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
