Intro To Nursing Final

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Ambiguity

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a condition where information can be interpreted or understood in more than one way. Context may play a role in solving ambiguity; suspending judgement

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Dissonance

Back 2

mental conflict; seek out info that is in opposition to one's own view provides practice in understanding and learning to be open to other viewpoints

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Nursing Process

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The purpose of the NP is to identify a client's health status and actual or potential health care problems or needs, to establish plans and to deliver specific nursing interventions to meet those needs.

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Steps of Nursing Process

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The NP is cyclical; its components follow a logical sequence, but more than one component may be involved at one time.

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Assess

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Collect, Organize, Validate and Document data; more data must be obtained about a client's cultural health

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Diagnose

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Analyze data, Identify health problems, risks and strengths; Formulate diagnostic statements; defer diagnoses until the client's priorities are known; these may differ from the nurses'

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Planning

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Prioritize problems/diagnoses; Formulate goals/outcomes; Select nursing interventions, Write nursing interventions; Use concepts from motivation, change theory, and MC nursing to understand the client's bhavior and motivation to change

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Implementing

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Reassess the client; Determine the nurse's need for assistance; Implement interventions; supervise delegated care; Document nursing activites; Plans of care based on ongoing assess ment of the clients cultural values, beliefs and needs

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Evaluating

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Collect data related to outcomes; compare data with outcomes; Relate nursing action to client goals/outcomes; draw conclusions about problem status; continue modify or terminate the client care plan; Evaluation of outcomes based on measurable criteria, and if outcomes have been validated. Measure client progress toward goals, and effectiveness of care plan

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Objective Data

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Signs or overt data can be measured or tested against an accepted standard. They can be obtained by observation or physical examination. They can be seen, heard, felt, or smelled using your senses.

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Vital signs, blood pressure, heart sounds, body odor, etc

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Subjective Data

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Symptoms or covert data are apparent only to the person affected and can be described only by that person.

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subjective data

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Itching, pain and feelings of worry, nausea.

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Subjective data includes

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the clients sensations, feelings, values, beliefs, attitudes and perceptions of personal health status. I feel…..is subjective data

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Steps of Decision Making Process

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DM is a CT process for choosing the best actions to meet a desired goal

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step 1-purpose

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Identify the purpose of the decision to be made

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step 2-set the criteria

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What is the desired outcome; what needs to be preserved; what needs to be avoided; outcome - relieve pain; preserve-physical/cognitive functioning; avoid system depression

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step 3-weigh the criteria

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set priorities from least to most important as they relate to this current situation

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step 4-seek alternatives

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Identify possbile ways to meet the criteria - select from a range of nursing interventions or client care strategies

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step 5-examine alternatives

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analyze options to ensure there is an objective rationale in relation to the established criteria for choosing a particular strategy

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step 6-project

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apply CT to determine what might go wrong as a result of decision; and develop plans to prevent, minimize or overcome any problems.

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step 7-Implement

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Decision plan is placed into action

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step 8-evaluate outcome

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Determine effectiveness of plan and whether initial purpose was achieved; The nurse uses DM in all phases of the NP

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Methods of Problem Solving

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Obtain info to clarify nature of the problem and suggest possible solutions. Evaluate options and choose best one

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Methods of Problem Solving

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Monitor situation to ensure effectiveness

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Trial/Error

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Try a number of approaches until solution is found. Don't know why the solution worked. Client may suffer harm; used in home setting where hospital procedures cannot work as efffectively

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Intuition

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understanding or learning of things w/out the conscious use of reasoning. Ability to recognize cues and patterns. Best used for nurses w/experience; hunch, instinct, feeling or suspicion

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Research Process/SM

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logical, systematic approach; best for controlled situations

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Attributes of CT

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Self assessment - to determine which attitudes need to be cultivated to foster CT. Reflection-to examine the ways the nurse gathers and analyzes data, makes decisions and determines the effectiveness; Pause to consider beliefs, knowledge, values and abilities

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Attributes of CT

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Tolerating dissonance and ambiguity-be open to other viewpts. Suspending judgement means tolerating ambiguity

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Attributes of CT

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Seeking situations where good thinking is practiced. Cultivate a questioning attitude and evaluate ur own thinking

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Attributes of CT

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Create environments that support CT-create a stimulating environment that encourages diff of opinion and fair examination of ideas and options. Embrace the differences in others and see what they can offer

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Attitudes of CT-Independence

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Think for themselves, examine beliefs in light of new evidence, make their own judgements, open minded, not easily swayed by the opinions of others

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Attitudes of CT-Fair Mindedness

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Consider opposing points of view; new evidence could change their minds

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Attitudes of CT- Insight into Egocentricity

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Personal biases or social pressures and customs could unduly affect their thinking. Identify a problem more relevant to the client's problems.

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Attitudes of CT- Intellectual Humility

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Having an awareness of the limits of one's own knowledge; admit what u do not know.

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Attitudes of CT- Challenge the status quo/rituals

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Beliefs are sometimes false and misleading, and not always acquired rationally. Rational beliefs are those that have been examined and supported by evidence/data

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Attitudes of CT-Integrity

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standards of proof; challenge beliefs and knowledge

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Attitudes of CT- Perseverance

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Continue to address problems/issues until they are resolved. Clarifyconcepts

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Attitudes of CT- Confidence

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well reasoned thinking will lead to trustworthy conclusions

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Attitudes of CT- Curiosity

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examine traditions to be sure they are still valid

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Attitudes of CT- Creativity

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Development and implement new and better solutions; sometimes traditional interventions are not effective; helping a child take their meds; or doing breathing exercises by blowing a balloon

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Plan of care

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The end product of the planning phase is a formal or informal plan of care. Provides direction for what needs to be documented in client progress notes, and as a guide for delegating and assigning staff to care for clients; Clients are more motivated to work harder to achieve goals that are personally impt to them.

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activities of care plan

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set priorities, est. client goals/outcomes, select nursing interventions, write intervention on care plans; sometimes a client priority may conflict with a nurses knowledge of potential problems or conflicts

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Outcome

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What the nurse hopes to achieve by implementing nursing interventions. Specific, observable outcomes used to evaluate client progress; actively listen to client to determine their values, goals and desired outcomes in relation to current health concerns.

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purpose of outcomes

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provide direction for planning nursing interventions

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serve as criteria for evaluating client progress; determine when problem is resolved and provide client w/sense of achievement

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components of outcome

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subject, verb, conditions/modifiers; criterion of desired performance

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JCHAO requirements

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Each client must have an initial assessment consisting of history and physical performed and documented w/in 24 hrs of admission as an inpatient

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Types of Assessment

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x

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Initial

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Performed w/in a specified time after admission to a health care agency. Est. db for problem id, ref, and future compare; Nursing admission assessment JCAHO

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Problem focused

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determine status of specific problem id'd in eariler assess

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ER

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Crisis mode; life threatening problems

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Time lapsed

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occurs several months after initial assmnt, to compare client's current status to baseline data

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Methods of Data Collection

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x

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Observing

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gather data by using the senses. U must notice the data and then select, organize and interpret the data

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Examining

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use observation to detect health problems; use inspection, auscultation, palpation and percussion; head to toe or body system approach

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Interview

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Planned communication or conversation w/a purpose. Uses non-directive interview which is rapport building.

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Closed questions

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used in the directive interview are restricitve and require yes or no answer; begin w/when, where, who what

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open ended questions

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assoc. with non directive interview invite clients to discover, explore, elaborate and clarify. Explain your feelings; may being w/what or how

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leading questions

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force a client into an answer

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neutral

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no pressure or direction from nurse

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Nursing Diagnosis Statement

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The 3 part NSD is called PES format and includes Problem - NANDA label, Etiology-factors contributing to or probable cause; Signs/Symptoms-defining characteristics manifestd by client; Problem, related to, etiology, as evidenced by the signs and symptoms

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the problem

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client health problem, NANDA label

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Etiology

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related factors/risk factors; probable causes

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Signs and symptoms

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defining characteristics

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Independent functions

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areas of health careunique to nursing. Activities that nurses are licensed to initiate on the basis of their knowledge and skills

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dependent functions

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Physician prescribed therapies and treatments

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Collaborative Intervention

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actions carried out with other health team members. Overlapping responsibilities of health personnel; therapists, social workers, dieticians, physicians

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Observational intervention

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Observations include assessments made to determine whether a complication is developing; as well as the client's response to therapies; The RN should write observations for real problems, and those for which the client is at risk

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Criteria to formulate intervention

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safe and appropriate for client's age, health condition; achievable w/ available resources; congruent w/clients values, beliefs, and culture; congruent w/other therapies;

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Criteria to formulate intervention

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based on nursing knowledge and experience, or knowledge from relevant sciences; w/in established standards of care as determined by state laws, prof assoc and policies

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Types of Nursing Care Plans

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Informal care plan exists in the nurses mind

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Types of Nursing Care Plans

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Formal care plan organizes info about the clients care; it provides for continuity of care. Direction about what needs to be documented in client progress notes, and as a guide for delegating and assigning staff to care for clients

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Types of Nursing Care Plans

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Standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs

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Types of Nursing Care Plans

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Individualized care plan is tailored to meet the specific needs of a client

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Criteria for Goals/Outcomes

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write in terms of client responses and behaviors; The client will…

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Criteria for Goals/Outcomes

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Be sure outcomes are realistic for client's capabilities, limitations (resources), and designated time span

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Criteria for Goals/Outcomes

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Ensure goals and outcomes are compatible with therapies of other professioinals

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Criteria for Goals/Outcomes

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Make sure each goal is derived from only one nursing diagnosis

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Criteria for Goals/Outcomes

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Use observable, measureable terms for the outcomes

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Criteria for Goals/Outcomes

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Make sure the client considers the goals/outcomes important and values them

Front 83

Delegation

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Occurs during planning phase; determine who should actually perform the activity. The nurse retains account ability for the overall outcome. Match client needs w/skills and understand what is w/in legal scope of practice; Assistants can perform tasks, but the RN is responsible for analyzing data, planning care and evaluating outcomes.

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Assignment

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Is a downward or lateral transfer of BOTH responsibility AND accountability