Week 3 Critical thinking, clinical judgement, admissions, transfers, discharge, client saftey Flashcards
Critical thinking
-life-long learning
-seeking truth, open-minded, thinking about why something is effective/ineffective
-critical thinking is a systematic process/pattern, using reason to guid decisions
-critical thinking includes …
Reflection: gain insight from past events
Language: clear/precise
Intuition: gut feeling, use data to confirm/disprove the feeling
**Levels of Critical Thinking
- Basic critical thinking- nurse trusts the experts
- Complex Critical thinking: nurse has autonomy by analyzing and examining data to determine the best alternative
- Commitment: nurse makes choices w/out help, fully responsible
Levels of critical thinking review
Basic->Complex->Commitment
Components of Critical Thinking**
CAKES
Competences- decision making, reasoning, problem solving
Attitudes: confidence, fair, perseverance etc
Knowledge: nurse edu/training
Experiences: goes into intuition
Standards:
review critical thinking and AAPIE
Assesment
data collection of client health status
critical thinking skills:
observe, good techniques when collecting data, differentiate relevant data, organize and validate data
Analysis and critical thinking
interpreting data to reach an appropriate nsg judgment
-know clusters/cues, inferences, knowing the potential problem or risk, no judgments
review the AAPIE and critical thinking in ppt
Nsg and Discharges
begins at admission
establish if the client can participate in the admission assessment
establish the therapeutic relationship with Pt and family at admission
promote professionalism
Admission Process**
Equipment:
-anything necessary for room, doc forms,
-equipment for vitals, pulse oximeter, hospital attire
Procedure
-Introduce your name and title
-give hospital wear
-facility brochures and info material
-info on advance directives*
-document advance directives status in med record*
Admission Assessment
Baseline: vitals, height, weight, allergies
Biographical info - wear do you live? is a a two floor?
Clients reason for seeking health care
Present illness and findings
Health History
Health History on admission assessment acronym
SAMPLE
Symtoms
Allergies
Medications
Past medical history
Last PO intake
Events leading to visit
Admission assessment
family history of serious illness
pschosocial assessment
-alc, tobacco, drugs, caffeine
-any mental illness
-abuse or homelessness
-home situation/ sig other
Nutrition
-diet, any dysphagia?
-weight
-supplements/herbal OTC
-dentures
Admission Assessment
Spiritual health/quality of life concern
Review of body systems: head to toe exam, any alterations
Safety assessments: fall risk, sensory deficits, assistive devices
Discharge info- fam in the home, transportation for discharge, phone numbers, medical equipment, home health care needs, stairs at home
Admission cont
Inventory of all personal items/devices
Orientations
-call light op, bed op, services, tv controls, lighting op, smoking policy, restroom locations, waiting areas, meal times, time for visits/policies
TRANSFER
-have special equipment ready
inform clients roommate of admission
-inform team of arrival and needs
-meet with client and fam at arrival to start admission process and orient pt/fam
asses how the client responds to transfer
documentation
implement any needed interventions
Transfer domumentation
Dx and care
demographic info
health status, plan of care, recent changes
meds, vitals
allergies
diet and activity orders
equipment and adaptive devices needs : vitals, suctioning, wheelchair
advance directives, emergency code status in medical history
family involvement in care
Discharge process
Indication for transfer and discharge
changes in level of care needed
-another setting is needed
Discharge planning
can pt ability to return home?
-does the pt have assitance at home?
-note any needed devices
-document pt discharged
-involve pt/family in discharge planning
Discharge edu
provide copy of clear instructions/discuss
-verify pt understanding
Standards:
-note safety issues at home
-review potential issues, and how to contact provider/emergency services
-give provider phone number
-phone # of community resources
-step-by-step instructions for continuing tx
-dietary restrictions guidelines, including interactions with meds
-enforce amount of therapies to do at home
-directions on medications, interactions, adherence, SEAE
Discharge Equpment
personal belongings
valuables from the safe
medications
assistive devices
medical records or a transfer form*
Discharge Px
-if transferring, confirm with facility or unit to expect the client
-communicate time of transfer to the receiving unit
-complete documentation, med rec, transfer form
-verbal transfer report by phone
-confirm the mode of transportation for client
-make sure client is dressed appropriately
-valuables
Discharge documentations
types: Provider prescription vs against medical advice AMA
date/time of discharge, who went with the client, and transportations, wheelchair to car, gurney to ambulance
-where the client went (home, facility)
-any unresolved issues, px, follow-up
-disposition of valuables, meds brought from home, prescriptions
Safety Nsg Action
use risk assessment for pt safety to environment
-encourage pt to speak up/active role
-culture of checks and balances
-speak of risk factors
-protocols for dangerous situations
-quality care priorities
know location of safety data sheets and hazardous chemicals in the environment
Falls at risk
elderly: impaired balance/mobility, improper use of mobility aids, unsafe clothing, environment, low endurance, low sensory
-impaired vision, weakness, urinary frequencies, balance problems,
cerebral palsy injury MS
cognitive dysfunctions
reactions to meds orthostatic hypotension drowsy
Fall prevention
fall risk assesment
fall risk alerts (bands on wrists)
-orientate call light, assistive devices
-lighting
-place at risk pt by nurse stations
-put frequent use items at bedside
-bed low/locked
fall prevention
-footwear
-gait belt
-clean floor
- electronic monitoring devices
report and document all incidents to prevent future incidents
Seizures
-sudden surge of electrical activity in the brain
-due to epilepsy, fever, medical issues
Partial seizure/focal: electrical surges in one hemisphere of brain
Generalized seizure: both hemispheres of brain involved
status epilepticus a prolonged seizure is a medical emergency
Seizure precautions
-rescue equipment: oxygen, oral airway, suction equipment, padding for side rails, saline lock for immediate IV access
-inspect environment for things that cause seizure
-assist clients at risk with ambulation
Seizures during
stay beside pt
call for help
keep airway open, suction as needed
note duration, sequence, and movements
-post seizure determine mental status, ox saturation, vital signs, explain what happened, comfort, understanding
-document the seizure and movements, injury, durations, aura, postictal state as well.
Seclusion and restraint
-shortest duration necessary if less restrictive methods are not working
-physical: mitt, belt, limp, vest
-chemical: sedatives, neuroleptic, psychotropic med
-it can cause complications: Pnuemonia, Incontinence, Pressure injuires*
Restraints should:
never interfere with Tx
restrict as little as is necessary
fit well and discreetly
be easy to remove
Restraint prescription***
-Provider prescription must be in writing, or face-to-face
-must include the reason for restraint, type, location on body, duration, and behaviors that warrant restraint
-only 4 hr restraints for adults
2 hr restraints for pt 9-17
1 hr restraints for clients younger than 9
providers can renew prescriptions with a max of 24 consecutive hours
Restraints Nsg role
assess skin
offer food/fluid
provide hygiene/elimination
-vitals monitor
-ROM exercise
-Pad bony extremities
secure restraints on movable parts of bed frame
-use buckle straps or quick release knot
replace restraints often
-Never leave a client alone with a restraint
-monitor if use is still needed
Restraint doc
events prior to restraining
-other actions to avoid restraints
-time of application/removal
-type of restraint/location
-type and frequency of cares ROM, nero chekc, removal, skin chekcs
condition of the restrained body part
response at removal of the restraints
med administrations
Fire Safety
know exits, alarms, extinguishers, and oxygen shut off valves **
keep fire doors unblocked
know the evacuation plan
RACE
RACE
Rescue- pt
Alarm-facility alarm system report the fires details and location
Contain - closing doors, shutting off oxygen source, electrical devices, ventilate clients who are on life support with a bag-valve mask
Extinguish-
fire extinguishing
PASS
Pull the pin
Aim at the base of the fire
Squeeze the handle
Sweep the extinguisher from side to side covering the area of the fire
