Nursing sensitive outcomes Flashcards
critical thinking
ability to reason to make and to reflection on rational, legal, and profession decisions founded on nursing knowledge to reflect to contemplate to consider all information and knowledge to rationalize to analyze all that you know to consider alternatives
ability to analyze and evaluate information and thinking
to be self-motivated and self-improving
to develop your knowledge, inquiry, reflection, and decision making
to be open minded and collaborative
requisite skills and abilities for becoming a registered nurse in alberta
cognitive behavioural communication interpersonal physical sensory perceptual environmental
cognitive
exercise critical inquiry skills to develop professional judgement
behavioural
manage own behaviour well enough to provide safe, competent and ethical nursing care (self regulation)
communication
speak and understand english well enough to avoid mixing up words and meanings including complex medical and technical terminology
interpersonal
maintain interpersonal (professional) boundaries
physical
having ability to perform activities needed to provide the care your patients require
eg- lifting, dexterity, coordination
sensory perceptual
sight, hearing, touch, smell
being able to assess your patients and situations
environmental
need to be able to function in situations with “commonly encountered and unavoidable environmental factors”
nursing sensitive outcomes
patient care outcomes responsive to the actions of the registered nurse
specific patient results which occur as a consequence of specific nursing interventions
nursing role effectiveness model
independent role = nursing interventions
medical care related role = care initiated in response to a medical order
interdependent role = interprofessional and multidisciplinary team communication, coordination of care
all of these lead to nursing sensitive patient outcomes
what do registered nurses do to positively impact the health and quality of life of the patient
independently as the registered nurse delivering patient care
inter-professionally/collaboratively as part of a multidisciplinary team delivering patient care
evidence for nursing practice
available information to support/demonstrate that a practice/intervention is the best means of achieving the desired outcome
tanner’s model
clinical judgement
clinical knowledge
clinical reasoning
clinical judgement
understanding of patient needs and selecting the appropriate interventions
application of clinical knowledge
clinical knowledge
textbook or researched
objective data = measurable, observable, see, hear, feel, smell
subjective data = patient information, what the patient says
clinical reasoning
the process undertaken to arrive at clinical judgments
integrating the knowledge and information with “knowing” the patients values and beliefs to determine best action
clinical judgement influenced by
context, background, relationship
decisions made are impacted by the culture and standards of the unit
decisions made include an understanding of the specific patient and his/her uniqueness
decisions made are shaped by the functioning and working relationship of the different healthcare professionals on the unit
4 phases of tanner’s model
noticing
interpreting
responding
reflecting
noticing
a perceptual grasp of the situation at hand
must know “norm” or baseline
interpreting
developing a sufficient understanding of he situation to respond
attending to most pertinent and relevant information
achieving understanding of information
developing appropriate plan
responding
deciding on a course of action deemed appropriate for the situation
having a planned action but being flexible and modifying as needed to adapt to patient responses
reflecting
attending to the patients responses to the nursing action while in the process of acting
being aware and carefully thinking about the patients response to your interventions
reflection-in-action
being cognizant of how your patient is responding to your intervention and modifying and adapting to that response as needed
reflection-on-action
thinking on the situation after the experience
gaining learning and using the experience to develop/improve personal practice
personal responsibility to critically reflect
SBAR
situation
background
assessment
recommendation
situation
concern, diagnosis, treatment plan and patients wants and needs what is occurring with the patient what are the acute changes what is the concern This is \_\_\_\_ im calling about \_\_\_
background
vital signs, mental and code status, list of medications and lab results
pertinent history (admitting diagnosis/pertinent comorbidities) and objective data that provides relevant information on patient situation
the patient has ___
assessment
current providers assessment of the situation what do you see what do you think is going on what do you think the issue is how severe is the problem a diagnosis is not necessary i think the problem is \_\_\_
recommendation
identify pending lab results and what needs to be done over the next few hours and other recommendations for care what do you think needs to be done what action do your propose state what the patient needs and when i request that you \_\_\_
what is documentation
any written or electronically generated information about a client that describes client status or the care or services provided to that client
CARNA and documentation
professional obligation
part of standards of practice and ethics code
legislative obligation
documentation is not optional
documentation is done
by the nurse
the nurse documents timely, accurate reports of data collection, interpretation, planning, implementation and evaluation of nursing practice
purpose of documentation
to communicate and provide continuity of care
to ensure accountability
legal implications of documentation
for quality improvement and risk management
facilitating evidence-informed practice and clinical decision support
principles of charting
precise, concise, accurate
objective data
subjective data
do not express opinion
should be clear, legible, accurate and should use proper terminology
chart chronologically at the time of occurrence or as soon as possible
narrative charting
written in sentence form
not a checklist
focus charting
a focus is identified which is based on client concerns or behaviours determined during the assessment
focus charting: DARP
focus column data action response plan
focus column
identifies the content or purpose of the narrative entry and is separated from the body of the notes in order to promote easy data retrieval and communication
data
is the subjective and objective information supporting the stated focus or describing the observations at the time of a significant event
action
describes past or present interventions of the health team member
response
describes the patient outcome/response to interventions or describes how goals have been attained
plan
describes future actions that are to be carried out at a later date or time
short or long term goals are clearly outlined
medication administration
requires nursing knowledge and critical thinking
safe, competent and ethical medication administration is expectation of nursing practice
safe medication administration includes
appropriate documentation
patient education documented
knowledge of medication actions, interactions, usual dose, route, side effects, and adverse effects
calculation of dosage and medication preparation
appropriateness of medication
know why patient is on medication
monitoring patient before, during, and after medication administration
evaluating impact of medication on patient status
3 checks of medication
while removing medications from medication drawer
while preparing medication
before giving it to patient
