Nursing Process, Interviewing, Cultural Competence, and Documentation

Holistic

based on the principle that a patients biological, social, psychological and spiritual aspects are interconnected

Levels of Health Prevention

1. Primary

   • prevention

2. Secondary

   • screening/diagnostics

3. Tertiary

   • treatment/restoration

Determinants of Health and Heath Goals

1. Centers for Disease Control and Prevention (CDC)

2. Healthy People 2030

3. U.S. Preventative Services Task Force (USPSTF)

Nursing Process

1. Assessment

2. Diagnosis

3. Planning

4. Implementation

5. Evaluation

**dfined by the American Nurses Association (ANA)

ADPIE

Critical Thinking

• organized cognitive process involving creativity, reflection, problem solving

• both rationale and intuitive judgement

• attitude of inquiry and philosophical orientation

Clincal Reasoning

when the nurse uses all that is available from the patient to create perfect plan of care for patient

what are the 6 functions of clinical judgement

1. recognize cues

   • what matters most?

2. analyze cues

   • what does it mean?

3. prioritize hypotheses

   • where do I start?

4. genrate solutions

   • what can I do?

5. take action

   • what will I do?

6. evaluate outcomes

   • did it help?

Critical Thinking

broad term that encompasses clincal judgement and clinical reasoning

Clincal Reasoning

• determine a plan

• data validation

• “applies”

Clinical Judgem

Health Assessment

systematic methhod of collecting data and analyzing it to plan patient cetnered care

1. health history is first

2. followed up with physcial assessment

Communication Skills (4 types)

• verbal

  • therapeutic communication

• nonverbal

  • body language

• written

  • documentation

• oral

  • verbal report

what does it mean to go in with a “CLEAR” mind?

CLEAR

C = center yourself

L = listen wholeheartedly

E = empathize with patient

A = attention

R = respect

Environment

gather as much background data as possible

Communication skills (what to do)

• share information and get a response

• share and exchange thoughts, perceptions, and feelings

• send, receive, and gather data

• share patient concerns

• exchange knowledge

Therapeutic communication

• active listening

• active observing

• broad opening questions

• clarification

• confrontation

• empathy

• respect

• exploring

• facilitation

• focusing

• reflection/stating

what not to do during communication

• ask too many questions

• now allow for enough response time

• use too much medical jargon

• use cliche’s

• stereotype

• use patronizing language

What not to do in regards to communications

• ask personel questions

• give personel opinions

• change the subject

• automatic response

• false reassurance

• sympathy

• asking for explanantions

• apprpval or disapproval

• defensive responses

• passive or agressive responses

• arguing

• lead the patient

Differences

• hearing impaired → asses level of hearing

• visually impaired

• aphasics → communicate slow and clear

• cognitively/challenging → simple focus questions

• aggressive/challenging → calm, empathetic, soft simple questions (keep self out of striking position)

• language barrier → interpreter (look directly at pateint NOT interpreter)

• low health literacy → very clear and specific language

Types of Physical Assesment

• comprehensive assessment

• problem-based/focused assessment

• episodic.follow-up assessment

• shift assessment

• screening assessment/examination

SBAR

S → situtation (what is happening at current time)

FICA

• includes faith, belief, and meaning importiance and influecne, community, adress and action of care

rules for chartting

• you only chart what you do

• if you don’t chart it, it didn’t happen

• chart it as if your license depends on it

• use medical jargon

• concise is key

• takes time

• never use normal, good, fine, abnormal

• always writ

SOAP

S → subjective (all details directly from patient)

O → objective (from assessment, inspection, palpation, percussion, and ausculation)

A → assessment (put in nursing diagnosis)

P → plan

Goals of Assessment

1. provide essential data to safely care for patients

2. identify normal and abnormal variant

3. provide objective assessment data

Standard Precaution

hand hygiene

transmision-based precautions

1. Contact - skin contact or open wound

   • wear gloves

2. Droplet - transmitted through droplets by coughing, talkink, or sneezing

   • gown, gloves, masks, sometimes goggles

   • Ex. RSV or Pneumonia

3. Airborne - ex. TB, Measles, Chicken Pox, COVID

   • gown, gloves, goggles, N95, or respirator

   • patient usually in n

Two Patient Identifiers

• name

• date of birth

Patients Rigths

• what the assessment is

• why we are doing it

• right to refuse

Organizing the assessment

systematic → noninvasive → invasive → organized → minimal postion changes

Gather equipment

• PPE

• Stethoscope

• Appropiate Lighting

• Special Tools

Assessment Techniques

1. inspection: what you see

2. Palpation: what you feel

3. Percussion: what sound echo’s

4. Ausculation: what you hear with your ears and stethoscope

Inspection

look and assess the physical aspects of the body, posture, appearance, and behvior carefully

• occurs throughout entire assessment

what look for in Inspection

• location

• size

• color

• pattern

• shape

• drainage

• symmetry

• odors

Palpation

feeling with your fingers/hands to assess parts of the body

1. light palpation

2. deep palpation

what to feel for during palpations

• texture

• masses

• pain/tenderness

• moisture

• warmth

• pulsation

• edema

different parts of hand

dorsal surface → back of hand (feel temp and moisture)

palmar surface and base of fingers → (fibration is palm of hand and pulsations, moisture, and grasping is fingers)

ulnar surface → fibrations

fingertips → grasping

fingers and thumb → grasping

Percussion

• use hands to tap on body

• assesses size, consistency, and borders of body organs to assess for any underlying fluid

• 1. direct → using fingers to directly tap on the surface of the patient

• 2. indirect

• 3. blunt

What to Listen for

1. Pitch → high, low, dull

2. Intensity → soft tones over solid tissue, moderate tones over fluid filled areas, loud tones over air filled spaces

3. Duration → length of time and sound is heard

Quality of Sound:

1. tympany → over tummy abdominal gas (hollow sound)

2. dull → over solid organs, fluid, or tumor mass scan be dull sound

3. resonance → over normal lung tissue

4. hyperresonnance → over air filled spaces such as lung fields in a patient that has emphysema (tapping on drum)

5. Flatness → heard over increased tissue density like bone

Auscultation

to listen to sounds of the body such as the cardiovascular system, respiratory, gastrointestinal system and peripheral vascular system

1. direct auscultation

2. indirect auscultation

Direct Ausculation

placing ear to patient, taking breath while next to you

→ respirations

→ bowel sounds

→ groans/moans

→ grunting

Indirect Ausculation

usually heard through stethoscope

Listen for:

→ amplitude or intensity (loud or soft)

→ pitch or frequency (high or low)

→ duration (times sound lasts)

→ quality (what it sounds like)