Module 2: Collaberative Nursing Process & General Survey

Factors of General Survey

* Physical Appearance
* Body Structure
* Mobility
* Behaviour

Physical Appearance

* ^^skin colour, age, sex, gender^^
* ^^age and gender:^^ individuals of certain gender or age are more likely affected with certain conditions
* ^^immediate and important^^ to the level of individuals well-being
* ex. skin is pale, looks malnourished, looks older than stated age, is frowning

Body structure

* ^^Stature:^^ appears trim and muscular, obese, or excessively thin
* ^^Nutrition^^
* ^^Posture:^^ Observe the patient for bent, erect, or slumped posture. Posture often reflects mood or pain
* ^^Position body build^^

Mobility

* GAIT(a person’s manner of walking): observe the patient walking into the room or at the bedside
* Range of Motion (ROM)

Behaviour

* ^^Facial Expression^^
* ^^Signs of distress:^^ sometimes there are obvious signs and symptoms ex. difficulty breathing, uncomfortable, shaking, anxiety
* ^^Mood^^
* ^^Speech:^^ Observe if the patient is speaking rapidly or slow.
* ^^Grooming and Personal Hygiene:^^ Observe hair, finger nails, skin. Note if the patient’s clothes are clean.
* ^^Dress:^^ Culture, lifestyle, socioeconomic status, and personal preference affect the types of clothes worn.
* ^^Victims of Violence:^^ Note if the caregiver has history of alcoholism, drug abuse and violence.

5 essential ingredients of a collaborative partnership

1. Sharing Power
2. Being non-judgemental and acceptance
3. Being open and respectful
4. Living with ambiguity
5. Being self-aware and reflective

Sharing Power

* less of hierarchical form
* more of ^^facilitator role^^ from the nurse: the nurse shares knowledge, skills and level of expertise and understands that clients have areas of expertise to contribute.
* ^^Knowledge is power:^^ a nurse is aware of what she is knowledgeable in, and what she is not
* Sharing Power is ^^NOT making decisions for patients,^^ but rather helping them make decisions for themselves
* Does not ^^have to agree with the patient^^
* Understands that ^^responsibility and workload can shift^^ where the nurse has more power, or the patient has more power.

Being non-judgemental and accepting

* ^^understanding^^ over people’s perspectives
* understanding that every individual has ^^different beliefs, values, behaviours, and perspectives^^.

Being open and respectful

* ^^Openness + respect = trust!^^
* Willingness to ^^develop a relationship^^ with the other person
* Willingness to ^^learn new ideas, opinions, perspectives.^^
* Willingness to ^^experiment, learn new things, change^^
* ^^Freedom to express^^ what one feels and have a common understanding

Living with Ambiguity

* being ^^flexible and adaptive^^
* the quality of being ^^open to more than one interpretation^^
* both the nurse and the other person understands ^^uncertainty and unpredictability^^ for long periods of time.
* understands that it is not always a ^^linear fashion.^^

Self-Aware and Reflective

* Being aware of what is going on in the relationship and ^^how one’s behaviour is affecting the other^^
* Reflective on ^^what you say or do^^, and how that is impacting the relationship.
* Recognition and ^^management of negative feelings^^ that may interfere with the relationship.

Factors of Critical Thinking

1. Interpretation
2. Analysis
3. Inference
4. Explanation
5. Self-Regulation

Interpretation

* be ^^orderly^^ in the collection of data
* look for ^^patterns^^ to categorize data
* ^^clarify^^ any data that you may be ^^uncertain about^^

Analysis

* avoid ^^careless assumptions^^
* being ^^open-minded^^ when looking at info about a patient.

Inference

* examining ^^meaning and relationships^^ in data
* form ^^reasonable hypotheses and conclusions^^ based on patterns.

Explanation

* ^^Support^^ your findings and conclusions

Self-regulation

* ^^Reflecting^^ on your experiences
* ^^Apply ethical principles^^ in your nursing practice

Specific Knowledge Base - Component of Critical Thinking

* ^^Information Literacy Skills:^^ Proficiency in knowing when information is needed, how to effectively find, retrieve, evaluate, and apply
* ^^improves^^ clinical practice
* formulate ^^accurate clinical judgement^^ and decisions

Experience - Component of Critical Thinking

* learn to ^^seek new knowledge^^ when needed and ^^act quickly when events change^^
* learning to ^^admit^^ when you do not know and taking the steps to learn
* learning to ^^accommodate^^ to a specific setting and desires of a patient

Diagnostic Reasoning

* ^^determining a patient’s health status^^ after making physical and behavioural observations and providing meaning to those behaviours

Clinical Decision Making

* defining the ^^patient’s problem^^ and ^^selecting appropriate interventions.^^

4 components:


1. noticing or grasping the situation
2. interpretation
3. responding and taking course of action
4. review/reflection of course of action

* requires ^^careful reasoning^^ = best outcome for the patient

Traditional Nursing Process (methods of data collection)

* aims to i^^dentify, diagnose, treat^^ actual potential health concerns


1. Assessment
2. Analysis
3. Planning
4. Implementation
5. Evaluation

Assessment

* ^^collection of data^^
* exploring health
* database of client’s health status is based on ^^strengths/concerns^^
* This database is dependant on:
* establishing trust
* exchanging information
* revealing concerns

subjective vs objective

^^subjective^^ = what the person/patient says about their health concerns

\*only patients provide subjective data

^^objective^^ = what the nurse observes (feels, hears, touches, smell, etc)

Analysis

* analyzing data
* verify interpretation
* prioritize concerns
* clarify and prioritize goals
* identifying strengths/concerns

Planning

\*considering alternatives

STROMMC

S: ingular

T : ime limited

R: ealistic

O: bservable

M: easurable

M: utual

C: lient Centred

Implementation

* trying out the plan
* ^^“doing” part^^
* independant nursing actions ^^OR^^ dependent or medically directed actions

Evaluation

* goal met? → reviewing
* plan effective?
* must document!
* \

4 basic techniques of physical assessment

1. Inspection
2. Palpation
3. Percussion
4. Auscultation

Inspection

* observing the patient in deliberate systemic matter

Palpation

* assessing the client through ^^sense of touch^^ to ^^determine specific characteristics^^ of the body
* including size, shape, location, mobility, vibrations, temperature texture, moisture, tenderness, edema

Percussion

* ^^striking a body part with an object, fingers, or a reflex hammer^^
* used to determine the size or shape of the organ
* used to determine if underlying tissue is solid or filled with fluid or air

Auscultation

* skill of ^^listening to the sounds produced by the body^^
* use of stethoscope