WEEK 4 Flashcards
When was the nursing process developed and by who?
The nursing process was developed by Ida Jean Orlando as a guide to direct nursing care in 1958
define critical thinking
Thought process that is systematic and logical in reviewing information and data, that is open to reflection, inquiry and exploration in order to make informed decisions.
How can a nurse promote spiritual well being?
assisting a client to observe a religious practice, providing a client time for meditation, or praying with a client
How can a nurse promote mental wellbeing?
teaching the client relaxation techniques, taking the client for a walk outdoors, and assisting the client to maintain relationships with friends and family
How can a nurse promote physical well being?
providing a nutritious diet, assisting the client to be physically active, and educating the client about recommended health screenings
Assessment
Involves application of nursing knowledge to the collection, organization, validation and documentation of data about a client’s health status.
The nurse focuses on the client’s response to a specific health problem, including the client’s health beliefs and practices. The nurse thinks critically to perform a comprehensive assessment of subjective and objective information.
Nurses must have excellent communication and assessment skills to plan client care.
Analysis
Involves the nurse’s ability to analyze assessment data to identify health problems/risks and a client’s needs for health intervention.
The nurse identifies patterns or trends, compares the data with expected standards or reference ranges, and draws conclusions to direct nursing care.
Planning
Involves the nurse’s ability to make decisions and problem solve. The nurse uses a client’s assessment data to develop measurable client goals/outcomes and identify nursing interventions. The nurse uses evidenced-based practice to set client goals, establish priorities of care, and identify nursing interventions to assist the client to achieve their goals.
Implementation
Involves the nurse’s ability to apply nursing knowledge to implement interventions to assist a client to promote, maintain, or restore health.
The nurse uses problem-solving skills, clinical judgment, and critical thinking when using interpersonal and technical skills to provide client care.
During this step, the nurse will also delegate and supervise care and document the care and the client’s response.
Evaluation
Involves the nurse’s ability to evaluate a client’s response to nursing interventions and to reach a nursing judgment regarding the extent to which the client has met the goals and outcomes.
During this step the nurse will also assess client/staff understanding of instruction and the effectiveness of interventions, and identify the need for further intervention or the need to alter the plan.
define clinical judgement
observed outcome of critical thinking and decision making. It is an iterative process that uses nursing knowledge to observe and assess presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care.”
Nurses must consider both environmental and individual factors when caring for clients. What is an examples of each?
Environmental- setting and situation considerations, equipment, and surroundings. Some other examples include staffing, supplies, health records, time pressures, cultural considerations, task complexity, and risk assessments.
Individual- nurse factors such as knowledge and skills; nurse characteristics that include attitudes, prior experiences, and level of experience, as well as cognitive load, such as demands on the nurse, stress, problem solving, and memory.
Who developed the Clinical Judgement Action Model?
The National Council of State Boards of Nursing (NCSBN)
Clinical Judgment: Recognize Cues (Assessment)
Filter information from different sources (i.e. signs, symptoms, health history, environment)
Clinical Judgment: Analyze Cues (Analysis)
Link recognized cues to a client’s clinical presentation and establish probable client needs, concerns, or problems
Clinical Judgment: Priortize Hypotheses (Analysis)
Establish priorities of care based on the client’s health problems (e.g., environmental factors, risk assessment, urgency, signs/symptoms, diagnostic tests, lab values).
Clinical Judgement: Generate Solutions (Planning)
Identify expected outcomes and related nursing interventions to ensure clients’ needs are met
Clinical Judgement: Take Actions (Implementation)
Implement appropriate interventions based on nursing knowledge, priorities of care, and planned outcomes to promote, maintain, or restore a client’s health
Clinical Judgement: Evaluate Outcomes
Evaluate a client’s response to nursing interventions and reach a nursing judgment regarding the extent to which outcomes have been met
The nursing process for RNs
Assessment
Analysis
Planning
Implementation
Evaluation
Assessment
the nurse collects, organizes, and validates data by using critical-thinking skills. Assessment can come in many forms and should be assessed holistically for each client need.
What should be done during the assesment part?
During assessment, the nurse obtains the client’s health history (interview), performs a physical assessment, and reviews the client’s medical record (laboratory results, diagnostic testing). Assessment also involves obtaining and documenting objective and subjective data that pertain to the client.
Objective data
are measurable, based on facts and what the nurse can observe or notice by using the senses—seeing (inspection), hearing (auscultation), smelling, and touching (palpation)
Examples of objective data
facial expressions, intake and output, physical assessment findings, and vital signs.
Subjective data
derived from the client’s self-report or from a family member.
Examples of subjective data
the client’s self-report of pain and the client’s reason for seeking care
How to document subjective data?
using quotation marks to indicate the client’s verbatim remarks.
What else is included in assesment?
he nurse should interview the client, asking about past medical history, medications, natural and herbal remedies utilized, substance abuse, sexual history, and support systems. The nurse should also assess the client holistically by asking questions about sociocultural, economic, and even spiritual needs.
Difference between RNs and PNs in assessment?
RNs must perform initial assessments on both new clients and unstable clients. PNs can perform data collection on clients who are deemed stable by the RN. However, based on any data collected by a PN or AP, the RN must determine if further physical assessment data are needed to gain required information and make decisions regarding the client’s current health condition. This can require interviewing the client and asking questions; performing further assessments, either physical or psychosocial; or reviewing assessment data such laboratory values and diagnostic tests.
Analysis
The analysis of assessment data to identify health problems/risks and a client s needs for health intervention. The nurse identifies patterns or trends, compares the data with expected standards or reference ranges and draws conclusions to direct nursing care.
When would a nurse need to reassess and reanalysis a patient?
triaging client
Planning
The planning step of the nursing process involves the nurse s ability to make decisions and problem solve. The nurse uses a client s assessment data to develop measureable client goals/outcomes and identify nursing interventions. The nurse uses evidenced based practice to set client goals, establish priorities of care, and identify nursing interventions to assist the client to achieve their goals.
How should a nurse plan for a client who is in pain?
as administering prescribed pain medications, repositioning the client, providing a quiet and calming environment, and utilizing relaxation techniques.
Implementation
it involves taking action to provide nursing care as outlined in the client’s plan of care
the best action is no action at all while continuing to monitor the client. At other times, the RN will take specific actions such as administration of prescribed medications or therapies.
Evaluation
the RN evaluates the effectiveness of the interventions provided and documents the client’s response
Practical Nurses (PN) Nursing Process
Data collection
planning
implementation
evaluation
Data collection (PN)
This step is like the RN nursing process of assessment; however, the PN can collect data but cannot assess it.
To collect subjective and objective data, the nurse can ask questions; collect information regarding the client’s physical state by using inspection, auscultation, and palpation techniques; obtain vital signs; review laboratory or diagnostic data; and so on. The PN should report any changes in client findings to the RN so that the RN can analyze the data—for example, a blood pressure that was previously within the expected reference range and is now elevated. Deviations from the client’s baseline may be clinically significant, so communication between the PN and the RN is crucial for client safety. The PN should document all findings in the client’s medical record.
Planning (PN)
assisting and collaborating with the RN, not assuming full responsibility for planning.
Implementation (PN)
he PN should collaborate with the RN to implement interventions included in the plan of care. Each state allows PNs to complete different tasks; therefore, PNs must be aware of the scope of practice within their state regulations and abide by these standards. Depending on the state, interventions may include medication administration, dressing changes, or intravenous fluid hydration, for example. All implementation of interventions should be recorded in the client’s medical record.
Evaluation (PN)
the PN should evaluate the care provided with the assistance, and under the supervision, of the RN. For example, collecting data after nausea medication administration to determine effectiveness can be done by asking questions such as “Have you had any vomiting since you received your nausea medication? Is your nausea improved? Is your nausea gone completely?” The PN then records the data in the client’s medical record, and collaborates with the supervising RN as needed.
Adverse situation
Prevention of a potential adverse situation is always better than having to treat a client for an actual adverse situation!
Therefore, early detection through nursing assessment is crucial
What is an example of early noticing?
rising blood pressure that could quickly escalate out of control, or recognizing that frequent urination after surgery could be an indication that the client needs an indwelling catheter to prevent bladder
factors that influence RN decision making in acute care setting
Awareness of client status
Goals/outcomes
Options to meet goals
Routines
Education
Nursing roles
Teamwork
Resources
Support from other staff
Patient education
Nurses should remember what cannot be delegated?
clinical reasoning and clinical judgment cannot be delegated.
What are the most common skills delegated to APs?
vital signs, ADLs assistance, and measurement of heigh and weight
Time management matrix
A tool that divides activities into four quadrants: important, not important, urgent, not urgent.
SMART goals
Specific
Measurable
Attainable
Realistic
Timely
Acuity level
complexity of clients condition
a client who is stable is on the low score of acuity level for example
Direct care activities vs indirect care activites
direct care activities- require client contact, such as wound dressing change
indirect care activities- those that take a great deal of time but do not require direct interaction with the client, such as charting.
Three standard process for making client assignments
Direct nursing assignments: the nurse is assigned to care for a specific client, such as when maintaining a 1:1 nurse client ratio in a cardiac care unit (CCU).
Area assignments: tend to be utilized in areas where clients have a shorter length of stay (LOS), such as the emergency department, intraoperative units, or obstetric units. In these situations, nurses are assigned to certain zones and care for the clients who temporarily reside there. An example of this type of client assignment would be a preoperative holding area where clients and nurses are assigned to specific bays.
Group assignments: involve sorting clients into groups first, then assigning a nurse to each group. The group assignment method is useful on large units, or units with a larger client census, because it allows for grouping of clients based on location and acuity.
IDEAL Discharge Planning
I: Include the client and caregivers.
D: Discuss the five key areas—medications, home life, warning signs, test results, and follow-up.
E: Educate the client on the condition, the discharge process, and next steps.
A: Assess the effectiveness of the education.
L: Listen to the client’s goals and preferences.
Rights of delegations
right task, right circumstance, right person, right directions and communication, and right supervision and evaluation
Maslow’s hierarchy of needs
from bottom to top
physiological needs
safety needs
love needs
esteem needs
self-acutalization
ABCDE priority framework
airway
breathing
circulation
disability
exposure
O2 sat
for clients w/o history of COPD- 92 to 96
w history of COPD- 88 to 92
Breathing
During the breathing assessment step, the nurse may potentially detect the presence of a pneumothorax (lung collapse due to air entering the pleural space) or bronchospasms (a condition in which the muscles in the airways tighten, causing decreased airflow). If a client is having difficulty breathing, continuously monitor the oxygen saturation and check other vital signs. A Venturi mask may be required for the delivery of oxygen to maintain therapeutic oxygen levels. If the client is experiencing respiratory distress, the nurse should place the client in an upright position to promote lung expansion.
Circulation
Adequacy of circulation is determined by evaluating a client’s blood pressure; capillary refill time; pulse rate, including volume and character; urine output; and level of consciousness, as well as by looking for changes in the client’s skin tone. Manifestations of decreased circulation or perfusion may include skin tone and temperature changes; decreased level of consciousness; prolonged capillary refill time; hypotension; changes in pulse rate, regularity, and volume; and decreased urine output. Impaired circulation can be caused by a number of factors, including acute and chronic cardiovascular conditions as well as alterations in circulating blood volume. Treatment for altered circulation depends on the cause, but usually includes fluid replacement, controlling bleeding, and restoring tissue perfusion.
A nurse is caring for a client with asthma. Which action is a priority
auscultate lung sounds
Airway
Nurse should see if airway is clear and listen to lung sounds
least invasive/least restrictive priority framework
vInterventions are selected that maintain client safety while producing the least amount of restriction to the client; the nurse chooses interventions that are the least invasive.
survival potential
based on doing the most good for the maximum number of clients at a time when health care resources are limited due to a large number of injuries
This priority-setting method is utilized during mass-casualty incidents such as natural disasters (wildfires and earthquakes), major road accidents, and acts of terrorism.
triage
to idenify the most severly injured clients with the highest survival potential
triage four main categories
emergent (red)- transported away from the scene immediately ( a client who has a major hemorrhagic wound or a client experiencing chest pain would be tagged as emergent.)
urgent or delayed (yellow)- clients who have a serious injury that does not pose an immediate threat to life. (For example, a client who has an open fracture without major bleeding would be tagged as delayed. Clients in this category have an injury or condition that requires treatment within 30 minutes to 2 hours.)
nonurgent or minimal (green)- who have only minor injuries. aka the walking wounded
and expectant (black) (dead)- either deseased or not expected to survive
What are some examples of a short-term goal and a long-term goal for a post op patient?
short-term: decrease pain to a more manageable level by the end of shift
long-term: manageable pain level by discharge or after discharge
When does discharge begin?
At admission! EXAM QUESTION
What is something that is never to be delegated?
Clinical judgement and clinical thinking and clinical reasoning
EXAM QUESTION
Five rights of delegation
right person
right circumstance
right task
right communication and directions
right supervision and evaluation
EXAM QUESTION
Team nursing
pairs two or more nurses together as a team to care for a group of clients
long term care: has more aids than nurses (nursing home, pallative care)
acute term care: has more nurses than APs (hospitals)
What are some barriers in interprofessional collaboration?
miscommunication
distrust
lack of respect among provider types
different levels of perceived importance
misunderstanding of each other’s roles
What is the outcome of clinical thinking and the nursing process?
clinical judgement
Does the nursing process have to go in order?
Initially yes, but once the nurse has seen more of the clients arising issues, it can and probably will have to go out of order
When would you put someone in lithotomy position?
pap smear, vaginal examination, child birth
What is a nurse initiated/independent interventions?
nurses use evidence and scientific rationale to take automonous actions that benefit clients that is in the SCOPE OF THEIR PRACTICE
example: repoistening a client every 2 hrs to avoid skin breakdown, showing a client how to use progressive muscle relaxation, preforming a daily bath after the evening meal
EXAM QUESTION
What is a provider initiated/dependent intervention?
interventions that a nurse initiates as a RESULT OF A PROVIDER’S ORDERS AND PRESCRIPTIONS (written, standing, verbal) or THE FACULTIES PROTOCOL (blood administration procedures)
examples: writing a prescription for morphine PRN, inserting NG tube to relieve gastric distension
EXAM QUESTION
What is a collaborative intervention?
interventions that nurses carry out in collaboration with other health care team professionals
examples: make sure client receives and eats evening snack
What is the difference between basic and complex critical thinking?
basic: a nurse trusts the experts and thinks concretely based on the rules. Basic critical thinking results from limited nursing knowledge and experience, as well as inadquate critical thinking experience
example: a client reports pain 1 hr after receiving pain medication. Instead of reassesssing the client’s pain, the nurse tells the client they have to wait two more hrs before receiving another dose.
example: a nurse uses the faculty’s procedure manual to change an IV dressing
complex thinking: the nursing begins to express autonomy by analyzing and examining data to determine the best alternative. complex critical thinking results from an increase in nursing knowledge, experience, intuition, and more flexible attitudes
example: a nurse realizes that a client is not ambulating as often as prescribed because of a fear or missing their daughter’s phone call. The nurse assures the client that the staff will listen for and answer their phone when they are out of their room.
example: a nurse repositions a client’s arm to improve function of the infusion of an IV.
EXAM QUESTION!
A nurse is teaching newly licensed nurses about ergonomics. Which is true about ergonomics?
The use of ergonomics increases job satisfaction.
A nurse is discussing proper body mechanics with a group of assistive personnel. Which is true regarding good body mechanics?
A stable center of gravity increases stability and balance.
A wide base allows for good balance.
Good body mechanics means the tightening of the abdomen.
In what order should one DON PPE?
gown-face mask-face shield (if needed)-surgical bonnet(if needed)-shoe covering(if needed)-clean gloves
always gloves last.
EXAM QUESTION!
In what order should one DOFF PPE?
gloves-bonnet-face shield-gown-shoe covers
always gloves first
EXAM QUESTION!
When’s the most common use of restraints?
Intubated patients in the ICU
What is the spectrum of ways to do procedures?
from least intense to most intense
clean: just clean hands
aseptic: clean hands, gloves, environment, etc.
sterile: as clean as one can get; absence of life!
When would a women be considered sterile?
when she is infertile or after she gets a mastectomy
What is a CAUTI (catheter associated urinary tract infection)?
A never event.
it is something preventable that can be controlled using sterile techniques
hospital pays for coverage when this happens.
you can get this when:
something isn’t sterile OR something gets infected after insertion
Rights of Medication Administration
right person
right time
right dose
right medication
right route
right documentation
right to refuse
right assessment
right education
right evaluation
Pharmacokinetics
study of absorption, distribution, metabolism, and excretion
absorption of medicaiton
movement of medication in body from where it was administered to the circulatory systemh
what is the most common spot to administer medicaiton?
oral (by mouth)
distribution of medication
process of medication delivery to target organs/tissues, following absorption into the circulatory system
What is distribution of medication effected by?
circulatory status (bradycardia)
metabolism of medication
chemical process of converting a medication’s structure (breaking down to be excreted easily)
Where are most medications metabolised in?
liver
but also kidney and small intestines
Who is at a great risk for medication toxicity?
people with kidney disease or renal kidney failure
older adults because their excretion process slows down
excretion of medication
process by which medication is removed from body
Where are most medications excreted from?
kidney
What could be going on with this client?
A nurse administers medication. The client is tachycardia, rash, and dyspnea. What is going on?
adverse drug reaction or anaphyaxis
What is anaphyaxis?
a life-threatening reaction that causes…
tachycardia, hypotension, and dyspnea
(aka anaphylactic shock)
Medication Reconciliation
educate clients to keep account of current medications and keep it updated
admission, transfer, discharge, levels of care
High Alert Medications
always need a second nurse to admin with you and make sure dose is right and that the medication is right as well
insulin, potassium chloride
Routes of Medication
Enteral: mouth, NG tube, feeding tube, stomach, GI, intestines, tablets, capsules, liquids, etc
Topical: creams, patches
Parental: IV, IM
Parental Medication Routes
Intradermal: TB skin test, allergy test
under the skin, barely, 26-27 gauge, forms a bleb, 10-15 degree angle
Subcutaneous: insulin, heparin
fatty tissues (adipose), 25-18 gauge, no more than 1.5 mL, 45-degree angle
Intramuscular: vaccines
muscle (multiple locations)
27-18 gauge, no more than 3mL (no more than 2mL in deltoid), 90 degree angle
Intramuscular Injection Locations
Deltoid: small muscle=small amounts!
most common for vaccines
upper arm
no more than 1mL is preferred
Ventrogluteal: bigger muscle=can hold more medicine!
antibiotics, antiemetics, steriods, pain meds
below hip
vastus lateralis: most common for small kinds
thigh
What position would you place someone who is having a seizure?
Lateral position
to prevent aspiration
What position would you place a client in for recieving a Foley catheter?
dorsal recumbant
What is something that cannot be delegated to unlicensed personnel?
Clinical judgement and clinical reasoning
Clinical judgement is..?
Clinical reasoning over an expanse of time
