WK 5 Nursing Process, Clinical Judgement Model, and SBAR Flashcards
nursing process -1950s
guide and promote safe, competent, quality pt care
NCBSN
clinical judgment - 2019
NCBSN
the nurse is conducting an interview of a pt admission. which datum should the nurse document as subjective data?
nausea, light-headedness, discomfort in the stomach
which statement describes a characteristic of clinical judgment in nursing practice?
it is the foundation of safe, competent practice
nursing interventions: what are those?
usually considered standard intervention that can be implemented quickly and appropriately
based on pt needs and preferences - usually included in clinical practice guidelines, protocols, and care bundle
independent vs. dependent
independent: assessment, monitor and teaching = VS, IO, height, weight
dependent: requires HCP = labs, meds, treatments needed
collaboration is unique
more about nursing intervention
need a timeframe and always speak to rationale
time frame for nursing interventions examples
assess VS q4 hours
teach about IS use and encourage use of q1 hour x15
the nursing process
assessment
diagnosis
planning
implement
evaluate
assessment
gather info ab the pt condition
diagnosis
identify the pt problems
planning
set goals of care and desired outcomes
implement
perform the nursing actions identified in planning
assess, monitor, implement, collaborate, teach, psychosocial
evaluate
determine if goals and expected outcomes are achieved
clinical judgement model
recognize cues
analyze cues
prioritize hypotheses
generate solutions
take actions
evaluate outcomes
recognize cues
identify and recognize relevant clinical data
analyze cues
be able to interpret cues, organize, and recognize patterns in order to link the pt clinical presentation to a problem
prioritize hypotheses
narrow problems down to the most pressing problem
generate solutions
determine desired outcomes and the best solutions
determine what resources you may need
take action
implement nursing interventions based on your plan
evaluate outcomes
compare observed outcomes to the desired/expected outcomes
assessment is
recognize cues
diagnosis is
analyze cues
planning is
prioritize hypotheses and generate solutions
implementation is
take actions
evaluation is
evaluate outcomes
after 0800 assessment, the nurse determined the pt is at risk for fluid imbalance. what part of the nursing process did the nurse determine this in?
diagnosis
what step in the clinical judgement model was she in?
analyzing cues
T/F: clustering of cues is the evidence of the nursing problem
truw
how do you prioritize problems?
use the ABCs and what is pressing RIGHT NOW
planning etc.
develop a goal with outcome criteria
implementation etc.
what interventions can you do
do you need the HCP for additional support
can you collaborate with the interdisciplinary team
evaluation etc.
determine if the goal is met, or not
what happens when something unexpected happens? how do you communicate this?
SBAR
SBAR
situational
background
assessment
recommendation
SBAR continued
a structured communication technique used clinically and is designed to convey a great deal of info in a succinct and brief manner
SBAR is a technique/process of delivering info no matter what:
emergent issue, FYI issue
if we are talking about SBAR and the need to call the HCP remember…
each SBAR may contain diff amounts of info from diff numbers of categories
do not include things that do not directly influence why the problem is a high priority
two types of SBAR
problem based
pt focused
problem based SBAR
when you identify a problem/concern that is worth dialoguing with the HCP about:
1, pick up the phone and call vs.
2. wait for the (scheduled/predictable) interdisciplinary rounds to occur
we use this type in class
pt focused SBAR
when you are giving report to night shift or to the unit where the pt is being transferred
need to call HCP and SBAR step 1
identify the problem and WHY you feel it warrants a call to the HCP
this helps you focus on the info that needs to be collected and reported
step 2 of SBAR
identify focused assessment that will add info to the conversation
what is there and maybe what isn’t there
step 3 and SBAR
know their medical history and how it may play a role in the problem
step 4 and SBAR
look for trend data in chart
step 5 and SBAR
be sure to include critical cues to help tell the story. these come in the form:
admission reason
allergies
meds
labs and diagnostics
physical assessment
situation
briefly describe the situation, give a succinct overview
background
briefly state pertinent history. what got us to this point?
assessment
summarize the facts. what do you think is going on?
recommendation
what are you asking for? what needs to happen next?
situation etc.
only things that goes in this is the symptoms that are the reason you felt the need to pick up the phone
be specific, but brief, use the fewest words possible
background
this info includes the critical cues you gather to persuade the HCP your identified problem is something worth dialoguing about
this is context for your issue and will lead your critical thinking to the assessment conclusions that you draw
background section should take no longer than 30-60 sec
must know critical cues that are of highest priority
assessment etc.
what you think is going on
requires you to think critically
okay to offer a medical diagnosis or be uncertain what it is, but know it is not normal
recommendation
what you want done, include timeframe in discussion
keep in mind: this is one solution from you vantage point
be sure that at the end of the conversation things are as specific as possible and you know exactly what the expectation for you and the HCP
SBAR notes
entire things should be no more than 2 minutes
it is important to have a good reaction time in times of pt need
