Nurs 200 - E2

10/25/26 - C9

Implementation

ADPIE, reassess patient, establish current priorities, perform appropriate interventions, document actions

Evidence-Based Complementary Therapies

integrated w/ allopathic medicine where focus is on nutrition, exercise, stress reduction

Integral Nursing

comprehensive worldview/process plus holistic theories that integrates with nursing theories, knowledge, and perspectives of health/healing

Integrative Healthcare

conventional medical treatment w/ evidence-informed complementary approaches (TCM/yoga/herbal supplements/chiropractic); does not seek to replace medical treatments; whole person approach - health is influenced by presence or absence of disease

Clinical Model

interprets health as the absence of signs/symptoms of diseases or injury

Transtheoretical Model

precontemplation, contemplation, preparation, action, maintenance, termination

Principles of Delegation

for LPN/UAP; Right person, task, circumstance, communication, evaluation (check in to gauge understanding of instructions)

Dependent Interventions

follow another healthcare provider’s orders; nurse must consider current state of patient, ex; supplemental potassium —> check current potassium levels

Interdependent Interventions

req both independent + dependent interventions, ex; provider prescribes as needed pain meds, nurse makes decisions on when meds are given

Supervisory Interventions

ensure other members of team carry out plan of care; ex; holding ppl accountable for their roles and responsibilities

Delegation

transfer of responsibility while holding accountability for outcome, ex; LPN or UAP delegation by RN

Set Priorities

patient’s condition (ABC), new info from reassessment, time/resources for nursing interventions, feedback from workers, nurse’s experience in assessment (Benner’s Theory)

SBAR

situation, background, assessment, recommendation - TeamSTEPPs tool for comms + ISBAR = introduction of nurse and patient using appropriate identifiers

Call-Out

comms for important info aloud so members aware; ex; “patient BP 80/50”

Check-Back

closed-loop comms technique to confirm info

Handoff

transferring essential patient info, “I PASS THE BATON” = structured tool

Brief

short discussion before beginning patient care of specific activity to establish plan

Huddle

brief meeting abt patient care when situation changes, reassess priorities

Situational Awareness

involves recog what’s happening and knowing its significance

Cross-monitoring

team members observe/support one another to prevent errors

Two-Challenge Rule

safety concern not acknowledged after first attempt; raise concern second time, then go thru chain of command, using CUS: concerned, uncomfortable, safety issues

eMAR

electronical medication administration record

CPOE

computerized provider order entry

CDS

clinical decision support - alerts on safety concerns, medication allergies

Intellectual Skills

Problem Solving, decision making, teaching

Interpersonal Skills

Peplau, work w/ others - comm skills (SBAR)

Technical/Psychomotor

Carry out treatments/procedures, usage of equipment + supplies

Cognitive Interventions

Educational, Supervisory, Delegation

Interpersonal Interventions

Coordinating (patient advocate, ex; patient refuse treatment/wants second opinion), Supportive, Psychosocial

Technical Interventions

Maintenance, Surveillance, Psychomotor

Evaluation

How well nursing care achieved thru patient’s stated goals, document level of achievement of goals, collect data, revise/modify plan of care

Structure Evaluation

Focuses on setting/surrounding

Process Evaluation

Focuses on nurse’s performance

Outcome Evaluation

Focuses on patient and patient’s function

Evaluation Activities

Review Goal and specific outcome, gather subjective/objective findings, decide level of goal achievement, identify factors that helped or prevented progress, document judgment and evidence/revise plan if needed

ANA

promotes prof. nursing standards and quality care

The Joint Commission

evaluates healthcare organizations w/ accreditation and patient safety standards

Peer Review

evaluates nursing practice by prof. colleagues

Nursing Audit

review nursing documentation/care processes

Individual Peer Review

reviews individual nurse’s prof. practice

Flow sheets

record routine assessments such as vital signs

Charting by Exception (CBE)

focus on findings that are exceptions

Nursing Progress Note Formats

SOAPIER: subjective, objective, assessment, plan, intervention, evaluation, revision

PIE: problem, intervention, evaluation

APIE - ADPIE w/out D

FOCUS DAR: data, action, response, organized around patient concern

Narrative Documentation: describe patient findings, nursing actions, responses in chronological order

Home Care Records

home safety, patient needs, caregiver needs

Long-term records

standardized assessment: RAI (Resident Assessment Instrument), MDS (Minimum Data Set) - evaluate resident ongoing needs

Incident Report

separate organization safety document to report unexpected events; never events; patient falls, medication errors

Clinical Pathway

standardized, interdisciplinary plan outline for patients w/ common conditions or procedures

I PASS THE BATON

I: illness severity; P: patient summary; A: Action List; S: situational awareness S: synthesis by receiver (confirm understanding of receiving nurse)

Health Belief Model

relationship btwn person’s belief and actions; readiness to change

Health Level Wellness

Health is ongoing process towards a person’s highest potential of functionality; assume responsibility for higher quality of life

Holistic Health Model

respects interaction of a person’s mind, body, and spirit w/ environment

Self-Care Deficit

unable to independently care for themselves

Martha Rogers

nursing is to help ppl achieve full potential

Primary Prevention

proactive intervention to reduce individual’s future likelihood

Secondary Prevention

identifying ppl who are at risk of developing illness

Prochaska and Prochaska

Precontemplation: Denial

Contemplation: Struck

Preparation: Planning

Action: Begin to modify behavior

Maintenance: Struggle to prevent lapses

Termination: Complete confidence

Allopathic Medicine

conventional western modern approaches

Iatrogenic Illness

illness results from medication/treatment

Receptive Meditation

focuses on deep interconnection btwn mind and body

Reflective Meditation

person chooses theme, question, topic of reflection to gain insight

Therapeutic Touch

Centering (attention into peacefulness), Assessment (moves hands 2 to 6 times on patient skin for assessing energy field), Rebalancing/Reassessing (direct energy and restore balance)

Tertiary Prevention

reduce complications/improve functioning in ill patients