete

R in SMART Goals

Relevant
- applicable to the patient; purpose that has been customized for the patient

T in SMART Goals

Time-Limited
- specific time frame; a date, hour, day, week, or month

Implementation

nurses implement the nursing interventions, delegate tasks, supervise other health care staff, and document the care and clients' responses
- interventions must MATCH the goal
- reassessment of the patient
- what the nurse will do (active)

Independent Interventions

activities that the nurse is licensed to initiate as a result of the nurse's own knowledge and skills
- actions are within their scope of practice
EX: raising the head of the bed, guided imagery, or repositioning the client to avoid skin breakdown

Dependent Interventions

interventions nurses initiate as a result of a provider's prescription or the facility's protocol
EX: prescribing medications or oxygen, blood administration procedures

Collaborative Interventions

Interventions nurses carry out in collaboration with other health care team professionals
EX: ensuring that a client receives and eats his evening snack or consulting with a respiratory therapist when the patient has deteriorating O2 levels

Evaluating

nurses evaluate clients' responses to nursing interventions and form clinical judgement about the extent to which clients have met the goals and outcomes
- collect data based on the outcome criteria then compare what actually happened to the planned outcomes
- determine whether to continue, modify, or terminate the nursing care plan

Conclusion: The Goal was Met

the actual problem was resolved and risk problems are being prevented

Conclusion: The Goal was Partially/Not met

the actual problem still exists, the plan of care needs to be revised, or the patient needs more time to achieve the goals

Components of an Evaluation

1. The date and time the evaluation was done
2. Whether or not the goal was met
3. Supporting statement giving the results
4. Whether to continue, modify, or terminate the plan

Delegation

the process of transferring the performance of a task to another member of the healthcare team while retaining accountability for the outcome

Why do nurses delegate?

so that they can complete higher-level tasks that only RNs can perform; it allows more efficient use of all team members

Who can an RN delegate to?

other RN's, LPN's, and UAP's

The 5 Rights of Delegation

1. Right Task: ensuring that the task is one that can be delegated according to the agency's policies and procedures
2. Right Circumstance: determining that the task addresses the patient's needs and contributes to a desired outcome
3. Right Person: the task must be within that individual's scope of practice
4. Right Direction: providing a clear and concise description of the task; ensure understanding
5. Right Supervision: monitor and evaluate the delegate's performance

The Texas Nurse Practice Act

determines what can be delegated to a UAP or LVN
- scope of how we practice

What can RNs NOT delegate?

- the nursing process
- client education
- tasks that require nursing judgement

Tasks that can be delegated to a UAP

vital signs, I&O, patient transfers and ambulation, bathing, feeding, and weighing

Tasks that can be delegated to a LVN

monitoring assessment findings, reinforcing client teaching, suctioning, and administering medications
- patient must be stable

Obstacles to Delegation

-Non-supportive Environment
-Delegator Insecurity
-Unwilling Delegate
-Ineffective Delegation
-Underdelegation

Prioritizing Care

a process that helps nurses manage time and establish an order for completing responsibilities and care interventions for a single client or for a group of clients
- a critical thinking skill

Syndrome Diagnosis

a cluster of nursing diagnosis that occur together and may result in best patient outcomes if addressed at the same time

Patients must consider a goal to be...

...important and valuable

Goals vs. Outcomes

Goals are broad statements and something the patient strives to achieve

Outcomes are specific, observable criteria used to evaluate the patient's response to plan of care

Critical Thinking Skills

Intellect
Creativity
Inquiry
Reasoning
Reflection
Intuition

Deductive Reasoning

Nurses work from top down
- Starts with a conclusion
- Analyzes the conclusion for significant cues
EX: "Patient has pneumonia; nurse knows the patient would have the symptoms of pneumonia"

Inductive Reasoning

Nurses work from bottom up
- Significant clues are put together to reach a conclusion
- Presence of signs and symptoms will lead nurse to conclude what disease process is going on

Triage

Process used to determine the priority of treatment for patients according to the severity of a patient's condition and likelihood of benefit from the treatment

The priority based on Maslow's Hierarchy of Needs

physiologic needs

Low Priority

Problems that typically can be resolved easily with minimal interventions and do not cause significant dysfunction
EX: responding to a patient's request for a midafternoon snack

Medium Priority

Problems that may result in unhealthy physical or emotional consequences but that are not life threatening
EX: a patient experiencing spiritual distress, anxiety

High Priority

Includes life-threatening problems of airway, breathing, and circulation, or conditions that have a potential to become life threatening within a short amount of time
EX: frequent monitoring for unexpected changes in the vital signs and drainage for a patient who has just had a chest tube inserted