a. Jean Watson’s Theory of Caring II. Thinking Like a Nurse / The NCSBN Clinical Judgment Model a. Recognize Cues b. Analyze Cues c. Prioritize Hypotheses d. Generate Solutions e. Take Action f. Evaluate Outcomes III. The Nursing Process a. Purpose of the Nursing Process b. Steps of the Nursing Process c. Nursing Process vs. Medical Model d. Assessment i. Clustering of Data ii. Steps in Analyzing Assessment Data iii. Types of Assessment 1. History and Physical 2. Subjective vs. Objective 3. Initial/Comprehensive Assessment 4. Focused Assessment 5. Emergency Assessment 6. Follow-Up Assessment e. Nursing Diagnosis i. Nursing Diagnosis vs. Medical Diagnosis ii. What is a Nursing Diagnosis? iii. NANDA iv. Types of Nursing Diagnoses 1. Problem-Focused (Actual) 2. Risk 3. Health Promotion/Wellness 4. Syndrome v. Parts of the Diagnostic Statement for each Type of Nursing Diagnosis 1. Common Errors Seen with Writing Diagnostic Statements a. Does the etiology and/or defining characteristics “match” the identified nursing diagnosis/patient problem? vi. Prioritization of Nursing Diagnoses f. Planning i. Goals 1. Goal Statement 2. Characteristics of Goals 3. Stem from the Patient Problem/Nursing Diagnosis ii. Outcomes 1. Partially Derived from the Defining Characteristics (if the problem is an actual problem) 2. Characteristics of Outcomes a. SMART Outcomes g. Implementation i. Nursing Interventions 1. Partially Derived from the Outcomes 2. Characteristics of Nursing Interventions 3. Types of Nursing Interventions a. Direct vs. Indirect b. Independent vs. Dependent vs. Collaborative (Interdisciplinary) ii. Implementation of Nursing Interventions h. Evaluation i. How Evaluation Takes Place ii. Continuation vs. Modification vs. Termination of the Plan of Care iii. Parts of an Evaluation Statement IV. The Concept of Elimination a. Intake & Output/Interpreting Fluid Balance b. Prevention of CAUTI c. Common Urinary Elimination Problems (urinary retention, urinary stasis, urinary reflux, urinary calculi, types of incontinence, anuria, dysuria, oliguria, urgency, frequency, UTIs) a. Assessment and prevention for each of the common urinary problems d. Signs of Upper and Lower UTI e. Causes and Prevention of UTI f. Lifespan considerations for urinary and bowel elimination g. Factors affecting urinary and bowel elimination h. Patient education related to urinary and bowel elimination i

Jean Watson’s Theory of Caring

A theory that emphasizes the importance of caring in the nurse-patient relationship.

NCSBN Clinical Judgment Model

A framework for nursing practice outlining steps like recognizing cues and evaluating outcomes.

Nursing Diagnosis

A clinical judgment about individual, family, or community responses to actual or potential health problems.

NANDA

North American Nursing Diagnosis Association, an organization that develops and maintains the official list of nursing diagnoses.

Assessment in Nursing Process

The systematic collection of data about a patient's health status.

Subjective vs. Objective Data

Subjective data is information reported by the patient; objective data is measurable and observable.

SMART Outcomes

Specific, Measurable, Achievable, Relevant, Time-bound objectives derived from patient problems.

Braden Scale

A tool used to predict pressure sore risk based on sensory perception, moisture, activity, mobility, nutrition, and friction.

Pharmacological Concepts

Key elements in understanding medication effects, such as half-life, therapeutic effect, and peak action.

Intramuscular Injection

A method of delivering medication deep into the muscle tissue using a specific needle length and gauge according to the patient's size.

HIPAA

Health Insurance Portability and Accountability Act; regulations ensuring patient privacy and security of health information.

Incident Report

Documentation used to report and analyze errors or adverse events occurring in a healthcare setting.

Medication Reconciliation

The process of ensuring that a patient's medication lists are accurate and up-to-date across transitions in care.

Complications of Immobility

Physical issues that can arise from prolonged inactivity, such as pressure ulcers and muscle atrophy.

Types of Pain

Different classifications of pain including nociceptive, neuropathic, acute, chronic, and idiopathic.

Chain of Infection

The series of steps or links that result in the spread of infection, including infectious agent, reservoir, portal of exit, etc.

Post-Op Complications

Potential issues that may arise following surgical procedures, such as infection or bleeding.

Causative Agent (in Infection)

The microorganism or pathogen that causes disease.

Clinical Decision Support (CDS)

A health IT system that provides clinicians, staff, patients, or other individuals with knowledge and person-specific information, intelligently filtered or presented, to enhance health and health care.

SOAP Note

A documentation format that stands for Subjective, Objective, Assessment, and Plan used in nursing and healthcare.