NP, CJM, SBAR Flashcards
(29 cards)
What is the purpose of the nursing process/clinical judgement models?
To guide and promote safe, competent, and quality patient care
What is a nursing intervention?
-Usually considered ‘standard’ intervention that can be implemented quickly and appropriately
-Based on patient needs & preferences
What is an example of independent nursing interventions?
Assessment, monitor and teaching, vital signs, IO, height, weight, etc.
What are dependent nursing interventions?
Requires healthcare provider- labs, meds, and treatments needed
What are the 5 steps to the nursing process?
Assessment, diagnosis, planning, implement, evaluate
Describe the assessment step of the nursing process.
-Gather information about the patient’s condition
-Gather from the history, head to toe assessment, medical record in order to gather a comprehensive history.
Describe the diagnosis step of the nursing process.
-Identify the patients problems.
-Not the patients actual diagnosis
-Ex: increased RE, inadequate gas exchange
Describe the planning step of the nursing process.
-Set goals of care and desired outcomes
-What are we going to do?
-Start thinking of interventions
Describe the implement step of the nursing process.
-Perform the nursing actions identified in planning
-Assess, monitor, implement, collaborate, teach, psychosocial
-Address patients needs (mental/physical)
Describe the evaluate step of the nursing process.
-Determine if goals and expected outcomes are achieved
What are the 6 steps of the clinical judgement model?
Recognize cues, analyze cues, prioritize hypothesis, generate solutions, take action, evaluate outcomes
Describe the recognize cues step of the CJM.
Identify & recognize relevant clinical date
-Sounds like assessment of NP
-Report, labs, history
Describe the analyze clues step of the clinical judgement model.
-Be able to interpret cues, organize and recognize patterns in order to link the patient’s clinical presentation to a problem
-Cluster cues (findings)
Describe the prioritize hypothesis step of the CJM.
-Narrow problems down to the most pressing problem
Describe the generate solutions step of the CJM.
-Determine desired outcomes and the best solutions.
-Determine what resources you may need
Describe the take action stage of the CJM.
Implement nursing interventions based on your plan
Describe the evaluate outcomes step of the CJM.
Compare observed outcomes to the desired/expected outcomes
What steps are similar in the nursing process and clinical judgement model?
-Assessment = recognize cues
-Diagnosis = analyze cues
-Planning = prioritize hypothesis
-Planning = generate solutions
-Implementation = take action
-Evaluation = evaluate outcomes
What does SBAR stand for?
Situation
Background
Assessment
Recommendation
What is SBAR?
A structured communication technique used clinically and is designed to convey a great deal of information in a succinct and brief manner
Describe problem-based SBAR.
When you identify a problem/concern that is worth dialoguing with the HCP about:
1. Pick up the phone and call HCP - versus
2. Wait for the (scheduled/predictable) interdisciplinary rounds to occur
Describe patient-focused SBAR.
When you are giving report to night shift or to the unit where the patient is being transferred.
What are the 5 steps of SBAR?
- Identify the problem & why you feel it warrants a call to HCP
- Identify focused assessment that will add information to the conversation
- Know their medical history & how it may play a role in the problem
- Look for trend data in chart
- Be sure to include critical cues to help “tell the story.” These come from admission reason, allergies, meds, labs/diagnostics, and physical assessment
Describe the situation step of SBAR.
The only thing that goes in situation is the symptom(s) that are the reason you felt the need to pick up the phone.
*be specific, but brief; using the fewest words possible
