Week 2-Engage Modules PPP (1) INTRO TO NURSING

Clinical Judgment Process

• Focus: Clinical judgment used by nurses
• Key Concept: Clinical judgment helps nurses provide safe and effective care across all clinical settings
• Related Concepts: Clinical decision-making, critical thinking, clinical reasoning, and clinical judgment are essential in nursing

Nursing Process for RNs

• Assessment
• Analysis
• Planning
• Implementation
• Evaluation

Nursing Process for PNs

• Data Collection
• Planning
• Implementation
• Evaluation
• Difference: The nursing process is slightly different for RNs and PNs

Nursing Process – Detailed Steps

Assessment

• Assessment: Collection, organization, validation, and documentation of client health data.
• Focus: Client's response to a health problem, health beliefs, and practices.
• Critical Thinking: Comprehensive evaluation of both subjective and objective information.
• Skills Required: Strong communication and assessment skills for effective care planning.
• Holistic Approach: The assessment should consider all client needs, including physical, emotional, and social factors.
• Types of Data Collected:
  • Objective Data: Measurable and observable (e.g., vital signs, physical findings, intake/output).
    • Collected through senses: seeing (inspection), hearing (auscultation), smelling, and touching (palpation).
  • Subjective Data: Self-reported by the client or family (e.g., pain, reasons for seeking care).
    • Documented verbatim using quotation marks for the client’s exact words.
• Steps in the Assessment:
  • Health History: Interview the client about medical history, medications, remedies, substance use, and support systems.
  • Physical Assessment: Conduct a thorough physical examination.
  • Review of Medical Records: Analyze lab results, diagnostic tests, and other relevant documents.
  • Sociocultural and Economic Factors: To understand the client’s overall well- being, ask questions about their background, social support, and spiritual needs.
• Roles of RNs and PNs in Assessment
  • RNs (Registered Nurses):
    • Perform initial assessments for both new and unstable clients.
    • Analyze and validate data to make decisions regarding the client’s health.
    • Conduct further assessments (physical or psychosocial) and review additional data (e.g., lab values, diagnostic tests) if necessary.
  • PNs (Practical Nurses):
    • Perform data collection on stable clients as directed by the RN.
    • Provide data that the RN will use to determine if further assessment is needed.
  • RN Responsibilities:
    • Based on PNs or APs (Assistive Personnel) data, RNs decide if further assessments are needed to understand the client’s health condition fully.
    • RNs are responsible for interviewing clients, reviewing medical records, and performing additional assessments when required.

Analysis

• Analysis: Interpreting assessment data to identify health problems/risks and client needs.
• Process: Identifying patterns, comparing data with standards, and drawing conclusions.
• Goal: Directing nursing care based on data analysis.
• Purpose: In this step, the RN reviews the assessment data to identify the client’s problem(s) and begins formulating a care plan.
• Key Steps:
  • The RN may need to reassess the client if more information is required.
  • If additional data is necessary, the RN may repeat the assessment and analysis steps, particularly in urgent or triage situations.
  • The analysis helps determine which issues should be prioritized in the plan of care.
• Example:
  • Simple Case: A client with pain shows facial grimacing, refuses to move, rates pain at 8/10, and reports stabbing pain in the left leg. In this case, pain is identified as the problem.
  • Complex Case: For more complicated conditions, such as acid-base or electrolyte imbalances, the nurse may need to analyze additional information (like lab results or diagnostic tests) to determine the root problem.

Planning

• Planning: Developing measurable goals/outcomes and identifying interventions based on assessment data.
• Process: Using evidence-based practice to set goals, prioritize care, and determine interventions.
• Goal: Help the client achieve their desired health outcomes.
• The RN develops a plan of care to address the client’s problems by creating individualized interventions and setting goals to achieve positive outcomes.
• Purpose:
  • Interventions: Specific actions are designed to help the client reach their goals.
  • Goals: Must be realistic, measurable, and achievable within a specified time frame.
    • Short-term: Achievable within a few days.
    • Long-term: Achievable over weeks or months.
• The plan should be individualized based on the client’s needs, preferences, and assessment data (including physical, emotional, and spiritual aspects).
  • The nurse must create interventions that address the client's holistic needs, considering their unique circumstances.
• Planning Considerations:
  • Client with Pain:
    • Short-term goal : "Client will rate pain as 3/10 within 24 hours."
    • Interventions: Administer pain medications, reposition the client, create a calming environment, and utilize relaxation techniques.
  • For clients with chronic or terminal conditions, like those receiving palliative care, the goals may shift toward comfort-focused interventions (e.g., improving pain management to allow the client to engage with family or perform ADLs).
• Customization of Care:
  • The plan should be tailored to the client’s needs, considering their physical, emotional, social, and spiritual requirements.

Implementation

• Implementation: Applying nursing knowledge to carry out interventions to promote, maintain, or restore health.
• Skills Used: Problem-solving, clinical judgment, critical thinking, and both interpersonal and technical skills.
• Responsibilities: Delegating, supervising care, and documenting the client’s response.
• Definition: Implementation is the action phase where the nurse provides care based on the client’s plan. It may involve administering medications, therapies, or other interventions.
• Key Points:
  • Sometimes, the best action is to monitor the client without taking immediate action.
  • Other times, specific actions, like administering medication, are required.
• Example:
  • The nurse may administer pain medication every 4 hours for a client with pain.
  • If pain persists and medication isn’t due, the nurse might suggest other pain-relief methods (e.g., guided imagery, deep breathing, repositioning).
• Continuous Process:
  • The nurse reassesses the client, analyzes the situation, and updates the plan.
  • The nurse documents the client's response to interventions, such as changes in pain levels.
• Example (Broken Femur):
  • For a client with a broken femur, pain relief will require ongoing interventions.
  • Pain management actions will be frequent, and the nurse must document each step in the care plan.
  • As recovery progresses, the frequency of interventions may change, but the nurse continues to document and adjust the care plan accordingly.
• Summary:
  • Implementation involves delivering nursing actions and continuously reassessing the client’s needs to ensure the best possible outcomes.

Evaluation

• Evaluation: Assessing the client’s response to nursing interventions and determining if goals/outcomes were met.
• Key Tasks: Evaluating client and staff understanding, assessing intervention effectiveness, and deciding if further action or plan modification is needed.
• Definition: Evaluation is the final step, during which the nurse assesses the effectiveness of the interventions provided and documents the client's response.
• It helps determine whether the plan of care needs to be continued, modified, or discontinued.
• Key Points:
  • The RN evaluates if the interventions worked and if the client’s needs were met.
  • If the client’s condition has changed, the RN may need to reassess and modify the care plan.
  • The nursing process is ongoing, and the RN may revisit any step to adapt the plan as new data becomes available.
• Process:
  • Reevaluation: The RN may need to revisit the assessment, analysis, planning, or implementation steps based on new information.
  • Continuous and Fluid: The nursing process is flexible and constantly evolving to meet the client’s needs.
• Questions for Evaluation:
  • What did the client say or do?
  • What did the nurse observe?
  • These questions help guide the nurse’s evaluation of the client’s progress.
• Summary:
  • Evaluation ensures that nursing interventions are effective and that the care plan is adjusted as needed to achieve the best client outcomes.
  • The nursing process is dynamic, requiring ongoing reassessment and modification.
• Evaluation for the Client Experiencing Pain:
  • Record the time and pain score after interventions (e.g., medication, guided imagery) to assess effectiveness.
  • Documentation:
    • Reevaluate if any changes could improve outcomes and adjust the approach if necessary.
  • Effectiveness of Interventions:
    • Update the care plan and pass information to the next shift nurse for continuity.
  • Ongoing Documentation:
    • Share key information with care managers or interprofessional team members to ensure coordinated care.
  • Reporting:
    • If the client isn't following the plan (e.g., not walking), investigate the reasons and collaborate with the team to improve adherence.
  • Adherence to Plan of Care:
    • Work with the physical therapist and other team members to optimize interventions, such as adjusting the timing of pain medication during therapy.
  • Collaboration:
    • Summary: Evaluation involves assessing intervention effectiveness, ensuring adherence to the care plan, and collaborating with the healthcare team to adjust care for optimal outcomes.

Nursing Process for Practical Nurses (PNs)

• Practical nurses (PNs) use a modified version of the nursing process, which consists of four steps:
  • Data Collection – Gather information about the client’s health status.
  • Planning – Develop a plan to address the client's needs.
  • Implementation – Carry out the planned interventions.
  • Evaluation – Assess the effectiveness of the interventions.
• PNs work under the supervision of RNs and follow this process to support client care.
• Data Collection (for Practical Nurses)
  • PNs gather subjective and objective data by asking questions and using physical examination techniques (inspection, auscultation, palpation).
  • PNs can also take vital signs and review lab or diagnostic data.
  • Necessary: PNs cannot assess the data but must report any changes (e.g., elevated blood pressure) to the RN for analysis.
  • Communication between PNs and RNs is essential for client safety.
  • All findings should be documented in the client's medical record.
• Planning (for Practical Nurses)
  • PNs assist and collaborate with the RN in developing the care plan but do not assume full responsibility.
  • PN planning includes:
    • Developing goals
    • Determining interventions
    • Setting time frames for the client’s care
  • Planning should be individualized, considering the client’s holistic needs (physical, emotional, social, and spiritual).
• Implementation (for Practical Nurses)
  • PNs collaborate with the RN to carry out interventions outlined in the care plan.
  • PNs must follow state regulations regarding their scope of practice, as different states allow different tasks for PNs.
  • Tasks may include:
    • Medication administration
    • Dressing changes
    • Intravenous fluid hydration.
  • All interventions performed should be documented in the client’s medical record.
• Evaluation (for Practical Nurses)
  • PNs collaborate with the RN to evaluate the care provided.
  • For example, after administering nausea medication, the PN may assess the client's response by asking questions like:
    • "Have you had any vomiting since receiving the medication?"
    • "Is your nausea improved or gone?"
  • The PN documents the data in the medical record and collaborates with the RN if needed.
  • The PN nursing process may be repeated multiple times, or steps may be taken out of order depending on the client's condition and new information.
• Summary for Practical Nurses (PNs)
  • Collect data and report findings to the RN.
  • Plan interventions in collaboration with the RN.
  • Implement interventions under RN supervision.
  • Evaluate effectiveness and report findings to the RN.
  • Steps of the PN Nursing Process:
    • The nursing process should consider clients' physical, emotional, spiritual, and social needs.
    • The process is dynamic and may move between steps as needed.
    • PNs must always work under RN supervision and in collaboration with the RN.
    • Effective communication and adherence to state guidelines for safe practice are essential for optimal client outcomes.

Clinical Judgment in Nursing

• Definition: Clinical judgment is the ongoing use of clinical reasoning throughout a nurse's career, helping to ensure safe and effective care.
• Challenges:
  • Staffing Shortages: Nurses may need to make quick decisions under pressure, leading to potential errors.
  • Complex Cases: Clients with multiple health issues require careful judgment to manage their many needs.
  • Medication Effects: Adverse medication effects can mimic other conditions, making accurate assessments challenging.
• Importance: Clinical judgment is developed through education and hands-on experience, enabling nurses to make safe, effective decisions for positive client outcomes.

Clinical Judgment and Client Outcomes

• Nursing Process and Clinical Judgment : The nursing process helps nurses make accurate clinical judgments, ensuring that client needs are met, and outcomes are optimized.
• Nurses as Gatekeepers: Nurses work closely with providers, discharge planners, and other team members at the bedside to ensure client care is coordinated and effective.
• Early Detection: Nurses who consistently assess and reassess clients can identify early signs of potential issues, allowing for early intervention and preventing adverse situations.
  • Example: Noticing a rise in blood pressure early or frequent urination post-surgery can prevent more serious complications, such as uncontrolled hypertension or bladder rupture.
• Key to Success: Proper assessment and clinical judgment are essential in preventing harm and achieving positive client outcomes.

Prioritization of Care Using the Nursing Process

• Collaborating for Accurate Clinical Judgment : RNs may miss subtle clues during busy shifts.
• RNs should collaborate with other nurses, such as bedside nurses, managers, and supervisors, to ensure accurate clinical judgments.
• This collaboration helps verify that decisions are in the client's best interest.
• Client Safety First: Client safety is the top priority. Collaboration among nurses is essential to prevent errors and provide the best care.
• Confidentiality: Nurses must maintain confidentiality when discussing client care.
• Adjusting Plans Based on Client Responses : Nurses must evaluate and adjust care plans based on client responses.
• Many factors can influence decision-making, making client care complex and dynamic.

Delegation and Clinical Judgment

• Risks of Improper Delegation : Delegating clinical judgment could result in adverse client outcomes. Nurses must ensure they delegate appropriately and stay within the guidelines of their state’s delegation rules.
• Clinical Judgment Cannot Be Delegated : Clinical reasoning and judgment cannot be delegated.
• RNs and PNs are responsible for tasks requiring clinical judgment. APs, being in a supportive role, should only be delegated tasks that do not require clinical reasoning, like assisting with ADLs or taking vital signs.
• Delegation: Delegation involves assigning a nursing task or procedure to someone else, such as from an RN to a PN or AP, with the proper training.
• RNs must ensure that delegated tasks are appropriate for those receiving them and follow the principles set by the NCSBN.

Priority Setting Frameworks

• Priority refers to the level of importance where tasks or needs are ranked to determine what requires immediate attention.
• Setting priorities allows nurses to address tasks sequentially, ensuring that the most urgent needs are met first.
• Priority-setting frameworks guide nurses in determining the correct order of client care.
• These frameworks rely on ongoing assessment, data collection, shift reports, communication with the healthcare team, and the review of electronic health records.
• Common priority-setting frameworks:
  • Maslow’s Hierarchy of Needs
  • ABCDE (Airway, Breathing, Circulation, Disability, Exposure)
  • Safety and Risk Reduction
  • Least Restrictive/Least Invasive
  • Survival Potential
  • Acute vs. Chronic
  • Unstable vs. Stable
  • Urgent vs. Nonurgent
• These frameworks assist in prioritizing care for individual clients and groups of clients.

Prioritizing Client Care

• Priority setting helps nurses address critical needs, ensuring better client outcomes.
• It involves organizing care based on the urgency and importance of client needs, whether for individuals or groups.
• Effective prioritization improves client well-being and health outcomes, while poor prioritization can harm them.
• Nurses develop prioritization skills through experience, using them to choose interventions, evaluate care plans, and make adjustments as needed.
• This skill is essential for managing care during shift changes or when a client is deteriorating.

Maslow’s Hierarchy of Needs

• Maslow’s hierarchy of needs, developed by Abraham Maslow, is a theory that identifies five levels of human needs, often illustrated as a pyramid.
• The pyramid's base contains basic needs, while psychological needs are in the middle, and self- fulfillment needs are at the top.
• Lower-level needs must be met before higher-level needs can be pursued.
• The first four levels—physiological, safety, belonging, and esteem—are deficiency needs. If these needs are unmet, they cause discomfort, motivating individuals to meet them.
• The top level, self-actualization, is a growth need.
• Maslow’s theory suggests that physiological needs must be met first, followed by psychological needs, before achieving self-actualization.

Physiological Needs

• Physiological needs, including food, water, air, shelter, sleep, clothing, and reproduction, are essential for survival.
• These needs are vital for maintaining homeostasis, as the body constantly regulates levels of substances like sugar, sodium, and oxygen in the blood.
• If any of these unmet needs are present, mechanisms like hunger and thirst drive the individual to fulfill them.
• For instance, if a client is thirsty, satisfying that need takes priority over other concerns.
• Nurses should focus on meeting these basic needs first, as all different needs in Maslow's hierarchy are secondary until physiological needs are addressed.

Safety and Security

• After physiological needs are met, individuals focus on safety and security.
• These include personal safety, environmental protection, employment, health, and property.
• People seek stability, predictability, and control in their lives.
• In nursing, once a client's basic physiological needs are addressed, the nurse should prioritize meeting the client's safety and security needs.

Love and Belonging

• After meeting physiological and safety needs, individuals focus on social needs, which involve love and belonging.
• This includes the desire for relationships, such as friendships, family connections, intimacy, trust, affection, and a sense of belonging.
• These needs are fulfilled through interactions with friends, family, and work relationships that provide emotional support and connection.

Self-Esteem Needs

• Self-esteem needs are driven by two factors: the desire to feel good about oneself and to gain the respect of others.
• Self-esteem is achieved through confidence in one's abilities and accomplishments and recognition, appreciation, and respect from others.

Self-Actualization

• Self-actualization is the desire for self-fulfillment and reaching one's fullest potential. It involves becoming the best version of oneself and achieving personal goals.
• After meeting all deficiency needs, individuals seek self-actualization, which can lead to restlessness until that goal is accomplished.
• This need is unique to each person and can change over time. According to Maslow, only a few individuals fully achieve self- actualization.

ABCDE Framework

• The ABCDE framework helps prioritize care by addressing the most critical issues first to stabilize the client and improve outcomes.
• It focuses on:
  • Airway – Ensuring the airway is clear and open.
  • Breathing – Assessing if the client is breathing properly.
  • Circulation – Ensuring adequate blood flow and perfusion.
  • Disability – Evaluating neurological status (e.g., consciousness level).
  • Exposure – Exposing the client to check for any signs of trauma or injury.
• This approach helps nurses identify and address life-threatening issues early, preventing further complications or death.

Airway Management

• A compromised airway requires immediate intervention to prevent serious complications or death.
• Airway obstructions can be partial or complete, caused by factors such as CNS depression, blockages from blood or vomit, inflammation, facial trauma, or foreign objects.
• If the client can communicate, the airway is open; immediate action is needed.
• Techniques like the head tilt-chin lift or jaw-thrust maneuver, artificial airway insertion, or suctioning may be used to clear the obstruction.
• Oxygen is administered to maintain oxygen saturation levels of 94\%-96\% for clients without COPD and 88\%-92\% for those with COPD.
• Pulse oximetry is a common tool for monitoring oxygen saturation, providing real-time data on how much oxygen is bound to hemoglobin.

Breathing Assessment

• Once the airway is clear, the nurse assesses the client’s breathing status.
• This involves auscultating the lungs, measuring the respiratory rate (including depth and pattern), observing for cyanosis, and checking for thoracic wall symmetry.
• The nurse should also note the use of accessory muscles, which indicates increased breathing work.
• The nurse should count respirations for a full minute and assess for equal chest movement.
• The use of accessory muscles signals difficulty breathing.
• If the client is fatigued, they may have trouble speaking due to shortness of breath.
• The nurse may identify conditions such as pneumothorax or bronchospasms during this assessment.
• Continuous monitoring of oxygen saturation and vital signs is essential.
• If respiratory distress is present, the client should be positioned upright to help with lung expansion, and a Venturi mask may be used to deliver precise oxygen levels.

Circulation Assessment

• To assess circulation, the nurse evaluates blood pressure, capillary refill time, pulse rate (including volume and character), urine output, and the client's level of consciousness, noting any changes in skin tone.
• Signs of decreased circulation include changes in skin color and temperature, prolonged capillary refill time, hypotension, altered pulse rate or volume, and decreased urine output.
• Impaired circulation can result from cardiovascular conditions or altered blood volume.
• Treatment typically involves fluid replacement, controlling bleeding, and restoring tissue perfusion, depending on the underlying cause.

Disability Assessment

• Disability assessment focuses on evaluating the client's neurologic status, including their level of consciousness, response to verbal or painful stimuli, and orientation.
• Impairments in the airway, breathing, or circulatory function can directly affect neurological status, so these systems must be stable before assessing for disability.
• The nurse observes the client’s alertness, response - ability, and cognitive awareness to determine neurological deficits.

Exposure

• The final step of the ABCDE framework is exposure.
• The nurse should uncover the client as necessary to conduct a thorough head-to-toe examination, ensuring privacy and maintaining body temperature.
• The nurse looks for signs of internal or external bleeding (e.g., bruising, abdominal distention), allergic reactions (e.g., rashes), or edema.
• The nurse also checks for signs of deep vein thrombosis (DVT), such as calf warmth, pain, and swelling.
• Monitoring the client's temperature can reveal infections or inflammation.
• Additionally, the nurse should review the client’s record for any relevant information that could guide the care plan.
• If the client’s condition worsens, assistance from more experienced healthcare providers should be sought.

Safety and Risk Reduction

• The World Health Organization defines client safety as the absence of preventable harm and minimizing the risk of unnecessary harm during health care.
• The goal is to reduce errors and risks associated with care delivery.
• The safety and risk reduction framework prioritizes situations or factors that pose the highest safety risk to the client.
• Issues that significantly threaten the client’s physical or psychological well-being are prioritized.
• When multiple risks are present, frameworks like Maslow’s hierarchy or ABCDE may be used to determine the priority.
• Nurses must recognize and address these risks to minimize harm.
• Proactive actions, such as drying a damp floor to prevent slips, can prevent damage.

Least Restrictive/Least Invasive

• This framework prioritizes using the least restrictive and invasive interventions while ensuring client safety.
• Before resorting to restraints, nurses should try alternatives like using alarms or having staff present.
• If restraints are necessary, the least restrictive option should be used.
• Similarly, less invasive measures, such as a toileting schedule for post-surgical incontinence, should be tried before more invasive procedures like inserting a catheter.
• This approach minimizes discomfort and the risk of infections.

Survival Potential

• The survival potential framework is used during mass-casualty incidents to maximize the benefit of limited healthcare resources.
• In these situations, triage helps determine which clients have the highest survival potential.
• Clients are categorized by injury severity: emergent (red), urgent or delayed (yellow) , nonurgent or minimal (green) , and expectant (black).

Triage Categories

• Emergent or Immediate (Red): Clients with life-threatening injuries but a high chance of survival. They need immediate transport and treatment, such as those with major hemorrhages or chest pain.
• Urgent or Delayed (Yellow): Clients with serious injuries that aren't immediately life-threatening. Treatment is needed within 30 minutes to 2 hours, like open fractures without major bleeding.
• Nonurgent or Minimal (Green): Clients with minor injuries who can wait for treatment. These clients, often called "walking wounded," may have sprained fingers or small cuts and can wait for care until more critical cases are treated.
• Expectant (Black): Clients who are either deceased or unlikely to survive due to severe injuries or multiple system failures. They are given comfort measures and allowed to die. Some systems use a blue tag for those still alive but expectant.

Additional Priority Frameworks

• Acute vs. Chronic : Acute problems take priority over chronic issues. Acute conditions need immediate attention (e.g., a sudden heart attack), while chronic issues can be addressed later.
• Urgent vs. Nonurgent: Urgent needs are prioritized over non-urgent ones. If delayed, urgent issues may cause harm (e.g., severe pain), while nonurgent needs can be postponed (e.g., a routine check-up).
• Unstable vs. Stable: Unstable conditions take priority over stable ones. Unstable clients may deteriorate quickly without intervention (e.g., shock), while stable clients are in less immediate danger.
• Additionally, client care can be categorized into:
  • Critical: Immediate intervention needed (e.g., respiratory distress).
  • Urgent: Needs addressing soon to prevent mild harm (e.g., postoperative pain).
  • Routine: Regular care tasks (e.g., administering medication, vital signs).
  • Extra: Non-essential tasks for comfort (e.g., providing a warm blanket).

Resource Allocation

• Resource allocation is distributing resources, such as materials, staff, or time, among clients or tasks.
• Nurses use priority-setting frameworks to determine how to allocate resources during their shifts.
• In doing so, they decide which nursing tasks are most critical and should be performed first.
• Rationing of care can occur when resources are limited, such as inadequate staffing levels, time, or supplies. This leads to care being left undone or missed, which can be considered a medical error and potentially compromise client safety.
• Missed care may result from supply chain issues, insufficient staffing, or lack of clinical resources, affecting the quality of care.

Delegation

• Delegation involves assigning client care tasks to other healthcare team members to help nurses manage their workload.
• Nurses can delegate tasks to staff members within their scope of practice who are competent to perform them.
• This allows nurses to focus on higher acuity tasks and clients with more urgent needs.
• Nurses can delegate tasks to other nurses at or below their licensure level and to assistive personnel.
• While the nurse delegates the task, they remain accountable for completing it correctly.
• However, functions that require nursing judgment or critical decision-making cannot be delegated.

Prioritizing Care in Various Settings

• In the acute care setting, prioritizing care for a group of clients starts at the beginning of a nurse's shift after receiving the hand-off report from the previous nurses.
• The nurse's first task is determining the order in which clients will be seen, starting with the most critical and ending with the least vital.
• This prioritization process should be revisited throughout the shift as the clients' care needs change.
• The nurse follows the same basic prioritization process in a medical-surgical unit or the emergency department (ED).
• The nurse uses the nursing process to assess each client’s acuity level and decides how care will be delivered, ensuring that the most urgent needs are addressed first.

Prioritizing Care in the Emergency Department (ED)

• In the Emergency Department (ED), prioritizing a group of clients begins with the nurse collecting initial focused data and assigning an acuity level to each client.
• The acuity level helps determine which clients need immediate care and which can wait.
• Most EDs use a five-level acuity system, where clients who are critically ill are classified as level 1, and those who are less ill are assigned level 5.
• Common acuity rating tools include the Emergency Severity Index (ESI) and the Canadian Triage Acuity Scale (CTAS), both of which are supported by the Emergency Nurses Association.
• Clients needing life-saving interventions (such as cardiopulmonary arrest, unresponsiveness, or shock) are given the highest priority, followed by those whose conditions may deteriorate without prompt care.
• While triage systems are used worldwide, there is no universal emergency system.
• Nurses in the ED require specialized skills to triage competently.
• In other settings, nurses can use frameworks like acute versus chronic, urgent versus nonurgent, or unstable versus stable to guide care and prioritize the most severe needs.

Evidence-Based Practice (EBP)

• Evidence-based practice (EBP) involves using credible, current scientific research to guide nursing decisions and improve client outcomes.
• This includes reviewing literature, evaluating findings, and forming evidence- based practice recommendations.
• These recommendations are then implemented and evaluated by measuring client outcomes.
• The benefits of EBP include improved client outcomes, reduced costs, and the delivery of high-quality care.
• Evidence-based interventions increase satisfaction among nurses and clients.
• Over time, EBP has evolved from focusing mainly on clinical issues to encompassing nurse-led research.
• The spirit of inquiry is a key aspect of evidence-based practice (EBP), where nurses seek to understand the knowledge and skills necessary for providing the best care for clients and families.
• It’s about questioning existing practices, which may rely on tradition, experience, or personal beliefs, and using EBP to improve care.
• This curiosity helps to foster better clinical judgments and better practices across different care settings.
• The spirit of inquiry represents Step Zero in EBP and helps nurses develop new approaches to problem-solving while keeping patient care up-to-date with the latest evidence.

Conducting a Review of the Literature

• Identifying the Problem: Recognize a clinical issue needing improvement.
• Searching for Evidence: Find credible sources like research studies or guidelines.
• Evaluating Findings: Critically assess the quality and relevance of the evidence.
• Implementing Recommendations: Apply the best evidence to improve care.
• Reviewing Effectiveness: Evaluate the impact of the intervention on patient outcomes.
• Disseminating Results: Share successful practices with others to promote broader adoption.

Using Evidence-Based Practice to Address a Clinical Problem

• Identify a Problem: Formulate a straightforward, focused question about the clinical issue.
• Search Credible Sources: Gather factual, reliable evidence from research, guidelines, or expert opinion.
• Evaluate Findings: Assess the quality and relevance of the evidence.
• Implement Recommendations: Apply the best evidence to change interventions or practices.
• Review Effectiveness: Measure if the new interventions improve patient outcomes.
• Disseminate Results: Share findings with colleagues to encourage widespread adoption of successful practices.

Identifying the Problem

• To identify a clinical problem, nurses can ask simple questions like “why” or “how.”
• If the rationale behind a practice isn’t clear, it’s time to explore the available evidence to find better solutions.
• This could focus on a specific clinical issue or a systems issue.
• To make the question more focused, use the PICOT framework:
  • Population: Define the specific group.
  • Intervention: Identify the treatment or action.
  • Comparison: Compare it with an existing method or alternative.
  • Outcome: Clarify what result is expected.
  • Time: Specify the duration, if applicable.

Using the PICOT Framework

• For example, a broad question like "Why do nurses change jobs?" can be narrowed to:
• In newly hired nurses (P), does participation in an organized biweekly stress reduction program (I) compared to no participation (C) affect retention rates (O) over one year (T)?
• This approach helps target relevant research and generates focused evidence for clinical decisions.

Searching for Credible Sources of Evidence

• The second step in the EBP process is conducting a literature search.
• This involves gathering information from credible sources, such as textbooks, research articles, and reputable websites.
• Be cautious of non-scientific literature, such as magazines, newspaper articles, and deceptive advertisements, which may appear credible but are poorly researched.
• To conduct a literature search, use scholarly databases with relevant search terms.
• A valuable tool for organizing this information is a table of evidence. This allows the nurse to review the key points from each article, recognize repeated information, and identify any gaps in the evidence.

Evaluating the findings

• Nurses should make notes about each article's focus and key results and then compare the information across sources.

Implementing Recommendations

• The next step in evidence-based practice (EBP) is using the evidence to implement changes in practice.
• This can be challenging, as various factors must be considered, such as the cost of supplies, time required for training, and potential resistance to change from staff who may be accustomed to traditional methods.
• Presenting findings and recommendations to management and care providers is essential to implementing evidence-based change, ensuring everyone is on board with standardizing practices based on the evidence.
• One key challenge in EBP is the theory-practice gap, the time lag between discovering new evidence and integrating it into practice.
• Nurses familiar with EBP processes can help reduce this gap by advocating for timely, evidence-based changes.

Evaluating Effectiveness

• Evaluating the effectiveness of an implemented intervention is crucial to determining whether the changes have successfully addressed the identified problem.
• This step directly addresses the "outcome" component of the PICOT question.