Week two Flashcards
what is Tanners Clinical Judgement model?
an interpretation or conclusion about a patients needs, concern, or health problems and the decision to act or not on the patient
how does a nurse apply the clinical judgment model?
- recognize the uniqueness of each patient using a holistic view
- understand the clinical situation (reasoning and interpretation)
- understand the nurses contribution to the patient care situation
describe the clinical judgement concept map
noticing - interpreting - responding -reflecting
what are things to look for in patients
- body language (close vs open)
- tone of voice
- what they’re wearing
what is needed to make a clinical judgement
- knowledge (science)
- experience
- ethical perspective (right and wrong)
- knowing the patient (being open to make them more comfortable)
what is clinical judgement used for?
- recognize the uniqueness of each patient
- understand the clinical situation
- understand the nurse’s contribution to the patient care situation
what is therapeutic interviewing?
the interaction focuses on the patient and their concerns, it is for a specific purpose and its focused
what is the purpose of interviewing?
- to obtain a health history
- to identify health needs and risk factors
- to determine specific changes in level of wellness and pattern of living
- to help clients relate their own interpretation and understanding of their condition
- the nurse and their client are partners
what is the communication process?
- a complex, ongoing, interactive process that builds the basis for a relationship
- always subject to interpretation
- perceptions about the relationship
- private and confidential
- caring and empathy (not sympathy)
- therapeutic communication
what are nonverbal communication skills?
- equally as important as verbal communication
- physical appearance of a nurse
- eye level
- touch is an essential and dominant component of the physical exam
what are verbal communication skills?
- setting up the room to provide for comfort
- introducing yourself and asking patient’s preferred name
- listening, avoiding giving advice
- giving the client time and opportunity to talk and ask questions
- effective interviewing skills
- effective noticing skills
types of therapeutic communication skills
- active listening
- restatement
- reflection
- encouraging
- silence
- focusing
- clarification
- summarizing
types of non-therapeutic communication skills
- false reasurrance
- sympathy
- unwanted advice
- biased questions
- changing subject
- distractions
- technical language
- interrupting
describe the preinteraction phase of the interview process
the nurse collects data before meeting the patient
- health records, medication list, concerns
- used to conduct an interview in which the nurse already has some background information
describe the beginning phase of the interview process
introduce yourself and ask the patient what they want to be called, states the purpose of the interview
describe the working phase of the interview process
- nurse collects data by asking specific questions
- close ended or direct questions (yes and no answers)
- open ended questions (more than yes and no questions)
describe the closing phase of the interview process
summarize key points of the interview
what is a nursing health assessment and what does it contain?
a collection of subjective and objective data in order to determine a health status
-includes physiological, psychological sociocultural and spiritual data
what is subjective and objective data?
subjective: stated by the client and family (feelings, sensations, symptoms)
objective data: observed by the nurse (vitals signs, skin, heart) signs
what are primary and secondary sources?
primary source: patient
secondary source: charts and family members (examples)
what is the nurses role in the reliability of the information?
- records the person who provides the information
- notes any discrepancies
- identifies other source (previous records) to confirm the history
what are the components of the health history?
-reasons for seeking care
-past health history
-family history
-current medications
-allergies
-lifestyle
-social considerations
-cultural and spiritual assessments
-human violence
-sexual history and orientation
history or present illness
-genogram
-functional health assessment
-growth and development
-review of systems
what is the criteria for pain?
- location
- duration
- intensity
- quality/description
- aggravating/alleviating factors
- pain goal
- functional goals
*OLDCARTS = onset, location, duration, character, aggravating factors, relieving factors, timing, severity
what is the demo graphical area needed for documentation
- Date of interview
- Patient name
- Date of birth
- Age
- Gender
- Health care number
- Primary language
- Martial status ( S M W D Other)
- Address
- Phone numbers
- Emergency contact
- Phone number
- Info obtained from: patient/other
- Patient accompanied: yes/no if yes then who?
- Religious preference
- allergies
what is required for documentation?
- accurate, relevant, timely, and comprehensive information
- both subjective and objective data
- signature and designation
- only relevant information from a third party (if given)
what are the three principles of documentation?
- communication
- accountability
- security
what is accountability?
- who did what and when?
- responsible for doing documentation in a timely manner
- includes date and time care was given
what is confidentiality?
- only access client information for the clients within our care
- safe storage of personal health information
when can a nurse share information?
- within the circle of care
- outside the circle of care with consent
- when legally obligated to report
what is colonization of an infectious disease?
when a microorganism invades the host but does not cause infection
what causes a disease?
the entry and multiplication of an organism
what is a communicable disease?
when the infectious process transmitted from one person to another
what is the chain of infection?
- infectious agent
- reservoir
- , portal of exit
- mode of transmission
- portal of entry
- host
what is an infectious agent?
a pathogen that must be killed by an antimicrobial ingredient
- has the ability to produce disease
- must have a sufficient number of organisms
what is a reservoir? give examples and how to control it
a place for the pathogen to grow (food, oxygen, water, warmth, pH, minimal light)
- in order to control reservoirs you need to eliminate sources of bodily fluids, drainage or solutions
what of exit? give examples and how to control it
the path by which the pathogen leaves the reservoir
- body openings: mouth nose, rectal, vaginal
- breaks in skin: scrape, cut, wounds
- breaks in mucous membranes: skin in mouth, eyes, nose, vagina, rectum
- wear PPE
what is a mode of transmission? give examples and how it can be controlled
the way pathogens travel
- contact: direct, indirect, droplet
- air
- vehicles
- vectors
- perform regular hand hygiene, clean all equipment
what is a portal of entry? give examples and how it can be controlled
the path in which a pathogen leaves the body (can be any portal of exit)
- protect the patients skin by lotion and preventing cracks
what is a susceptible host? how can it be controlled?
the person in which the pathogen is growing
- perform regular bathing’s, use lotions, regular oral hygiene, fluid intake promotes normal urine
- resistance is increased by immunizations
what are examples of defense against infection
- a bodies normal flora (microorganisms that protect against infection found in deep layers of the skin, saliva and mucus
- inflammation
- vascular and cellular responses
- tissue repair
describe the infectious process
- incubation period (between the entrance of the pathogen and the appearance of the first symptoms)
- prodromal stage (onset of nonspecific signs and symptoms)
- ilness stage (patient has signs and symptoms specific to the type on infection
- convalescence acute symptoms of infection disappear)
what are risks for health care workers with associated infection?
- hospital-aquired infections
- community-acquired infections
- exogenous/endogenous infections
what does an assessment for risk include?
- review of past diseases, travel history
- immunizations and vaccinations
- status of defense mechanisms
- client susceptibility
- clinical appearance
- laboratory results
what are traits of a susceptible host?
- vary among individuals
- age
- physical and mental health
- duration of exposure
- immunization status
what does the transmission of an infection require?
- portal of exit
- mode of transmission
- route to enter the host
what are four different types of an infectious agent?
viral
bacterial
fungal
parasitic
what are the 5 main modes of transmission?
- contact
- droplet
- vehicle
- airborne
- vector-borne
describe contact transmission
direct: between the infectious agent and the susceptible host (handshake)
indirect: between a susceptible host and a contaminated intermediate object (needle)
describe droplet transmission
contact with mucous membrane of the susceptible host
- released through talking, sneezing, coughing, suctioning
describe vehicle transmission
an object or substance carrying an infectious agent to a susceptible host via contaminated objects or consumed substances
-food, water, medications
describe airborne transmission
the suspension of small particle residue of evaporated droplets in the air for long periods of time
- dust particles can contain an infectious agent
- particles can be dispersed by air currents
describe vector-borne transmission
vectors (insects) harboring an infectious agent and transferring it to humans through bites
what are the four standard statements?
- application of evidence-based measures
- application of professional judgement
- risk reduction
- communication infection prevention and control
what is preventative practice?
- hand washing
- protective barriers
- care of equipment
- health procedures
when should we wash our hands?
- before and after administering medications
- before preparing, handling, serving, or eating food/drinks
- between task procedures
- before and after removing protective wear
- after contact with body substances, specimens, soiled items
- after personal body functions
- whenever you are in doubt
when should we wear PPE? what does the type of barrier depend on?
- when you come in contact with blood, secretions, or bodily fluids that can penetrate clothing
- the type of situation
- the presence of blood or bodily fluid and the potential for direct contact
- the integrity of the care givers skin
how do we care for equipment
- proper disposal of waste, contaminated laundry and sharps
- cleaning, sterilizing and disinfecting equipment, instruments and devices
how to prevent infection
- breaking the chain
- control infectious agents/reservoirs
- hand hygiene
- isolation precautions
describe hand hygiene
- wash for 15 seconds
- use alcohol based antiseptics
- wear gloves:
- discard gloves after each procedure
how to clean hands
- alcohol based hand rub when hands are not soiled
2. hand washing with soap and water when hands are soiled
what are the four moments of hand hygiene
- before entering the room, touching the patient or any furniture
- after exposure risk to body fluids (and after glove removal)
- immediately before any aseptic procedure
- leaving the room after touching the patient or the furniture
what are the two different environments?
- health care environment - beyond the patients area
- patient environment
- patients area
what is point of care?
involves the: patient, health care provider, and the care involving contact is taking place
what are the categories for sterilization
- critical items
- devices that enter sterile tissue (surgical instruments, catheters, needles - semi critical items
- come in contact with mucous membranes or non-intact skin but do not penetrate (thermometers, endotracheal tubes, endoscopes) - non-critical items
- touch only intact skin not mucous membranes or not the patient (bedpans, BP cuffs, linens, stethoscopes)
