1-6 Flashcards
Methods of data collection used in assessment
a. Sources of data:
a. Client
b. Family & Significant other- most reliable source
c. Medical Records
Process of data analysis –
cluster data
- planning phase
- implementation phase
- evaluation phase
Process of data analysis
Planning phase
b. Discharge Planning-when does
- Develop a list of nursing interventions and outcomes-be realistic
- Discharge Planning-when does it begin? On admission!
Process of data analysis
Implementation phase
- carry out interventions with ongoing assessment
- document- legal requirements
Process of data analysis
Evaluation phase
- validate effectiveness
- are the goals attainable? Are they realistic?
- have the pt participate in goal setting process.
Critical thinking
Includes clinical reasoning and clinical judgments
Define critical thinking/reasoning/ judgement
purposeful, informed, outcome-focused thinking that is:
- guided by standards, ethnic and laws
- based on nursing process
- focuses on safety and quality (QSEN)
- identifies key problems, issues and risks
- applies logic, intuition, creativity.
Application of Nursing Process
- Define Nursing process: decision-making approach that enhances critical thinking.
- Systematic approach to the nursing process
- The focus of nursing care
- Addresses the response of the pt
- Primary purpose of the NCP is communications with the healthcare team.
Critical thinking/reasoning/judgment helps you to :
Gain confidence- crucial for success
Be safe- helps to decide when to take initiative and when to get help
Improve outcomes and job satisfaction
Ideal critical thinker
Attitudes and mental habits that foster critical thinking
Independent thinking
Intellectual courage- listen and be fair in your evaluation of others intellectual empathy- put yourself in another’s place
Intellectual sense of justice- be fair minded, consider all view points
Intellectual humbleness
Consider alternatives
Be creative and self-confident
Essential critical thinking skills
- Divergent thinking- weigh the importance of information (not one track mind)
- Reasoning- discriminate b/t facts and guesses
- clarifying-defining terms, noting similarities and differences
- reflection/ Debrief- think about it, learn from it.
Teaching learning theory
Define learning readiness
Requires assessment of clients willingness, goals, edu. Level, socioeconomic level, support system, age and culture.
- clients must be accepting of their DX and need for teaching in order to learn
Learning readiness
Motivational principles
Pt desire to regain control of situation. 102 care plan. Communication skills evaluation
-assess what pt most wants to know or be able to do themself.
Learning readiness
Planning, implementing, and evaluation
Measurable learning goals
- goals must be mutually established by pt and nurse.
- client centered, time specific and measurable
Learning readiness
Examples of Teaching techniques and strategies
- establish trust and repor with pt
- preceded slowly
- set goals and boundaries
- set priorities
- assess how and when pt learn best
- use demonstration and hands on learning whenever possible
- involve SO
- limit distraction
- safety first
- go from simple to complex
- give praise
- review before proceeding to new material
Learning readiness
Evaluation of clients learning
Are goals being met
Are revision nessary
Is timeframe realistic
Is client satisfied with experience
Professional role/issues
Accountability
The responsibility you have to explain your actions to :
Your pt
Instructors - unit procedure manual
The hospital- policies, dress code, HIPAA, social network
Pain management
McChaffery & Beebe
“Whatever the person experiencing it says it is, and existing whenever the person says it does”
Pain management
JCAHO
Joint commission on accreditation of health organizations
- pain standards and protocols
Pain management
Definition of pain
known as the 5th vital sign
Subjective response to both phyoand psychological stressors
Common reason for seeking health care
Unpleasant sensory and emotional experience
Serves as a basis for nursing assessment and care of pt
- pain has a personal meaning
- all pain is real
Pain management
Pain has many dimensions
Personal
It’s real
It’s physical, emotional, cognitive, socio-cultural, spiritual
Affects the whole body
Can impede on healing
Serves as a response and warning of trauma
Pain management
Nociecptors
Nerve receptors that respond to pain
Pain management
Pain occurs
When biological, mechanical, thermal, electrical, or chemical factors stimulate nociceptors
Tissue damage 👉inflammation (initial response )👉bradykinin and prostaglandins (gives pain sensation )
The intensity and duration of the stimuli determine sensation minutes to hr.
Pain management
Characteristics of acute pain
Sudden onset, usually temporary and localized
