Exam 1 Flashcards
Clinical Judgement
Interpretation that influences actions in a clinical practice (patient’s needs, concerns, health problems, and decision to take action, modify approach, or improvise new plan)
Clinical Reasoning
Thinking process by which you reach a clinical judgement (Noticing, Interpreting, Responding, Reasoning)
Critical Thinking
Interpretation of what a patient needs and use appropriate approach
Experience, Commitment, Active Curiosity, “Why?” “How?”
Non linear process of collecting, interpreting, analyzing, and drawing conclusions
Decision making
use of algorithms, decision trees, patient care guidelines, and standards of care
Standard based approach
Clear cut guidance, best practice=best treatment
Evidence based practice
Problem solving approach to clinical decision making (combines best scientific evidence with best patient/nurse evidence)
Clinical judgement equals?
Safe implementation of EDP
Nursing Process
Assessment, Nursing Diagnosis, Outcomes, Identification, Planning, Implementation, and Evaluation (decision making)
Interpretivist Approaches
What nurse personally contributes to care
4 Attributes of Clinical Judgement
- Hollistic View
- Process Orientation
- Reasoning and Interpretations
- Ethical Comportment
Tanner’s Model of Clinical Judgement
(No Idiot Rules Red)
Noticing
Interpreting
Responding
Reflecting
Reflection-In-Action
Nurse’s understanding of patients response to actions within care
Real time thinking
Example: Patient’s response to medication
Reflection-on-action
Consideration of situation after patient care
Significant learning from practice
Example: “What was successful what was unsuccessful?”
Nursing Process
Systematic method of critical thinking to develop individualized plans of care and provide care for patients (organized and methodica)
5 Steps of Nursing Process
ADPIE
Assessment, Diagnosis, Planning, Implementation, Evaluation
What does Clinical Judgement require?
Knowledge, ability to recognize and identify patient needs, nursing diagnosis, evidence-based practice (EBP), and skill to evaluate patient responses to interventiond
Critical thinking (complex thinking process)
Clarity - allows nurses to collect essential patient data
Increase Precision - articulate specific needs
Recognize Relevance - realistic patient goals
Fair & Consistent - Customized Interventions
Characteristics of Nursing Process
Analytical - “Is data collection accurate?”
Dynamic - Changes in response to patient’s needs
Organized - Standard method for all patients
Outcome Oriented - Care plans made specifically to a patient
Collaborative - Involvement of various healthcare professionals
Adaptable - Plan of care for individual
Assessment
Data gathered through observation/interview, physical assessment and cues are recognized
Diagnosis
Data and cues analyzed, validated, and clustered to identify problems and patient needs
Planning
Prioritize hypothesis and nursing diagnosis
Identify short and long term goals
Implementation
Taking action by initiating specific nursing intervention and treatment
Evaluation
Determine whether or not goals and outcomes were met and plan of care status
Types of physical assessment
Comprehensive
Focused
Emergency
Comprehensive Physical Assessment
Thorough interview - health history, review of systems, laboratory and diagnostic tests, physical head to toe assessment (evaluate cranial nerves and sensory organs)
Happens during hospital admission/ annual physical
Focused Physical Assessment
Brief individualized physical assessment
Happens when signs indicate a change in patient condition or complication
- Pain level, pulse oximetry reading, vital signs
Emergency Physical Assessment
Time is a factor, treatment must begin immediately
Quick survey -> narrow focused assessment (signs, symptoms, injuries)
Primary Data
Directly from patient
Secondary Data
Information shared by family members, friends, or other health care team
Subjective Data
What the patient is feeling
Spoken information or symptoms (difficult to validate)
Objective Data
Signs that can be measured or observed
Asepsis
Free from disease and prevention of disease-causing contamination
Infection
Establishment of a pathogen in a susceptible host
A disease state caused by infectious agent
Body natural barriers/defenses
Skin
Mucous membranes
Respiratory tract
GI/GU Tract
What are the 4 main defenses?
Natural Barrier
Normal Flora
Inflammatory Response
Immune Response
Normal flora
Group of microorganisms that live on body but do not cause disease
Found on skin, eyes, nose, mouth, GI tract
Inflammatory Response
Directs immune system components to injury
Local response to cellular injury or infection
Produces: redness, heat, pain, swelling, increased blood supply
Immune Response
Body’s attempt to protect itself form foreign substances.
Initiated by recognition of ANTIGENS.
Recognizes and destroys substances that contain foreign antigens
Antigen
Any substance that provokes an adaptive immune repsonse
Chain of infection
Infectious agent
Source of infection
Portal of exit
Mode of transmission
Portal of entry
Susceptible host
Pathogen
Infectious agent that causes disease
Bacteria
Single celled. Live on normal flora. Most common and prevalent in hospital settings. Most commonly cause infection
Example: Strep throat, TB
Viruses
Smallest of all microorganism. Nucleic acid must enter living cells to reproduce
Example: Common cold and AIDS
Fungi
Plant-like organisms present in air, soil, and water
Example: Ringworm
Parasites
Live on other organisms
Example: Worms and ticks
Types of Infection
Colonization
Localized Infection
Systemic Infection
Acute Infection
Chronic Infection
Colonization
Microorganisms grow/multiply but do NOT cause disease
Example: S.aureus
Localized Infection
Most common in skin or mucous membrane breakdown (surgical wounds, oral lesions, abscesses)
Example: Redness, warmth, swelling
Systemic Infection
Fever, fatigue, malaise
In bloodstream (tachycardia)
Acute Infection
Sudden for a short period of time
Chronic Infection
Slow can last years
Infectious/Etiological agent
Virulence, invasiveness, pathogenicity
Break the Chain
Control or eliminate infectious agent
Example: Clean, disinfect, and sterilize
Reservoir
Natural habitat of organism (where they thrive and reproduce)
Break the chain: Control or eliminate reservoir
Portal of exit
Point of escape for organism
Break the chain: Control portal, hand hygiene, gloves, cover nose/mouth
Means of transmission
Direct contact: from reservoir to host
Indirect contact:
- vehicle (transport like water, food, blood)
- vector (insects)
- airborne (germs aerosolized)
Break the chain: Standard precautions/Transmission based precautions
Portal of entry
Point where organisms enter a new host (through broken skin or respiratory tract)
Break the chain: Control portal (mask)
Susceptible host
Individual at risk for infection (very young, very old, chronic disease, nutrition, stress)
Break the chain: Protect host
Stages of infection
Incubation period
Prodromal stage
Full stage of illness
Convalescent period
Incubation period
organisms growing and multiplying (can take hours or years)
Prodromal Stage
person is most infectious
vague and nonspecific signs of disease
Example: malaise or fatigue
Full stage of illness
presence of specific signs and symptoms of disease
Example: cell lysis, fevers, chills, tachycardia
Convalescent period
recovery from infection (tissue repaired)
Health Care-Associated Infection (HAIS)
infections that patient get while receiving treatment for medical conditions
HAI Risk Factors
Medical procedures and antibiotic use
Organizational factors
Patient characteristics
Common types of HAI
CAUTI - catheter-associated urinary tract infection
SSI - surgical site infection
CLABSI - central line-associated blood stream infection
VAP- ventilator-associated pneumonia
HAI Exemplars
MRSA - methicillin-resistant S. aureus
CAUTI - catheter-associated urinary tract infection
C.diff - Clostridioides difficile
MRSA
cause of staph infection that is difficult to treat because of antibiotic resistance
transmitted by direct physical contact
can cause severe problems in: bloodstream, pneumonia, SSI, and daycares
CDC Guidelines for Proper Catheter Use
- Limit catheter use
- Minimal duration use
- Avoid placing in nursing home residents
- Consider alternatives
- Provide catheter care
- Changed as needed
C.diff
bacterium that causes diarrhea and colitis (colon inflammation)
risk factors
- after taking antibiotics
- 65 or older
- recent hospitalization
- weak immune system
- previous C.diff infection
CDC Recommendation to prevent C.diff infection
- prescribe antibiotics cautiously
- use contact precaution (private room)
- use of gowns and gloves
- effective hand hygiene
- disposable equipment
- clean with bleach or disinfectant
Priority Setting Framework Purpose
“Which client should I see first?”
“What is most important assessment finding?”
“Which interventions should I do now, which can I do later?”
“Which situation poses a risk to client safety?”
Priority Setting Framework
- Nursing Process
- ABC’s
- Maslow’s Hierarchy of Needs
- Urgency Factor Model
- Triage
ABC
Assess and prioritize threats to airway, breathing, and circulation
Airway
A patent airway so oxygen will have a pathway into the lungs for gas exchange and for carbon dioxide to be expelled from body
Breathing
Effective breathing pattern and respiratory effort to take in enough oxygen to meet cellular demands for oxygen throughout the body
Circulation
Effective circulatory system to deliver oxygen throughout the body and exchange carbon dioxide and oxygen throughout the pulmonary circulatory network
Maslow’s Hierarchy of Needs
- Self-actualization
- Esteem
- Love/belonging
- Safety
- Physiological
Self-actualization
Morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts
Esteem
Self-esteem, confidence, achievement, respect of others, respect by others
Love/Belonging
Friendship, family, sexual intimacy
Safety
Security of body, of employment, of resources, of morality, of the family, of health, of property
Physiological
Breathing, food, water, sex, sleep, homeostasis, excretion
Low priority
Problems can typically be resolved easily with minimal interventions
Medium priority
Problems that may have unhealthy physical or emotional consequences
Not life-threatening
High Priority
Life-threatening problems
ABC problems
Conditions that have potential to become life threatening in short term
Urgency Factor Model
Time priority
Deadlines for completion of nursing interventions
Essential activities not preformed may result in negative consequences for patients
Urgency Levels
Non-acute
Acute
Critical
Non-acute
Low urgency factor
Delay would not negatively affect patient outcomes
Acute
Medium priority
Low potential for patient’s condition to become life threatening if interventions not completed in short time
Interventions can be schedules when time constraints of higher-priority interventions allow
Critical
Medium-high urgency
Urgent need to respond to physical or psychologic problems in short amount of time
Potential for patient’s condition to become life-threatening if interventions delayed
Quick recognition, rapid response required to prevent worsening or problem
Imminent death
Highest urgency
Action takes priority over everything else
Nurse must act immediately to prevent further deterioration
Threat to life
Triage
- Emergent (immediate)
- Urgent
- Nonurgent
Emergent (immediate)
Life-threatening issues that require prompt treatment care
Stabilization of patient’s condition is critical
Urgent (delayed)
Serious conditions in which delay would not result in life-threatening conditions
Nonurgent
Patients who have minor issues not requiring prompt care
Often patient can ambulate and is stable
Assessment
deliberate and systemic collection of data about a client’s health status to identify concerns and needs that can be managed by nursing care
Assessment includes:
- Physiological
- Psychological
- Sociocultural
- Spiritual
- Economic
- Lifestyle factors
Nursing Diagnosis: Taxonomy
- NANDA-I
- Omaha System
- Saba System
Three-part format (PES system)
- Nursing diagnosis (diagnostic label)
- “Related to” (related factor)
- Defining characteristics (“as evidenced by”)
3 elements of comprehensive planning
- Initial (nurse who preforms history & physical assess.)
- Ongoing (keeping plan of care up to date)
- Discharge (teaching & consoling skills)
Goal
broad statement that describes that desired change in a patient’s condition or behavior an aim, intent, or end
Expected outcome
Measurable criteria to evaluate goal achievement
Long-term outcomes require a longer period to be achieved and may be used as discharge goals.
Goal & Outcomes
- Client centered
- Singular goal or outcome
- Observable
- Measurable
- Time limited
- Mutual
- Realistic
SMART
S - Single specific action
M - Measurable
A - Attainable (Achievable)
R - Relevant
T - Time limited
Types of Interventions
- Nurse initiated
- Physician initiated
- Collaborative
Nurse-initiated Intervention
Independent: Actions that a nurse initiates
Physician initiated
Dependent: require an order from a physician or other health care professional -> carried out by a nurse
Collaborative
Interdependent- require combined knowledge, skill, and expertise of multiple health care professionals
Direct care
Treatments preformed through interactions with patients
Example: Medication administration, Inserting IV
Indirect Care
Treatment preformed away from the patient but on behalf of the patient
Example: Managing patient environment, Documentation
Isolation Precautions
Universal/Standard Precautions
Transmission-based Precautions
Isolation Practices
Disposal of soiled equipment and supplies
Disinfection sterilization
Patient transport
Universal Precautions
- Hand hygiene
- PPE
- Cough etiquette
- Clean and disinfect
Transmission based Precautions
Contact
Airborne
Droplet
Contact precaution
- Private room
- PPE
- Contain infected area
- Disposable PPE
- Clean and disinfect
Droplet Precaution
- Private room
- Don mask upon entry
- Cough etiquette
Airborne Precaution
- Airborne infection isolation room (AIRR)
- PPE (NIOSH approved N95)
Example: tuberculosis, measles, chickenpox
Disinfectant
Used on inanimate objects
Example: Chlorine
Antiseptic
used on skin, tissue
example: isopropyl
Bactericidal agent
destroys bacteria
Bacteriostatic agent
prevents growth
White blood cell count
Normal is 5,000 to 10,000 mm3
Collaborative Therapies
Collecting specimen for lab testing
Retrieving lab results
Administering medications
Pharmacologic Therapy
Provider looks for anti-infective agent that:
- is effective
- little toxicity
- can be administered conveniently
- cost effective
Nonpharmacologic Therapy
- Elevating affected area
- Rest
- Hydration
- Sterile saline dressings on wounds
- Cold/warm compress
