Unit 3: Nursing process, Ctiritcal thinking & Factors impacting patient care Flashcards
Assessment:
How What Who When Where
Assessment: How
Compiling a health history, physical examination, and analysis of diagnostic and lab results
Assessment: Who
Client, family/significant others, healthcare team
Assessment: What
• Client’s past history and current health status • Determinants of health • Subjective Data • Interview or conversation • Source: • Client • Family/Significant Others • Interprofessional team • Medical Records • Research Literature • Objective Data • Examination or assessment
Assessment: When
- Occurs with every interaction
- 4 Types:
- Initial Assessment; what brought you in
- Focused Assessment
- Ongoing Assessment
- Emergency Assessment; ABC’s
Assessment: Where
- Interview
- Start with their current illness and their concerns
- Their Experience: signs & symptoms, past medical experience, ADLs, lifestyle, desired outcomes, and participation
- Key is therapeutic communication: respect, empathy, and trust; with professional boundaries
- Verbal Communication
- Nonverbal Communication
- Tools and Forms
- Intake and history forms
- Screening Tools: MOCA, Falls Risk, Pain Assessment tools, OR checklist
- Physical Assessment
- Gather further information regarding the area of concern
- Include Head-to-toe assessments and vital signs
- Inspection, palpation, percussion and auscultation
- Review of diagnostic and lab results
Nursing diagnosis
a clinical judgement that describes the client/family/community response to health conditions or life processes
Planning
- Identify desired health outcomes
- Formulate Care plans
- Prioritize Appropriate Nursing Interventions
- Coordinate Resources
Planning: Three types of planning
- Initial Planning
- Ongoing Planning
- Discharge planning
Planning: Prioritization methods
- Maslow’s Hierarchy
- Synthesizing Information
- Setting SMART goals
Implementation
• When what a nurse has planned is put into action
What does implementation include?
- Reassessing the client
- Determining resources
- Implementing nursing interventions
- Delegation of Care
- DOCUMENTATION
Evaluation
- You need to review the Care plan as a whole as well as its parts
- Review the clients response to interventions but also the resources provided
- Outcomes and evaluations will identify new assessment data used to identify new priorities and planning going forward.
Types of care plans:
- Standards of care
- Standardized care plans
- Protocols
- Policies and procedures
Elements included in Nursing Care Plans:
- Sign and date the plan
- Use category headings
- Used standardized & approved terminology
- Be specific
- Specific to patient
- Include prevention and health promotion principles
- Include discharge and home care plans
What does documentation promote?
- Promotes quality improvement and manages risk
- Promotes quality improvement and manages risk
- Liability protection
- Expands the science of nursing
Developing critical thinking
- Internal and external processes
Nursing Informatics
the meeting of nursing clinical, information, and management sciences in the development, design, implementation, and evaluation of technology related to computer software, hardware, and health care devices as they are used.
What does the CNA say about nursing informatics?
• It “enhances decision-making in all direct and indirect nursing roles, through the collection, extraction, aggregation, analysis and interpretation of standardized data, using the emerging principles and methods of data science.”
Information literacy
understanding when information is required, where to find it, evaluate and ultimately use the information.
Current uses of nursing informatics:
- Research: Nursing Outcomes Classification, CINAHL, MEDLINE, electronic books, Organizational webpages
- Patient Care: electronic records, electronic charting/nursing actions, coordination of flow within the hospital, procedure manuals, pharmacy information. Each patient encounter creates data
- Electronic Health Records: everything that happened with or for the patient: lab and diagnostics, administration, radiology, nursing, pharmacy
- Professional
