Outline Unit 1 Flashcards
initiation of independent nursing interventions without medical records
autonomy
reasonably independent and self-governing in decision making
reach through experience, advanced education
professionally and legally responsible for the type and quality of nursing care provided
accountability
code of ethics and legal aspects of nursing
ANA - American Nurses Association
NPA - Nurse Practice Act
regulates the scope of nursing practice for the state and protects public health, safety, and welfare
NPA differs from
state to state
concepts for a critical thinker
truth seeking open-mindedness analytic approach systematic approach self-confidence inquisitiveness maturity
critical thinker reflecting on your own judgments
maturity
being eager to acquire knowledge and learn explanations
inquisitiveness
trust own reasoning processes
self-confidence
organized and focused critical thinker
systematic approach
alert to potentially problematic situations
analytic approach
tolerant to diff views and clearly know the views of PT
Open-mindedness
be courageous, honest, and objective about asking questions
truth seeking
make more conscious effort to apply critical thinking BC initially you are more task oriented and trying to learn how to organize nursing care activities
Level 1 basic critical thinking
develop new thought or idea based on your experience and knowledge over time
Level 2 Complex critical thinking
anticipate the need to make choices without assistance from others - accept accountability for decisions you make
Level 3 commitment critical thinking
scientific method to critical thinking
- identify the problem
- collecting of data
- forming a question or hypothesis
- testing the questing or hypothesis
- evaluating results of the test or study
drawing conclusions from related pieces of evidence and previous experience with the evidence
diagnostic reasoning and inference
requires careful reasoning so you choose the options for the best PT outcomes on the basis of PT condition and priority of the problem
Clinical decision making
components of critical thinking
- knowledge base
- experience
- competence
- attitude
- standards
visual representation of PT problems and interventions that illustrates and interrelationship
concept mapping
reasoning process used to reflect on and analyze thoughts, actions, and knowledge
developing critical thinking skills
decision making
responsibility, autonomy, authority, accountability
duties and activities an individual is employed to perform
responsibility
independent decisions about PT care
autonomy
legitimate power to give commands and make final decisions specific to give position
authority
answerable for the actions
accountability
leadership skills for nursing students
clinical care coordination, team communication, delegation, knowledge building
requires knowing which skills are transferable
delegation
improves PT care, improves efficacy, increased productivity
delegation
5 rights of delegation
Task, circumstance, person, direction/communication, supervision
always care for PT as if they can hear everything you say; tell them what you’re doing before you do it
nonverbal communication
nonverbal communication
- personal appearance
- posture & gait
- facial expression
- eye contact
- gestures
- territoriality and personal space
all factors that influence communication
metacommunication
factors influencing communication
- psychophysiological
- relational
- situational
- environmental
- cultural
ability to understand and accept another persons perspective
empathy
attentive to what PT says verbally and nonverbally
listening
therapeutic communication technigues to listening
S-Sit facing PT O- Open posture L- Lean toward the PT E- Eye contact R-Relax
observe and comment on PT appearance, sounds, acts
sharing observations
helps communication without extensive questioning
sharing observations
time to collect thoughts
using silence
helps PT make decisions, less anxiety, feel safe & secure
providing info
validates whether the person interpreted correctly
clarifying
direct convo on specific topic when it becomes unclear
focusing
restating senders message in receivers own worlds to make sure info understand accurately
paraphrasing
review main ideas from discussion
summarizing
personal statements intentionally revealed to other person
self-disclosure
“sense of possibility”
instilling hope
standards are set by federal & state regulations, state statuses, standards of care, & accreditation agencies
documentation
require each PT have an assessment:
physical, psychosocial, environmental, self-care, PT edu, knowledge level, discharge planning
guidelines for documentation
factual, accurate, complete, organized, current
descriptive, objective info - what you see, hear, feel, and smell
factual - guidelines of documentation
precise measurements make documentation more…
accurate
episode oriented, info can be lost from one episode to another
paper record
Electronic health record
- a digital version of PT medical records
- integrates PT info in one record
- improves continuity of care
Progress notes
narrative, SOAP, SOAPIE, PIE, focus charting
charting by exception
focuses on documentation deviations from norms
incorporate a multidisciplinary approach to care; focuses to providing quality care in a cost-effective manner
case management plan and critical pathways
Methods of Documentation
paper records, electronic health record, progress notes, charting by exception, case management plan and critical pathways
SOAP
Subjective, Objective, Assessment, Plan
SOAPIE
Subjective, Objective, Assessment, Plan, Intervention, Evaluation
guides the nurse through a complete assessment to identify relevant nursing diagnoses
Admission nursing history form
help team members quickly see PT trends over time and decrease time spend on writing narrative notes
flow sheets in graphic records
computerized systems provide certain basic information in the form of a PT care summary
Patient care summary or Kardex
“flip-over” file a notebook with PT info
Kardex
Preprinted, established guidelines used to care for PT who have similar health problems
Standardized care plans
begin at admission and before admission on same-day surgery
discharge summary forms
system determines the hour of care for nursing unit and the number of staff required to care for given group of PT
acuity records
purpose of records
communication, reimbursement, research, legal documentation, education, quality process and performance improvement
standards for PT education
- all state NPA recognize PT edu is a professional responsibility of every nurse
- PT edu is considered basic nursing competency
- edu takes place, evaluate if learning occurred and document all steps of the process
- help individuals, families, or communities achieve optimal levels of health, safety and independence
cognitive learning
what the PT knows and understands
affective learning
PT feelings, attitudes, opinions and values
Psychomotor learning
PT acquires skills that require the integration of knowledge and physical skills
Domains of learning
cognitive, affective, psychomotor
basic learning principles
motivation and ability to learn
motivation to learn
address the PT desire or willingness to learn
ability to learn
depends of physical and cognitive abilities, developmental level, physical wellness, thought process
ACCESS model
Assessment Communication Cultural negotiation/compromise Establishment of respect Sensitivity Safety
