Week 3 Lecture Flashcards
Collect and analyze subjective and objective Data about the paitents health problems
Assessment
State the health problem
Nursing Process
Diagnosis / Analysis
ID expected results
Nursing Process
Outcome identification
Write a ______ that includes the nursing interventions designed to achieve expected outcomes
Which part of the nursing process is
Care plan
Planning
Which part of the nursing process is document the actions?
Implementation
Clinical Judgment Measurement Model: Recognize Cues
Assessment
Clinical Judgment Measurement Model: Analyze Cues
Diagnosis / Analysis
Clinical Judgment Measurement Model: Prioritize Hypothesis
Outcome Identification
Clinical Judgment Measurement Model: Generate Solutions
Planning
Clinical Judgment Measurement Model: Take Actions
Implementation
Clinical Judgment Measurement Model: Evaluate Outcomes
Evaluation
Which Org. Formally classifies nursing diagnoses
NANDA North American Nursing Diagnosis Association
How to formulate a nursing Diagnosis
Use assessment to develop a problem list.
Then prioritize the problems
Make diagnosis for biggest problems
Diagnosis (Patients Response): Impaired gas exchange
_______: ineffective airway clearance
_______: copious tracheostomy secretions, decrease in O² saturation, and increase WOB (work of breathing)
r/t (related to)
AEB (as evidenced by)
AEB in a nursing Diagnosis is aka
Symptoms
Actual nursing diagnosis have ___ parts: Name them
Problem, r/t, AEB
Risk nursing diagnosis has ___ parts: Name them
2
Problem, r / t
Wellness nursing diagnosis have 1 part - Name it
Statement of ability to transition to a higher level of well
SMART
Specific
Measurable
Appropriate
Realistic
Timely
Evidence Based Practice
Hierarchy of Evidence(Top = Greatest)
Systematic Review
____________
Cohort Studies
___________
Expert Opinion
Randomized Controlled trails
Case reports
______ transforms evidence into recommendations for practice
Translation
______ refers to using the research findings in clinical practice
Integration
Steps in Implementing EBP
- Ask a question about a clinical area of interest or intervention
- Collect the most relevant and best data
- ________
- Integrate the evidence with clinical expertise, paitent preferences, and ___ in making a decision to change
- Critically appraise the evidence
- Values
Sources for Evidence Based Practices
(EBP)
Quality improvement, risk management, and benchmark data
International, national, and local standards/ guidelines
________
________
______
Journal Articles
Research Reports
Infection Control Data
Used to promote essential knowledge, skills, and attributes necessary to improve patient outcomes and reduce errors
(QSEN)
Quality and Safety Education for Nurses
Clinical Judgment Model / Nursing Process
what information is relevant/ irrelevant?
What information is most important
What is your immediate concern
Identify relevant and important information from different sources ( medical history, vital signs)
Recognize Cues / Assessment
NCSBN Clinical Judgment Measurement Model / Nursing Process
What client conditions are consistent with the Cues
Are there Cues that support or contraindicate a particular condition
Why is a particular cue or subset of Cues or co concern
What other information would help establish the significance of a Cues or set of Cues
Organizing and linking the recognized Cues to the clients Clinical presentations
Analyze Cues / Diagnosis
NCSBN Clinical Judgment Measurement Model / Nursing Process
Which explanations are most / least likely
Which possible explanations are the most serious
Evaluating and ranking hypotheses according to priority (urgency, likelihood, risk difficulty, time
Priority hypothesis/ Outcome Id
NCSBN Clinical Judgment Measurement Model / Nursing Process
Item development should focus on ranking the potential issues and should use phrases such as “most likely “
Prioritize hypotheses/ Outcome Identification
Hierarchy of Evidence
Which is th3 most bias / weakest
Expert opnions
Hierarchy of Evidence
The 2nd lowest (2 of 5) has to do with a Single Patient and treatment given to them
Case Report
Hierarchy of Evidence
When you take a preselected group (have something in common)
And do a treatment on them
(3 of 5)
Cohort studies
Hierarchy of Evidence
A group of people are randomly assigned a treatment/ not given treatment. (Double Blind)
4/5
Randomized controlled studies
Hierarchy of Evidence
Reviewing multiple Randomized Control Studies and considered the most reliable
Systematic review aka meta analysis
Taking research and making recommendations to start new procedures in Healthcare
Translation
Difference between Translation & Intergration
Translation is recommended
Integration is actually doing
Steps in Implementing EBP
(5) in order
Ask
Collect
Appraise
Integrate
Evaluate
When asking clinical questions, use this format?
Population
Intervention
Comparison
Outcome
Time
Looking at charts and labs, Dr notes, and medical history
Nursing process
Assessment
PICOT
clinical research question
Population
Intervention
Comparison
Outcome
Time
Clinical Judgment Model
Clinical Judgment Model
Define a set of interventions for the expected outcomes
Evaluation and ranking hypotheses to priority
Generate solutions/ Planning
Establishing goals is this part of the nursing process
Outcome ID
Convert nursing process to CLINICAL JUDGMENT MODEL
Assessment
Recognize Cues
Convert nursing process to CLINICAL JUDGMENT MODEL
Diagnosis/ Analysis
Analyze Cues
Convert nursing process to CLINICAL JUDGMENT MODEL
Outcome ID
Prioritize Hypothesis
Convert nursing process to CLINICAL JUDGMENT MODEL
Planning (actions you will take to achieve goals)
Generate Solutions
Convert nursing process to CLINICAL JUDGMENT MODEL
Implementation
Take action
Convert nursing process to CLINICAL JUDGMENT MODEL
Evaluación
Evaluate outcomes
How do you write Outcomes in the nursing diagnosis
SMART
Paitents Values and Preferences
Best Research Evidence
Clinical Expertise
Make up
EBM (Evidence Based medicine)
Ask
Collect
Appraise
Integrate
Evaluate
Steps in Implementing….
EBP
Evidence Based Practices
List the nursing process
Access
Diagnose
Outcomes
Planning
Interventions
Evaluación