SBAR

Uploading Assignments

• Ensure all settings are correct for assignment uploads.

• Students should verify instructions for document upload if unclear.

• Attempt the upload again after troubleshooting.

• First two assignments will not be graded, easing the technology transition.

Attendance Check

• Instructor takes attendance of students present.

Overview of Today's Class

• Focus: Three key chapters: Nursing Process, Critical Thinking, Admission/Transfers/Discharges.

• Introduction to a case study for practical understanding of nursing diagnoses and assessments.

• The importance of documentation through SFR (Situation, Background, Assessment, Recommendations).

Nursing Process Framework

• Framework established by the American Nurses Association (ANA).

• Consists of five key phases:

  • Assessment: Data gathering through subjective and objective means.

  • Diagnosis: Identification of nursing diagnoses, separate from medical diagnoses.

  • Planning: Setting patient-centered SMART goals (Specific, Measurable, Attainable, Realistic, Timely).

  • Implementation: Execution of the care plan.

  • Evaluation: Assessing effectiveness of interventions and patient outcomes.

Assessment Details

• Subjective data: Information shared by the patient.

• Objective data: Observable and measurable information by the nurse.

• Importance of a holistic view, including psychosocial factors in assessment.

• Focused assessments based on immediate issues (e.g., a patient with abdominal pain).

Nursing Diagnosis

• Distinct from medical diagnosis; addresses patient responses to health conditions.

• Example of a nursing diagnosis: "Impaired comfort related to…"

Planning and Prioritization

• Importance of prioritizing care using ABCs: Airway, Breathing, Circulation.

• Communicating care priorities through care plans.

Implementation of Care

• Conducting interventions based on assessment and planning.

• Need for evidence-based practices in nursing interventions.

Evaluation Process

• Determine the success of implemented interventions.

• Adjust care when goals are not met.

Interdisciplinary Team Members

• Understanding of roles:

  • Provider: Includes MDs, DOs, PAs, and NPs.

  • Occupational Therapy (OT): Assists patients with daily living skills.

  • Physical Therapy (PT): Focuses on mobility and muscle strengthening.

  • Speech Language Pathologist (SLP): Works with communication issues and swallowing difficulties.

SBAR Communication

• SBAR: Standardized format for effective communication in healthcare settings.

  • Situation: Describe the patient’s current situation.

  • Background: Relevant medical history.

  • Assessment: Current observations and clinical findings.

  • Recommendation: Suggestions for further actions or interventions.

Continuity of Care

• Essential for ensuring quality patient care during transitions: admission, transfers, and discharge.

• Start planning for discharge upon admission.

• Conduct a medication reconciliation at all transition points.

• Importance of educating patients on care, restrictions, and follow-up appointments at discharge.

Importance of Critical Thinking in Nursing

• Encourages questioning and understanding the reasoning behind actions.

• Develops confidence and competency in decision-making.

• Aids in identifying potential issues in patient care and ensuring high-quality outcomes.

Principles of High Reliability Organizations

• Preoccupation with Failure: Consider potential risks in every task.

• Deference to Expertise: Value input from frontline staff for improvements in patient care.

Personal Reflection and Growth

• Emphasis on daily reflection of lessons learned and areas for improvement.

• Importance of being aware of personal feelings and self-doubt in clinical environments.

• Encourages ongoing learning and adaptation in nursing practice.