Intro to Nursing Exam 3

5 steps of the nursing process

assessment, diagnosis, planning, implementation, evaluation

assessment

Gather information about the patient's condition

diagnosis

Identify the patient's problems

planning

- set goals of care and desired outcomes and identify appropriate nursing actions
- select nursing interventions

implementation

- perform the nursing actions identified in planning
- implement nursing interventions

evaluate

- determine if goals and expected outcomes are achieved
- determines whether a patient's condition or well-being improved after nursing interventions were delivered

primary source

the patient

secondary source

- Family members (obtain patient's permission first)
- Other healthcare providers
- Medical or electronic health record (EHR)

rounding

- Visiting patient at set intervals
- Allows the nurse to build trust
- Facilitates information retrieval that will help you identify healthcare problems more accurately and effectively

sources of data

- Patient ( Interview, observation, or physical examination)
- Family and significant others
- Health care team
- Medical records
- Scientific literature
- Nurse's experience

subjective data

our patients' verbal descriptions of their health problems. Subjective data include patient feelings, perceptions, and self-reported symptoms.

objective data

- the findings resulting from direct observation or measurement, including what you see, hear, and touch
- inspecting the condition of a wound, observing a patient walk down the floor, measuring blood pressure, and describing specifically an observed behavior (patient seizure)
- Can observe directly via physical assessment

comprehensive assessment

- Patient centered interview or nursing health history
- Physical examination (head to toe assessment)

focused assessment

- make during rounding or administering care; may be focused on a specific problem
- pain, skin, fall risk

cue

- information you obtain through the use of your senses
- is an objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a diagnostic conclusion (also clinical criterion)
- ex. pain rating, tense appearance

inference

- judgement or interpretation of cues
- conclusions: patient is in pain, pain prevents patient from moving around freely

effective communication

enable patients to tell their stories and nurses to understand patients and the experiences they express

interview preparation

-Review patient record
-Allow sufficient time
-Ensure good lighting
-Maintain privacy
-Sit or stand at the same eye level
-Introduce yourself
-State how long the interview will approximately take
-Reassure confidentiality
-Encourage patient to ask questions

orientation, working, termination

phases of nurse-patient relationship/interview

orientation phase

- introducing yourself, and explain why you are collecting data
- assure patients that information will be kept confidential.
- setting an agenda

working phase

- gathering accurate, relevant, and complete information about a patient's condition
- Begin by using open ended questions to better understand patient's concerns and problems

termination phase

Summarize discussion, verify accuracy of information, and provide clue that interview is coming to an end

leading questions

- May be risky
- can limit the information a patient will provide to what a patient thinks you want to know
- It appears that you are upset, is that true?

back channeling

- Validate that you have heard what the patient is saying and are interested
- "Alright", "go on", "uh huh"

probing

encourage a full description without trying to control the story's direction

cultural considerations

- To conduct an accurate and complete assessment, you need to consider a patient's cultural background
- When cultural differences exist between you and a patient, respect the unfamiliar and be sensitive to a patient's uniqueness
- If you are unsure about what a patient is saying, ask for clarification to prevent making the wrong diagnostic conclusion

diagnostic and laboratory data

- Results provide further explanation of alterations or problems identified during the health history and physical examination

interpreting and validating assessment data

- ensures collection of complete database
- leads to second step of nursing process
- inference and cues (interpreting)

validation

the comparison of data with another source to determine data accuracy.

data documentation

- use clear, concise appropriate terminology
- becomes baseline for care

concept mapping

- visual representation that allows you to graphically show the connections among a patient's many health problems
- helps you critically think about a patient's diagnoses and how they relate to one another.
- graphically represents the connections among concepts that relate to a central subject.

medical diagnosis

- the identification of a disease based on specific evaluation of signs and symptoms, medical history, diagnostic tests and procedures
- Only a physician or advanced practice provider is licensed/competent to treat
- ex. diabetes, HTN, osteoarthritis, stroke

nursing diagnosis

- a clinical judgement concerning a human response to health conditions or life processes or vulnerability (risk for) for that response by an individual, family or community
- will ensure that you select relevant and appropriate nursing interventions
- nurse can diagnose deficient knowledge, decreased cardiac output, chronic pain, risk for aspiration

collaborative problems

- a problem that requires both medicine and nursing interventions to treat (infection, bleeding, seizures)
- all physiological complications are not collaborative problems (ex. pressure injuries or risk for aspiration)
- collaboration will better manage the multiple factors that influence the health of individuals, families, communities

NANDA-I

- provides standard, formal diagnostic statements (including definitions, defining characteristics, and related or risk factors)
- categorizes nursing diagnosis into three types (problem focused, risk diagnosis and health promotion)

ICNP

- a classification of nursing phenomena (diagnoses), nursing actions or interventions, and nursing outcomes that describes nursing practice.
- categorizes diagnosis as positive and negative (problem focused or risk for)

problem focused (NANDA) or negative (ICNP0

- acute pain
- patient has an active problem
- based on defining characteristics/assessment findings and cues

related factor

- an etiological or causative factor for the diagnosis, and allows you to individualize a problem-focused nursing diagnosis for a specific patient

risk for (NANDA) or Negative (ICNP)

- patient doesn't have an active problem
- risk factors (associated factors) are present
- environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem
- risk for infection; risk for injury; risk for falls

health promotion (NANDA) or positive (ICNP)

- a clinical judgement concerning a patient's motivation/desire to increase well-being and actualize human health potential
- include assessment findings
- anytime a nursing diagnosis starts with readiness it is positive (readiness for enhanced knowledge, readiness for enhanced nutrition, readiness for enhanced coping)

components of a diagnostic statement

diagnostic label, related factors, major assessment findings

data cluster

- a set of cues or group of signs or symptoms gathered during assessment
- patterns in this are recognized and compared with standards to reach a conclusion about a patient's response to a health problem

PES format

- problem, etiology, symptoms
- impaired physical mobility related to incisional pain as evidenced by limited ability to turn and reposition self

problem

- NANDA or diagnostic label; nursing diagnosis (terms are used interchangeably)
- impaired physical mobility

etiology

- related to factor or contributing factor
- related to incisional pain
- helps to individualize the most appropriate interventions

symptoms

- defining characteristics/assessment:
- as evidenced by limited ability to turn & reposition self

sources of diagnostic error

- data collection
- data clustering
- interpretation and analysis of data
- diagnostic statement errors

documentation and informatics

- Once you identify a patient's nursing diagnoses, enter them either on the written plan of care or in the electronic health information record (EHR) of the agency.
- Computer helps organize data into clusters
- Enhances ability to select accurate diagnoses

original care plan

place the highest-priority nursing diagnosis first.

priority setting

- the ordering of nursing diagnoses or patient problems to establish a preferential order for nursing interventions.
- begins at a holistic level when you identify and prioritize a patient's main diagnoses or problems
- ethical care
- ordering of nursing diagnoses or patient problems uses determinations of urgency and/or importance to establish a preferential order for nursing interventions

high priority

- emergent or life threatening
- choking, asystole (flatlining)

intermediate priority

- non life threatening
- risk for infection, risk for bleeding, abd pain, diarrhea

low priority

- affect patient's future well-being
- impact patients future well being; patients ability to cope, knowledge deficit

goal

- a broad statement that describes a desired change in a patient's condition, perceptions, or behavior
- the client will achieve pain relief by the end of the shift

expected outcome

- measurable change that must be achieved to reach a goal
- many times, several must be met to meet a single goal
- the client will report a pain score of 0 out of 10 by the end of the shift
- the client will ambulate 500 ft in the halls without any complaints of pain by the end of the shift

role of patient in goal setting

-always partner with patients when setting their individualized goals
-mutual goal setting includes the patient and family in prioritizing the goals of care and developing a plan of action
-act as a patient advocate

interprofessional collaboration

a complex process that is formed between two or more people from various professional fields to achieve common goals for a patient

patient centered goals

- a patient's highest possible level of wellness and independence in function, based on patient needs, abilities, and resources
- resolution of a nursing diagnosis (problem), progress towards improved health, function, knowledge, or well-being

nursing sensitive patient outcomes

- a measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing interventions
- decreased pain, pressure ulcers, or falls

nursing outcomes classification (NOC)

- a valuable resource in selecting patient goals and outcomes
- this resource is an option that you can use in selecting goals and outcomes for your patients.

writing goals and expected outcomes

- must be patient-centered
- Each goal should start with either "The client", "the patient"
- SMART acronym (specific, measurable, attainable, realistic, timed)

specific

- a specific outcome addresses only one behavior or response.
- outcomes and goals reflect a specific patient behavior or response.
- a correct goal statement is: "Patient will ambulate independently in 3 days."
- a correct outcome statement is: "Patient ambulates in the hall 3 times a day by 4/22.

measurable

- you must be able to measure or observe whether a
change takes place in a patient's status
- changes occur in physiological findings and in a patient's knowledge, perceptions, and behavior
- "Body temperature will remain below 98.6°F (37°C)" and "Apical pulse will remain between 60 and 100 beats/min" allow you to objectively measure physical changes in a patient's status.
- The outcome statement "Patient's pain is less than 4 on a scale of 0 to 10 in 48 hours" allows you to objectively measure patient perception using a pain-rating scale

attainable

- the client must have the ability to meet the goal
- A goal and an outcome are more attainable or achievable when you mutually set them with a patient
- a goal of ambulating 500 feet for client who has been bedridden for days would not be attainable

realistic

- set goals and expected outcomes that are realistic or relevant for patients.
- consider the patient's preferences and needs and the resources of the health care agency, family, and patient.
- set realistic goals and outcomes within the patient's limitations and abilities.

timed

- set a time for each goal and outcome to be met
- this helps the health care team collaborate to resolve patient problems
- timing is needed in order to have a time to evaluate the goal
- client will ambulate 50 feet in the hallway by the end of this shift
- short term goals, long term goals

nursing interventions

- treatments or actions based on clinical judgment and knowledge that nurses perform to enhance patient outcomes
- Requires nurses to:
---know the scientific rationale for the intervention
---possess the necessary psychomotor and interpersonal skills
---be comfortable talking to the patient and explaining the procedure
- ex. teaching

independent nursing interventions (nurse initiated interventions)

- nurse initiates in response to a nursing diagnosis without supervision, direction, or orders from others.
- examples include positioning patients to prevent pressure injury formation, initiating early mobility protocols, offering counseling for coping, or instructing patients in side effects of medications.

dependent nursing interventions (HCP initiated interventions)

- require an order from a health care provider
- the interventions are based on a physician's or nurse practitioner's choices for treating or managing a medical diagnosis
- Administering medications; inserting a foley, or IV catheter, suctioning a pt, preparing a patient for diagnostic tests

collaborative/interdependent

- require combined knowledge, skill, and expertise of multiple health care professionals
- consulting a case manager for discharge needs
- consulting respiratory therapy to manage oxygen therapy
- collab with other health care providers

types of interventions

- when preparing for health care provider-initiated or collaborative interventions:
--- do not automatically implement the therapy
--- determine whether it is appropriate for the patient.
- clarifying an order is competent nursing practice and it protects patients and members of the healthcare team

selection of interventions (six factors)

- desired patient outcomes
- characteristics of the nursing diagnosis
- research based knowledge for the intervention
- feasibility of the interventions
- acceptability to the patient
- nurse's competency

nursing care plan

- nursing diagnosis, goals and expected outcomes, nursing interventions, and a section for evaluation of findings
- allows nurses to quickly identify a patients clinical needs and situation
- reduces the risk for incomplete, incorrect, inaccurate care
Changes as the patient's problems and status change

interprofessional care plan

- includes contributions from all disciplines involved in patient care
- focuses on patient priorities and improves the coordination of all patient therapies and communication among all disciplines.

student care plan

- helps you apply knowledge gained from the nursing and medical literature and the classroom to a practice situation
- is more elaborate than a care plan used in a hospital or community agency because its purpose is to teach the process of planning care

community care plan

- complete a more comprehensive community, home, and family assessment.
- a patient/family unit must be able to provide the majority of health care independently.
- educate patient and family about care, how to integrate it into family activities, and provide greater percentage of care over time
- includes nurses' and patients/families' evaluation of expected outcomes

critical pathways

- the main purpose of critical pathways is to deliver timely care at each phase of the care process for a specific type of patient
- used for specific populations
- need to meet goals for pt to progress

hand off reporting

- critical time, when nurse collaborate and share important information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventions
- transferring essential information from one nurse to the next during transition in care such as (shift report, when the patient leaves the floor and returns to the floor, when the patient is transferred to a different unit/facility_
- ask questions, clarify, and confirm important details about a patient's progress and continuing care needs

consultation

- a process by which you seek the expertise of a specialist such as your nursing instructor, a physician, or a clinical nurse educator
- helps you to identify ways to handle problems in patient management or in planning and implementation of therapies
- occurs most often during planning and implementation

when and how to consult

When:
- the exact problem remains unclear
How:
- begin with your understanding of the patient's clinical problem.
- direct the consultation to the right professional.
- provide the consultant with relevant information about the problem area: Summary, methods used to date, and outcomes
- do not influence consultants.
- be available to discuss the consultant's findings.
- incorporate the suggestions.

standardized interventions

- most often set a level of clinical excellence for practice
- nurse and health care provider-initiated standardized interventions are available in the form of: care bundle, (CAUTI, CLABSI), preprinted standing orders, Nursing Interventions Classification (NANDA, NOC, NIC)

care bundles

- a group of interventions related to a disease process or condition.
- treat or prevent a cluster of symptoms
- when implemented together, result in better patient outcomes than when the interventions are implemented individually
- improve quality of care while preventing the most common complications associated with their conditions or diagnoses

clinical practice guidelines and protocols

- A systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations
- They are NOT hospital policies

standard orders

preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific clients with identified clinical problem

nursing interventions classification (NIC)

- differentiates nursing practice from that of other health care disciplines by offering a language that nurses use to describe a set of actions in delivering nursing care

standards of practice

- used as evidence of the standard of care that registered nurses (RNs) provide their clients
- developed by professional nursing organizations, such as the American Nurses Association (ANA)

QSEN

- Quality and Safety Education for Nurses
- to prepare nurses so they can continuously improve the quality and safety of the health care systems within which they work.
- establishes standard competencies in knowledge, skills, and attitudes (KSAs) for the preparation of future nurses

critical thinking in implementation

- review the set of all possible nursing interventions for a client's problem
- review all possible consequences associated with each possible nursing action
- determine the probability of all possible consequences
- judge the value of the consequence to the client

implementation process

1. Reassessing a client
2. Reviewing & revising existing nursing care plan
3. Preparing for implementation
4. Preventing complications
5. Identifying areas of assistance

1. reassesing a client

- continuous process with each client interaction
- reassess prior to implementation of interventions

2. reviewing & revising existing nursing care plan

- validate a client's nursing diagnoses
- review the care plan and determine whether the nursing interventions remain the most appropriate for the client's needs

3. preparing for implementation

Time management
--- always allow enough time to complete the task
Equipment
--- gather equipment prior to implementation
Personnel
--- delegate to the right personnel
Environment
--- ensure the environment is appropriate for the intervention
--- focus on privacy and safety
Client
--- the client needs to be agreeable to the intervention & stable
--- ensure the client is physically and psychologically ready for any intervention

4. preventing complications

1. Identify risks to the client
---Is the client a high falls risk?
2. Adapt interventions to the situation
---Give the client a walker to ambulate
3. Evaluate the relative benefit of a treatment vs. the risk
4. Initiate risk-prevention measures

5. identifying areas of assistance

- seek information about a procedure
- collect all necessary equipment
- ask another nurse provide assistance and guidance

direct care

- Treatments performed through interactions with patients or a group of patients
- ex. medication administration, insertion of an IV catheter, insertion of a foley catheter, counseling a grieving client, educating a client, assistance with ADLs
-

indirect care

- measures are nursing actions that manage the client care environment and interdisciplinary collaborative actions that support the effectiveness of direct care interventions
- treatments performed away from the client but on behalf of the client or group of clients
- do for or on behalf of the patient
- communicating nursing interventions, delegating and supervising
- ex. managing the client's environment (safety and infection control), communication, documentation, interdisciplinary collaboration, delegation and supervision

ADLs

- direct care measures usually performed during a normal day
- ex. ambulation, eating, dressing, bathing, and grooming

IADLs

- refer to activities that support daily life and are oriented toward interacting with the environment
- ex. shopping, preparing meals, house cleaning, writing checks, and taking medications.
- more complex than ADLs and generally are managed by occupational therapists

physical care techniques

- the safe & competent administration of nursing procedures
- positioning, dressing changes, med administration, inserting IV, foley catheter, or a nasogastric tube, and wound care
- require you to protect yourself and patients from injury

lifesaving measures

- a physical care technique that you use when a patient's physiological or psychological state is threatened
- the purpose of lifesaving measures is to restore physiological or psychological homeostasis
- CPR and administering emergency medications