NUR116 Lect - Priority Setting Frameworks (Week 3) Flashcards
What are the Steps of the Nursing Process?
ADPIE
Assessment - Collect (and validate) information about pt’s status
Analysis/Diagnosis- Analyze information to determine (diagnose) client’s problem
Planning - make plans to address client’s problems with interventions and goals; SMART goals
Implementation - Take action and do interventions
Evaluation - Evaluate whether the plan worked or not, document
What is Clinical Judgment?
The skill/outcome of critical thinking and decision making
- Observe presenting situations
- Identify a prioritized client concern
- Generate the best possible evidence-based solution for safe client care
-Clinical Reasoning across an expanse of time
Critical Thinking vs Clinical Reasoning
Critical Thinking: the use of logic and reasoning to identify areas of client needs, while considering alternative approaches and solutions
(Logic to figure out solutions for client needs)
Clinical Reasoning: the mental process used when analyzing all data pertaining to a clinical situation
(The mental process used when analyzing all data)
Difference between Clinical Judgment and Reasoning
Clinical reasoning - Constant and repeated action that nurses use in practice
Clinical judgment - The idea of clinical reasoning that happens repetitively and forms a major nursing skill
What is Delegation?
Assigning a nursing activity/procedure to another person who has the appropriate training for said activity/procedure
What are Maslow’s hierarchy of needs from lower to higher?
Physiological Needs: Basic human needs; air, water food, sleep
Safety Needs: Secure environment where one can live, work & play
Love Needs: Need to give and receive love
Esteem Needs: Need to have high self-image
Self-Actualization: Need for achievement and mastery
Define “ABCDE”, in regards to evaluating care prioritiy
Airway: Airway obstruction requires immediate intervention; examples: asthma, overly sedated, obstructed, etc
Breathing: Evaluate breathing itself; resp rate (depth and pattern), effort (labored), wheezing, conversational
Circulation: VS (Vital signs: BP, heart rate), skin color
Disability- Neurological:awake,alert, oreitnation;”Who’s the president? What year is it?”
Exposure: Assess the skin head to toe (dryness, bruising, etc)
- In PACU, Pain comes after Circulation
How do we go about Safety and Risk Reduction?
Provide examples of safety issues
Priority given to whatever finding poses the greatest or immediate risk to client’s physical or psychological well-being
Surgical complications, device malfunctions, HAIs, falls, pressure injuries, wet floors, dangling cords,
LPN can and cannot’s:
Can: Place NG tubes and foley catheteres, get vital signs
Cannot: Any assessment, IV push medications, should NOT be assigned to unstable patients (may require frequent assessments and emergency interventions)
A nurse is planning care for a post-operative patient. What should the nurse do first
before writing the care plan?
Consult with the patient.
- The patient is the most important part of the care plan!!
When/how often should assessment occur?
Assessment is an ongoing process
- First step in nursing process
- Ongoing
- Only RNs, not LPNs, can do assessment
An RN delegates the task of getting a patient out of bed to a new AP (assistive personnel). The AP accidentally drops the patient, and the patient is injured. Who is most liable for the patient’s injury?
The RN is most liable because they assigned a complex task to a new AP.
The delegator retains accountability for any task they assign.
We must be sure that when assigning tasks, the person we assign is competent to perform that task.
How should restraints be administered?
When should they be administered?
- Tied to a non-movable part of the bed (NOT the side rails) giving the patient as much range of motion as possible, while maintaining safety
- Should be tied with quick-release knots
- Last resort; use should be reduced
What is the survival potential framework for disasters?
Red/Emergent/First priority: Red tag to clients who have life-threatening injuries but have a high chance of survival with immediate treatment
Yellow/urgent/second priority: Yellow tag to clients who have an urgent condition that could wait a short time for treatment
Green/Nonurgent/Third Priority: Green tag to the walking wounded, or clients who have injuries that are non-life threatening and could wait hours to days for treatment
Black/Expectant/Lowest Priority: Black tag to clients who are deceased or have a minimal chance of survival despite treatment, and promote comfort for these clients
