Ch. 1 & Ch.2 Clinical Judgement Management Model (CJMM)/ Drug Development and Ethical Considerations

Nursing Process

1.) assessment

2.) analysis

3.) planning

4.) implementation

5.) evaluation

assessment

gathers patient data through observation, interview, and physical assessment

analysis

the nurse analyzes, validates, and clusters patient data to identify patient problems

planning

he nurse prioritizes the nursing diagnoses and identifies goals that are realistic, measurable, and patient-focused, with specific outcomes.

implementation

- be accountable for safe practice

- perform the steps of intervention accurately

- understand why an intervention is planned

evaluation

examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.

nursing process key principles

- critical thinking

- patient centered care

- goal oriented tasks

- nursing intuition

nursing process is

dynamic, collaborative, outcome-oriented, organize, analytical, adaptable

CJMM

clinical judgement measurement model

CJMM Components

recognize cues, analyze cues, prioritize hypothesis, generate solutions, take action, evaluation outcomes

assessment

the systematic collection of patient data, and it is the first step in providing patient care.

holistic assessment

assess the state of a patient's physical, psychological, emotional, environmental, sociocultural, economic, and spiritual health to gain a better understanding of the patient's overall condition. This holistic approach promotes patient-centered care.

primary data

obtained directly from pt

secondary data

collected from caregivers, firends, family members, other members of health care team, & written sources

subjective data

information collected from the patient's point of view; cannot be objectively measured

Symptoms (e.g., back pain or fatigue)

Verbal

Feelings

Concerns

Perceptions

Generally gathered during an interview or health history

Documented in the medical record using quotation marks

objective data

information collected via what is seen, measured, or tested

Signs (e.g., skin rash or lump)

Observable

Generally collected from physical assessment (inspection, palpation, percussion, and auscultation), medical records, diagnostic tests, and laboratory findings

Clinical cues

"symptoms" but also more. Diet, exercise, family/health history, etc

Recognize cues

forming patterns to identify health problems, risk for problems, and level of wellness. Form diagnostic conclusions according to identified patterns that reflect patient conditions requiring nursing care.

Analyze cues

what are these signs and symptoms (analyze cues), what is the cause (hypothesis), preventing harm/ optimizing benefit

nursing diagnosis

to identify patient problems and communicate related patient needs to all members of the health care team.

Generate solutions

realistic and measurable goals, patient-centered, address the problem

- What is high priority?

- How do you optimize?

- How do we expect the patient to improve?

planning patient care

dynamic, changing as the patient's conditions or needs change

Take action

Monitoring, Educating this is disease, this is what happens, this is the drug(s) to take, how/ when to take the drug(s)

Evaluate outcomes

Was the outcome predicted?

Was the intervention successful?

Monitoring side functions for adverse effects

evalutation

1.) examine results

2.) compare achieved affect with goals & outcome

3.) recognize errors

assessment v. evaluation

The purpose of assessment is to identify patient problems, whereas the purpose of evaluation is to determine if known problems are improving, declining, or unchanged.

questions for evaluation interventions

Did the patient meet the goals and outcome criteria established during the planning phase?

Since care began, have new assessment data been identified that should be taken into consideration?

Does the care plan need to be modified in response to patient changes?

Based on the patient’s response to the implemented interventions, should the plan of care be continued, revised, or discontinued?

questions for revising care

Were the original goals realistic?

What unanticipated events occurred?

What steps in the process can be handled differently?

What barriers did the patient encounter that prevented goal attainment?

International Classification for Nursing Practice (ICNP)x

a standardized nursing language system used for point-of-care documentation for patient data and clinical activity. ICNP language can be used to identify diagnoses, interventions, and outcomes.

Impaired Respiratory System Function

Apnea

Aspiration

Cough

Dyspnea

Hyperventilation

Impaired Airway Clearance

Impaired Gas Exchange

Postnasal Drip

Potential for Risk

Risk for Activity Intolerance

Risk for Adverse Medication Interaction

Risk for Complications During Pregnancy

Risk for Dehydration

Risk for Embolism

Risk for Impaired Gastrointestinal System Function

Risk for Social Isolation

Risk to Be Victim of Neglect

Data Analysis

- actual problem

- potential problems

establishing priorities

high importance

intermediate importance

low importance

high importance

If not addressed can result in patient harm or harm to others (e.g. ABC's airways, breathing, circulation)

intermediate importance

Nonemergent and non-life-threatening, but important to address the identified problem or to prevent complications (e.g., risk for infection)

low importance

Often focused on long-term patient needs; may not be directly linked to the patient's current condition, but can affect future well-being (e.g., chronic pain or inability to pay for medications). Note that these conditions could become a higher priority if not addressed.

SMART Goals

Specific, Measurable, Attainable, Realistic, Timed

short term

The patient will achieve effective pain relief by day of discharge.

long term

The patient will achieve pain relief without the use of pain medication within 2 weeks of surgery.

setting goals

Goals are broad statements describing desired changes in a patient's behavior, condition, or perception.

Goals should be patient-focused, realistic, and measurable.

Depending on the patient's immediate and future needs, nurses establish short- and long-term goals.

Short-term goals may be achieved in 1 week or less.

Long-term goals may extend over weeks or months.

types of nursing interventions

1.) nurse- initiated intervention

2.) health care provider initiated intervenions

3.) collaborative interventions

nurse- initiated interventions (independent)

independent nursing interventions or actions that do not require a health care provider's prescription (e.g., patient positioning and patient teaching).

health care provider initiated interventions (dependent)

dependent nursing interventions that may require a prescription from a health care provider (e.g., medication administration or catheter insertion).

collaborative interventions (interdependent)

interdependent interventions that require the combined knowledge, skill, and expertise of multiple health care providers; tasks are coordinated with members of the health care team (e.g., respiratory therapy).

Drug Development

10-15 years

ANA Code of Ethics

adopted in 1950, revised in 2015, a guide for carrying out nursing responsibilities.

Nurse's Role in Clinical Research

1) responsible for patient safety

2) responsible for integrity of the research protocol

Drug Standards & Legislation

drug standards, federal legislations, nurse practice acts, canadian drug regulation

Drug Standards

the united states pharmacopeia and the national formulary

Nurse Practice Acts

all states and territories have rules and regulation. Baseline standards of practice. Based on state some nurses may be able to do certain things others can not

Drug Scheduling

no acceptable use for schedule one drugs

Highest Risk

schedule 2, yes schedule 1, but it is not easily accessible/ used

Schedule IV

sleep drugs, also high risk

Drug names

chemical names, generic names, brand/trade names

Over the counter drugs

safe and appropriate for use without direct supervision of health care provider with correct dosing and order, as needed, usually short term use

Standardized OTC labeling

2002 FDA, consumers with better info, describes benefits and risks of OTC drugs

Nurse's Role

be aware of the OTC drugs and their implication. We ask multiple times what drugs/substances people are on

Primary purpose of federal legislation in drug standards

ensuring public safety

nursing care

direct care

indirect care

direct care

performed on or with patients, such as giving an injection or helping a patient ambulate.

indirect care

performed on behalf of patients, such as having the health care provider prescribe a special diet or arranging with a social worker to set up home care.

documentation

nurses must document all implemented nursing interventions

Proper documentation of interventions facilitates communication with all members of the health care team and provides an essential legal record. Documentation also allows nurses to evaluate the effectiveness of nursing interventions in meeting patient goals and outcomes, which is the final step in the nursing process.

Implementing the plan of care

Reassess the patient.

Review and revise the existing plan of care.

Organize resources and care delivery.

Anticipate and prevent complications.

Implement nursing interventions.