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
