Nursing Fundamentals Theory Flashcards
Purpose of Evidenced Based Care
Incorporates best scientific and clinical evidence for treating and managing a problem
Benefits of Evidenced Based Care
Reduces costs and improves quality and safety of patient experience and improves patient outcomes
Sources of Evidence Based Practice(EBP)
Text Books, articles for healthcare literature, peer reviewed journals , practice guidelines
How can application of evidence differ
Differ based on patients’ values, state of health, preferences, concerns, or
expectations
What is Performance Improvement(PI)
A formal approach for the analysis of health care–related processes
Where does PI begin
at staff level when identifying quality problems
Types of problems that may require performance improvement
- Sentinel events
- Active errors
- Latent errors
PI + EBP=
Is the foundation for excellent patient care and
outcomes.
What is Critical Thinking
the objective analysis and evaluation of an issue in order to form a judgment
How is critical thinking obtained
u Is gained only through experience, commitment, and active curiosity towards
learning
What is Clinical Judgement
u Conclusion about a patient’s needs or health problems
What helps make a clinical judgement
a nurse’s experience and knowledge , and knowing the patient
What is reflection
Purposefully reviewing a situation or practice experience to describe, analyze and evaluate results.
Is reflection intuitive
No, It is purposefully visualizing a past situation and taking the time to honestly review everything you remember about it.
Another benefit is it improves ability to problem solve
3 Levels of critical thinking(BCC Thinks critically)
basic critical thinking, complex critical thinking, commitment
Basic Critical Thinking
beginning nursing students are task oriented and
trust that experts have the right answers for every problem
Complex Critical Thinking
thinkers begin to rely less on experts and trust their own decisions more.
Commitment
at this level one anticipate when to make choices without assistance from others and accept accountability for decisions made.
Nursing Process
Assessment, Diagnosis, Planning, Implementation, Evaluation
Types of Assessment
patient centered interview, periodic assessments, physical examination
Patient-Centered Interview
Conducted during a nursing history
Periodic Assessments
Conducted during ongoing contact with patients
Physical Examination
Conducted during a nursing history and at any time a
patient presents a symptom
Subjective Data
Patients’ verbal descriptions of their health problems -Includes patient feelings, perceptions, and self-reported symptoms
Objective Data
Findings resulting from direct observation- physical testing, signs, and testing
Phases of the Interview
orientation & agenda setting, working phone, termination phase
Orientation and Setting and Agenda
- address person with surname, shake hands if appropriate
- introduce self
- give reason for interview/visit
Working Phase
Data collection . Involves Interview techniques.
- Observation
- Open-ended questions
- Direct closed-ended questions
- Leading questions
- Back channeling
- Probing
- Interpret
Termination Phase
signals that the interview is ending and gives pt a last chance to share concerns and self-expression+ summarizes the interview
summary in more detail
final statement of what you and the patient agree the health state to be
- should include positive health aspects and any health problems that have been identified, any plan for action, and explanation of the following physical exam
Parts to the nursing assessment?
not sure
Parts of a Nursing Diagnosis
Problem, etiology, defining characteristics/risk factors
Problem Focused Nursing Diagnosis Statement
Problem (x) related to the etiology(y) as evidenced by defining characteristics(z)
Example of a problem focused nursing diagnosis
Ineffective Breathing Pattern related to pain as evidenced by pursed-lip breathing, reports of pain during inhalation, use of accessory muscles to breathe
Risk Nursing Diagnosis Statement
Risk for x related to y
Example of a risk nursing diagnosis
Risk for Falls related to muscle weakness
What is a Health promotion Nursing Diagnosis
Health promotion diagnosis (also known as wellness diagnosis) is a clinical judgment about motivation and desire to increase well-being.
Health promotion Nursing Diagnosis Statement
Readiness for x as evidenced by
Example of a Health promotion Nursing Diagnosis Statement
Readiness for Enhanced Family Coping as evidenced by verbalization of desire for information that will enhancehealth choices
Planning Process
Plan out objectives and make SMART goals and set priorities
Priority Levels (want to no more)
High, intermediate, low
High Priority Levels
If untreated, result in harm to a patient or other
Intermediate Priority Levels
u Nonemergent and not life-threatening
Low Priority Levels
Not always directly related to a specific illness or prognosis but affect a patient’s future well-being
Goal Types
Short Term and Long Term
Types of Interventions
Nurse, hcp, or other provider initiated
Types of Nursing Interventions
Direct , indirect care interventions
Direct Care Interventions
Treatments nurses provide through interactions with patients or a group of patients
Indirect Care Interventions
-Treatments performed away from a patient but on behalf of the patient or group of patients, documentation, and interprofessional collaboration
Standard Nursing Interventions
Allow nurses to act more quickly and appropriately. Help capture patient care information that can be shared across disciplines and care settings
Nurse and HCP Initiated Standard Interventions
Clinical practice guidelines and protocols ,Care bundles, Standing orders, Nursing Interventions Classification (NIC) ,interventions ,Standards of practice.
Clinical Practice Guidelines
A systematically developed set of statements about appropriate health care for
specific health care problems or clinical situations
Care Bundles
Group of interventions related to a disease process or condition
Standing Orders
Preprinted document containing medical orders , Directs patient care in a specific clinical setting
Nursing interventions classification(NIC) interventions
Common interventions recommended for various nursing diagnoses
Standards of practice
Nurses use the ANA Standards of Professional Nursing Practice as evidence of the standard of care provided to patients
Quality and safety education for nurses (QSEN)
Standard competencies in knowledge, skills, and attitudes for the preparation of future nurses
What to have during implementations
time management, equip, personnel, environment, patient
What happens during a direct care intervention
counseling, teaching, controlling for adverse rxns, preventive interventions
What happens during a indirect care intervention
Communicating nursing interventions and Delegating, supervising, and evaluating the work of other staff members
Evaluation
Determines whether a patient’s condition or well-being improved after nursing interventions were delivered
-Continuously examine results by gathering subjective and objective data from a patient, family, and health care team members
What is teaching
The concept of imparting knowledge through a series of directed activities.
What is learning
Acquiring new knowledge, skills, and/or attitudes that can be measured
Are nurses legally required for educating a patient
yes
Steps for the teaching process
- Identify a need for information
- Establish learning objectives
- The nurse (the sender) conveys information
- The patient (the receiver) learns the information
- Provide feedback
- Evaluate the success of the teaching plan
Basic Learning Principles
motivation to learn, readiness to learn, ability to learn, good teaching environment, good resources for learning, health literacy
Examples of Nursing Diagnoses for Patient education
Lack of Knowledge (Affective, Cognitive, Psychomotor)
Impaired Health Maintenance,
Impaired Ability to Manage Dietary/Exercise Regime,
Self-Care Deficit
Instructional Methods(Implementation)
1-1 discussion group instruction prep instruction demonstrations analogies role playing simulation
Evaluation of education implementations
Have the patient’s learning needs been met? If not, revise the plan of care and offer additional instruction or reinforcement
Examples of patient education evaluation
teach back
