Week 6 - clinical judgement Flashcards
Nursing Process Definition - and steps? (and how to put down others)
“A critical thinking process that professional nurses use to apply the best available
evidence to caregiving and promoting human functions and responses to health and
illness.” (ANA 2010)
A series of steps or processes leading to the achievement of a goal
assessment - step 1 (assess the data and cluster)
-COLLECT DATA: - look for cues and make inferences - then validate those inferences (don’t apply w/out evidence) just describe in measurable terms what you see. Also cluster - wound care, diabetes, - cluster so that it supports the idea you are addressing.
during diagnosis, what steps are you taking? (ACNP) All care needs patients for diagnosis)
-Analyze data
-Draw conclusion
-Nursing Dx-NANDA-I
-Prioritize problem
planning
-Create care plan
-Identify goals and outcomes
implementation (and it’s always what - this soapie)
-The action step
-Carrying out the care plan
THIS IS ALWAYS past tense - it’s what you carried out
nursing practice act - (practice act mandates that each patient must have what?)
-Evaluate goals and outcomes. Must have written care plans that are individualized based on patient problem, medical diagnoses, unique needs, Written Care plans outline the nursing
process
standards of competent care - when is a nurse considered competent? (competent when I’m a scientist)
A registered nurse shall be considered to be competent when he/she consistently
demonstrates the ability to transfer scientific knowledge from social, biological and
physical sciences in applying the nursing process, as follows:
Competent performance - applies the nursing process by Formulating a nursing diagnosis through….
observation of the client’s physical condition and behavior, and through interpretation of information obtained from the client and others, including the health team
Competent performance - applies the nursing process by Formulating a care plan (care plan involves patient safety, hygiene, etc. that’s it)
in collaboration with the client, which ensures that direct and indirect nursing care services provide for the client’s safety, comfort, hygiene, and protection, and for disease prevention and restorative measures.
Competent performance - applies the nursing process by Performs skills essential to the…(competence is just explaining the treatment and teach family how to care for patient)
kind of nursing action to be taken, explains the health
treatment to the client and family and teaches the client and family how to care for the
client’s health needs.
delegate assessment - what cannot be delegated? (assess and eval)
The ANA’s Code of Ethics for Nurses, Provision 4 (2015), Interpretative statement four
addresses the “assignment and delegation of nursing activities or tasks.” The revised
Code specifically indicates nurses may not delegate nursing process duties of
assessment and evaluation, and “employer policies do not relieve the nurse of
responsibility for making assignment or delegation decisions
During your observations, or assessment, what to be alert for (HELP) (help the environment by looking at people)
H = Help: Observe the first signs patient may need help. Signs of distress? e.g. pain,
labored breathing
E = Environmental equipment: Safety hazards? Is equipment working?
L = Look: Examine patient - quick survey of patient - USE This for critical thinking worksheet
P = People: Who is in the room and what are they doing?
Subjective Data*
Subjective Data
Information expressed by person affected; Cannot be perceived or verified by another person.
Includes sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life/home situations - History
“I am having trouble breathing.”
”My pain level is 8/10.”
“I am really nauseous.”
Objective Data*
Observable and measurable data
Can be seen, heard, felt or measured (or smelled)
Resp Rate 24 breaths per min,
SpO2 93% on room air (vital signs)
Lungs with expiratory wheezes throughout (physical assessment details)
assessment - make sure you
have gathered all necessary information
Interpret/analyze/validate data
Organize and cluster set of related signs and
symptoms and data to identify health problems.- don’t draw conclusion based on one finding (tearful after surgery - could be anything, pain, emotional)
Identifying Cues and Making Inferences
Interpretation of problem based on cues observed
Avoid judgment and stereotyping here
Cluster set of related signs & sx to identify health problems (data clustering helps to
organize problems)
Validating Data (validate that I’m free from error)
Purpose is to keep data as free from error, bias and misinterpretation as possible. Must confirm or validate to be sure inferences are correct.
document assessment
Document as soon as possible in real time
When recording patient’s words, use “quotation” mark
Document change in patient condition, physician notifications and patient events in notes using SOAPIE or SBAR
nursing diagnosis - this is the analysis part - what is wrong w/ the patient
*Within the scope of nursing practice
Standardized: Approved NANDA (you must use NANDA diagnoses)
* Describes patient responses to health and illness (physical, emotional social, etc.)
* Not a medical dx or medical pathology
* Focus is broad
* Fluid - can change from day to day (cannot predict a patient’s nursing dx based on a medical dx)
medical diagnosis
- Within the scope of medical practice
- Describes a disease, illness, or injury
- Focus is narrow and on treating or
preventing complications of the pathology - Presentation and treatment of problem predictable
Potential complications:
“A certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses
manage collaborative problems using physician-prescribed and
nurse interventions to minimize the complications of the event”
(Carpenito, 2017, p.21)
* Role of nurse is to prevent, monitor for undesirable outcome and report
* Treatment from nursing, medicine and other disciplines
* The problem is r/t a medical disease, treatment, or diagnostic
study
Examples:
➢ PC: Paralytic ileus related to anesthesia
➢ PC: Urinary retention related enlarged prostate
person centered practice
focus on what can go wrong
don’t test on diagnosis
it’s the terminology
ADPIE
These steps provide an
efficient method for
organizing thought
processes for clinical
decision making,
problem solving and
the delivery of high
quality, individualized
patient care
sources of data
usually from assessment
collaborative problems
potential complications: “A certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using physician-prescribed and nurse interventions to minimize the complications of the event”
(Carpenito, 2017, p.21)
* Role of nurse is to prevent, monitor for undesirable outcome and
report
* Treatment from nursing, medicine and other disciplines
* The problem is r/t a medical disease, treatment, or diagnostic
study
Examples:
➢ PC: Paralytic ileus related to anesthesia
➢ PC: Urinary retention related enlarged prostate
North American Nursing
Diagnosis Association –
International
Purpose: For nurses to standardize a set of
language in order to communicate the needs and care for patients with actual and potential problems
NANDA
Assembly approved an official definition of nursing diagnosis:“Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.” (NANDA, 1990).“The registered nurse analyzes assessment data to determine actual or potential diagnoses, problems, or issues” ANA Standards of Practice 2015 (p. 55)
Nursing Diagnosis (diagnose the problem and don’t forget to cluster)
A problem statement of how person is responding to an actual or potential problem
Can be actual or potential problem that requires nursing intervention
Requires interpretation and analysis of clustered data according to body systems, risk factors, family/social factors, emotional factors, etc.
nursing diagnosis - actual diagnosis
factors, etc.
Actual diagnosis: Present at time of
assessment. The patient will have actual signs and symptoms.
nursing diagnosis - risk diagnosis
Potential diagnosis
that is likely to develop in a vulnerable patient if the nurse and patient don’t intervene to prevent it.
***There are NO S/S present.
Priorities
Establishment of priorities - when do you establish priorities? After what? And how to decide what is important?
After formulating nsg dx, the nurse establishes the priorities of the dx by ranking them in order of importance (MASLOW). Establishing priorities is not
merely a matter of numbering the nsg dx on the basis of severity or physiological importance, rather it is a method by which the nurse and the client mutually rank the dx’s in order of importance based on the client’s desires, needs and safety
Establish Priorities - usually includes (include the ABCs)
ABC’s
Maslow’s Hierarchy of Needs
Actual vs. Potential
Components of a
Nursing Diagnosis - what is acronym - the short one
PES Format (or PED)
3 Part Statement
PES and PED (or 3 part problem)
P=Problem=Nursing Dx: Decreased Cardiac Output
E=Etiology (cause) of problem or related factors-etiology of problem
within the domain of nursing-NOT MEDICINE-so don’t list medical dx’s as related factors: Altered pre-load and after-load and impaired contractility.
S=S/S or defining characteristics (Subjective and objective data, clinical manifestations): Edema, weight gain, crackles, SOB, RR 24
3 part statement***(PES or PED)
Don’t write a medical diagnosis - Correct way: Decreased cardiac output related to altered preload, increased afterload, and impaired contractility as evidenced by edema, weight gain, crackles, SOB, RR 24 (by the
S/S the patient is exhibiting that led you to this diagnosis)
Wrong way to state based on medical dx: P=Decreased cardiac
output R/T heart failure as evidenced by weight gain, edema, crackles, SOB, RR 24
case study - you don’t need to know this - it’s just an example
Ineffective airway clearance by mucus (this is NANDA on the list)
planning (plan your goals and then what will you do?)
1 - what are the measurable goals -
This is when the nurse organizes a nursing care plan based on the nursing diagnoses. What am I going to do for this patient?
It’s helpful to have the patient and family assist with identifying goals
TYPES OF GOALS - in general
- Short term
- Long term >7 days
COMPONENTS OF A OUTCOME STATEMENT - (the outcome is SAPT) - the outcome is what you want to see happen. Pain reduction for example, how to state that…this is it Person will report pain decreased to 1 out of 10 one hour after administration of pain medication
SUBJECT –Assumed to be the person or a function or part of the person
* Person will…or Patient will…
ACTION VERB – What activity will the person perform?
* Person will report…
PERFORMANCE CRITERIA – the extent in which you expect the person to behave that is observable or measurable
* Person will report pain decreased from 4 out of 10 to 1 of 10
TARGET TIME – realistic date, time or statement indicating time person will achieve goal
* Person will report pain decreased to 1 out of 10 one hour after administration of pain medication
Vague outcome statement: Person will report better pain relief after
administration of pain medication
Planning
Interventions are selected and written
The nurse uses clinical judgment and professional knowledge to select appropriate interventions that will aid the patient in reaching their goal. Interventions should be patient centered and based on scientific rationale.
Interventions should be examined for feasibility and acceptability to the patient
Interventions should be written clearly and specifically
nursing process - method for what? (the process is to reach the goal. that’s it)
organizing and delivering nursing care
The essential core of practice for the registered nurse to deliver holistic patient-focused care
A series of steps or processes leading to the achievement of a goal
what is the essential core practice for nurses to deliver holistic patient-focused care?
the nursing process
assessment involves what type of data?
subjective and objective
5 steps in the nursing process
ANPIE
do NOT draw a conclusion about a patient based on…
one assessment. Tearful after surgery. You need more data to support a conclusion.
examples of when you need to validate info. (validate my pain, it might not be correct)
Examples of times when validation is necessary:
Subjective/objective data do not agree or make sense e.g. Pt. reports no pain, but facial grimacing noted.
Client’s statements differ at different times in the interview
Data are far outside normal range - Recheck again to confirm to validate e.g. defective
equipment, incorrectly placed O2 sat probe.
Factors are present that interfere with accurate measurement e.g. high BP after strenuous activity.
use clinical reasoning during which part of ADPIE?
analysis part
nursing diagnosis - Health promotion (wellness) diagnosis:
Readiness to enhance specific health behaviors
The nursing diagnosis has to be approved by who?
NANDA
at risk diagnoses are always..
lower priority than actual diagnoses.
goals are centered around? (under planning)
they are person-centered.
what characteristics should goals have? (under planning) ***(have a goal, MSTR or SMART)
Measurable, specific observable, time-limited, and realistic
the goal is___and the outcome ____
Broad; measures the goal.
Expected outcomes are identified interventions (nursing orders) are selected to aid the client reach these goals.
Goal = broad statement
Expected outcome = objective criterion for measurement of goal
The aim of longterm goals - types of longterm goals (CPAP is the longterm goal)
Cognitive function
Psychomotor
Affect
Physiological
Cognitive function as a goal and is it long or short term?
Increase person’s knowledge
longterm
Psychomotor as a goal and is it long or short term?
Increase person’s skill
longterm
affect as a goal - and long or short term?
Change person’s attitude for self-care, compliance
longterm
Physiological as a goal - and is it long or short term goal?
improve a health problem
longterm
standards of implementation
box 17-1 in reading - copy it here - using evidence based interventions. may be interprofessional.
implementation - the action step
The “Action” step of carrying out planned interventions
The “DOING and DELEGATING steps
types of interventions - Nurse initiated
THESE are Independent Actions, that a nurse initiates that don’t require a MD order – e.g. providing pt. education, ambulating, turning patient every 2 hours. assisting with ADL does not require order, within scope of practice
step 5 - evaluation (check goal, see if client met goal, compare outcome w/ goal, see how close you are to the goal)
objective evaluation - 1. Examine the goal statement to identify the exact desired client behavior or response
2. Assess the client for the presence of that behavior or response
3. Compare the established outcome criteria with the behavior or response
4. Judge the degree of agreement between outcome criteria and the behavior or response
collaborate
Collaborate with the patient and family.
Use evaluative measures. - ex. can patient walk 100 ft?
Interpret and summarize findings.
Document results.
Revise plan of care.
documentation
Legal and professional responsibility, Requires accurate and approved terminology and abbreviations
Data Documentation
Record all observations succinctly. Factual and as descriptive as possible on what you:
Hear
See
Feel
Smell
in SOAPIE, do not use
the word appears, or any vague statements.
document SOAPIE in
third person. Don’t use I statements.
Nursing care plans
A product of the planning component. Involve nursing dx, goals, specific nursing activities and strategies, and expected outcomes. It is a written guideline for client care.
what can be delegated?
some interventions, vital signs, ambulating, meds, to an LVN if there are parameters - like notify nurse of abnormal findings.
what is the point of nanda?
just to standardize nursing language
during implementation, you’re still doing what?
assessing. You’re assessing the steps, the outcome, etc.
interventions - physician initiated
Physician initiated
Dependent—Require an order from a physician or other health care professional – pain medication given by RN, inserting indwelling catheter, medications – requires an MD order
interventions - Collaborative
Interdependent—Require the combined knowledge, skill, and expertise of multiple health care professionals – Both RN and MD and other interdisciplinary collaborate- teamwork
ex - physical therapy
incentive spirometer - independent or dependent action?
independent as long as no contraindications
what senses do you document?
what you hear, see, feel, and smell
What is the analysis part in ADPIE?
the nursing diagnosis
how can you cluster info?
clustered data according to body systems, risk factors, family/social factors, emotional factors, etc.
what should interventions include?
teaching and learning
when do you cluster data?
during the assessment and diagnosis
