Week 6 - clinical judgement

Question 1

Nursing Process Definition - and steps? (and how to put down others)

Answer 1

“A critical thinking process that professional nurses use to apply the best available
evidence to caregiving and promoting human functions and responses to health and
illness.” (ANA 2010)

A series of steps or processes leading to the achievement of a goal

Question 2

assessment - step 1 (assess the data and cluster)

Answer 2

-COLLECT DATA: - look for cues and make inferences - then validate those inferences (don’t apply w/out evidence) just describe in measurable terms what you see. Also cluster - wound care, diabetes, - cluster so that it supports the idea you are addressing.

Question 3

during diagnosis, what steps are you taking? (ACNP) All care needs patients for diagnosis)

Answer 3

-Analyze data
-Draw conclusion
-Nursing Dx-NANDA-I
-Prioritize problem

Question 4

planning

Answer 4

-Create care plan
-Identify goals and outcomes

Question 5

implementation (and it’s always what - this soapie)

Answer 5

-The action step
-Carrying out the care plan
THIS IS ALWAYS past tense - it’s what you carried out

Question 6

nursing practice act - (practice act mandates that each patient must have what?)

Answer 6

-Evaluate goals and outcomes. Must have written care plans that are individualized based on patient problem, medical diagnoses, unique needs, Written Care plans outline the nursing
process

Question 7

standards of competent care - when is a nurse considered competent? (competent when I’m a scientist)

Answer 7

A registered nurse shall be considered to be competent when he/she consistently
demonstrates the ability to transfer scientific knowledge from social, biological and
physical sciences in applying the nursing process, as follows:

Question 8

Competent performance - applies the nursing process by Formulating a nursing diagnosis through….

Answer 8

observation of the client’s physical condition and behavior, and through interpretation of information obtained from the client and others, including the health team

Question 9

Competent performance - applies the nursing process by Formulating a care plan (care plan involves patient safety, hygiene, etc. that’s it)

Answer 9

in collaboration with the client, which ensures that direct and indirect nursing care services provide for the client’s safety, comfort, hygiene, and protection, and for disease prevention and restorative measures.

Question 10

Competent performance - applies the nursing process by Performs skills essential to the…(competence is just explaining the treatment and teach family how to care for patient)

Answer 10

kind of nursing action to be taken, explains the health
treatment to the client and family and teaches the client and family how to care for the
client’s health needs.

Question 11

delegate assessment - what cannot be delegated? (assess and eval)

Answer 11

The ANA’s Code of Ethics for Nurses, Provision 4 (2015), Interpretative statement four
addresses the “assignment and delegation of nursing activities or tasks.” The revised
Code specifically indicates nurses may not delegate nursing process duties of
assessment and evaluation, and “employer policies do not relieve the nurse of
responsibility for making assignment or delegation decisions

Question 12

During your observations, or assessment, what to be alert for (HELP) (help the environment by looking at people)

Answer 12

H = Help: Observe the first signs patient may need help. Signs of distress? e.g. pain,
labored breathing
E = Environmental equipment: Safety hazards? Is equipment working?
L = Look: Examine patient - quick survey of patient - USE This for critical thinking worksheet
P = People: Who is in the room and what are they doing?

Question 13

Subjective Data*

Answer 13

Subjective Data
 Information expressed by person affected; Cannot be perceived or verified by another person.
 Includes sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life/home situations - History
 “I am having trouble breathing.”
 ”My pain level is 8/10.”
 “I am really nauseous.”

Question 14

Objective Data*

Answer 14

 Observable and measurable data
 Can be seen, heard, felt or measured (or smelled)
 Resp Rate 24 breaths per min,
SpO2 93% on room air (vital signs)
 Lungs with expiratory wheezes throughout (physical assessment details)

Question 15

assessment - make sure you

Answer 15

have gathered all necessary information
Interpret/analyze/validate data
Organize and cluster set of related signs and
symptoms and data to identify health problems.- don’t draw conclusion based on one finding (tearful after surgery - could be anything, pain, emotional)

Question 16

Identifying Cues and Making Inferences

Answer 16

Interpretation of problem based on cues observed
Avoid judgment and stereotyping here
Cluster set of related signs & sx to identify health problems (data clustering helps to
organize problems)

Question 17

Validating Data (validate that I’m free from error)

Answer 17

Purpose is to keep data as free from error, bias and misinterpretation as possible. Must confirm or validate to be sure inferences are correct.

Question 18

document assessment

Answer 18

Document as soon as possible in real time
When recording patient’s words, use “quotation” mark
Document change in patient condition, physician notifications and patient events in notes using SOAPIE or SBAR

Question 19

nursing diagnosis - this is the analysis part - what is wrong w/ the patient

Answer 19

*Within the scope of nursing practice
Standardized: Approved NANDA (you must use NANDA diagnoses)
* Describes patient responses to health and illness (physical, emotional social, etc.)
* Not a medical dx or medical pathology
* Focus is broad
* Fluid - can change from day to day (cannot predict a patient’s nursing dx based on a medical dx)

Question 20

medical diagnosis

Answer 20

• Within the scope of medical practice
• Describes a disease, illness, or injury
• Focus is narrow and on treating or
  preventing complications of the pathology
• Presentation and treatment of problem predictable

Question 21

Potential complications:

Answer 21

“A certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses
manage collaborative problems using physician-prescribed and
nurse interventions to minimize the complications of the event”
(Carpenito, 2017, p.21)
* Role of nurse is to prevent, monitor for undesirable outcome and report
* Treatment from nursing, medicine and other disciplines
* The problem is r/t a medical disease, treatment, or diagnostic
study
Examples:
➢ PC: Paralytic ileus related to anesthesia
➢ PC: Urinary retention related enlarged prostate

Question 22

person centered practice

Answer 22

focus on what can go wrong

Question 23

don’t test on diagnosis

Answer 23

it’s the terminology

Question 24

ADPIE

Answer 24

These steps provide an
efficient method for
organizing thought
processes for clinical
decision making,
problem solving and
the delivery of high
quality, individualized
patient care

Question 25

sources of data

Answer 25

usually from assessment

Question 26

collaborative problems

Answer 26

potential complications: “A certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using physician-prescribed and nurse interventions to minimize the complications of the event” (Carpenito, 2017, p.21) * Role of nurse is to prevent, monitor for undesirable outcome and report * Treatment from nursing, medicine and other disciplines * The problem is r/t a medical disease, treatment, or diagnostic study Examples: ➢ PC: Paralytic ileus related to anesthesia ➢ PC: Urinary retention related enlarged prostate

Question 27

North American Nursing Diagnosis Association – International

Answer 27

Purpose: For nurses to standardize a set of language in order to communicate the needs and care for patients with actual and potential problems

Question 28

NANDA

Answer 28

Assembly approved an official definition of nursing diagnosis:“Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.” (NANDA, 1990).“The registered nurse analyzes assessment data to determine actual or potential diagnoses, problems, or issues” ANA Standards of Practice 2015 (p. 55)

Question 29

Nursing Diagnosis (diagnose the problem and don't forget to cluster)

Answer 29

A problem statement of how person is responding to an actual or potential problem Can be actual or potential problem that requires nursing intervention Requires interpretation and analysis of clustered data according to body systems, risk factors, family/social factors, emotional factors, etc.

Question 30

nursing diagnosis - actual diagnosis

Answer 30

factors, etc. Actual diagnosis: Present at time of assessment. The patient will have actual signs and symptoms.

Question 31

nursing diagnosis - risk diagnosis

Answer 31

Potential diagnosis that is likely to develop in a vulnerable patient if the nurse and patient don’t intervene to prevent it. ***There are NO S/S present.

Question 32

Priorities Establishment of priorities - when do you establish priorities? After what? And how to decide what is important?

Answer 32

After formulating nsg dx, the nurse establishes the priorities of the dx by ranking them in order of importance (MASLOW). Establishing priorities is not merely a matter of numbering the nsg dx on the basis of severity or physiological importance, rather it is a method by which the nurse and the client mutually rank the dx's in order of importance based on the client's desires, needs and safety

Question 33

Establish Priorities - usually includes (include the ABCs)

Answer 33

ABC’s Maslow’s Hierarchy of Needs Actual vs. Potential

Question 34

Components of a Nursing Diagnosis - what is acronym - the short one

Answer 34

PES Format (or PED) 3 Part Statement

Question 35

PES and PED (or 3 part problem)

Answer 35

P=Problem=Nursing Dx: Decreased Cardiac Output E=Etiology (cause) of problem or related factors-etiology of problem within the domain of nursing-NOT MEDICINE-so don’t list medical dx’s as related factors: Altered pre-load and after-load and impaired contractility. S=S/S or defining characteristics (Subjective and objective data, clinical manifestations): Edema, weight gain, crackles, SOB, RR 24

Question 36

3 part statement***(PES or PED)

Answer 36

Don't write a medical diagnosis - Correct way: Decreased cardiac output related to altered preload, increased afterload, and impaired contractility as evidenced by edema, weight gain, crackles, SOB, RR 24 (by the S/S the patient is exhibiting that led you to this diagnosis) Wrong way to state based on medical dx: P=Decreased cardiac output R/T heart failure as evidenced by weight gain, edema, crackles, SOB, RR 24

Question 37

case study - you don't need to know this - it's just an example

Answer 37

Ineffective airway clearance by mucus (this is NANDA on the list)

Question 38

planning (plan your goals and then what will you do?)

Answer 38

#1 - what are the measurable goals - This is when the nurse organizes a nursing care plan based on the nursing diagnoses. What am I going to do for this patient? It's helpful to have the patient and family assist with identifying goals

Question 39

TYPES OF GOALS - in general

Answer 39

* Short term * Long term >7 days

Question 40

COMPONENTS OF A OUTCOME STATEMENT - (the outcome is SAPT) - the outcome is what you want to see happen. Pain reduction for example, how to state that...this is it Person will report pain decreased to 1 out of 10 one hour after administration of pain medication

Answer 40

SUBJECT –Assumed to be the person or a function or part of the person * Person will...or Patient will... ACTION VERB – What activity will the person perform? * Person will report... PERFORMANCE CRITERIA – the extent in which you expect the person to behave that is observable or measurable * Person will report pain decreased from 4 out of 10 to 1 of 10 TARGET TIME – realistic date, time or statement indicating time person will achieve goal * Person will report pain decreased to 1 out of 10 one hour after administration of pain medication Vague outcome statement: Person will report better pain relief after administration of pain medication

Question 41

Planning

Answer 41

Interventions are selected and written The nurse uses clinical judgment and professional knowledge to select appropriate interventions that will aid the patient in reaching their goal. Interventions should be patient centered and based on scientific rationale. Interventions should be examined for feasibility and acceptability to the patient Interventions should be written clearly and specifically

Question 42

nursing process - method for what? (the process is to reach the goal. that's it)

Answer 42

organizing and delivering nursing care The essential core of practice for the registered nurse to deliver holistic patient-focused care A series of steps or processes leading to the achievement of a goal

Question 43

what is the essential core practice for nurses to deliver holistic patient-focused care?

Answer 43

the nursing process

Question 44

assessment involves what type of data?

Answer 44

subjective and objective

Question 45

5 steps in the nursing process

Answer 45

ANPIE

Question 46

do NOT draw a conclusion about a patient based on...

Answer 46

one assessment. Tearful after surgery. You need more data to support a conclusion.

Question 47

examples of when you need to validate info. (validate my pain, it might not be correct)

Answer 47

Examples of times when validation is necessary: Subjective/objective data do not agree or make sense e.g. Pt. reports no pain, but facial grimacing noted. Client’s statements differ at different times in the interview Data are far outside normal range - Recheck again to confirm to validate e.g. defective equipment, incorrectly placed O2 sat probe. Factors are present that interfere with accurate measurement e.g. high BP after strenuous activity.

Question 48

use clinical reasoning during which part of ADPIE?

Answer 48

analysis part

Question 49

nursing diagnosis - Health promotion (wellness) diagnosis:

Answer 49

Readiness to enhance specific health behaviors

Question 50

The nursing diagnosis has to be approved by who?

Answer 50

NANDA

Question 51

at risk diagnoses are always..

Answer 51

lower priority than actual diagnoses.

Question 52

goals are centered around? (under planning)

Answer 52

they are person-centered.

Question 53

what characteristics should goals have? (under planning) ***(have a goal, MSTR or SMART)

Answer 53

Measurable, specific observable, time-limited, and realistic

Question 54

the goal is___and the outcome ____

Answer 54

Broad; measures the goal. Expected outcomes are identified interventions (nursing orders) are selected to aid the client reach these goals. Goal = broad statement Expected outcome = objective criterion for measurement of goal

Question 55

The aim of longterm goals - types of longterm goals (CPAP is the longterm goal)

Answer 55

Cognitive function Psychomotor Affect Physiological

Question 56

Cognitive function as a goal and is it long or short term?

Answer 56

Increase person’s knowledge longterm

Question 57

Psychomotor as a goal and is it long or short term?

Answer 57

Increase person’s skill longterm

Question 58

affect as a goal - and long or short term?

Answer 58

Change person’s attitude for self-care, compliance longterm

Question 59

Physiological as a goal - and is it long or short term goal?

Answer 59

improve a health problem longterm

Question 60

standards of implementation

Answer 60

box 17-1 in reading - copy it here - using evidence based interventions. may be interprofessional.

Question 61

implementation - the action step

Answer 61

The “Action” step of carrying out planned interventions The “DOING and DELEGATING steps

Question 62

types of interventions - Nurse initiated

Answer 62

THESE are Independent Actions, that a nurse initiates that don’t require a MD order – e.g. providing pt. education, ambulating, turning patient every 2 hours. assisting with ADL does not require order, within scope of practice

Question 63

step 5 - evaluation (check goal, see if client met goal, compare outcome w/ goal, see how close you are to the goal)

Answer 63

objective evaluation - 1. Examine the goal statement to identify the exact desired client behavior or response 2. Assess the client for the presence of that behavior or response 3. Compare the established outcome criteria with the behavior or response 4. Judge the degree of agreement between outcome criteria and the behavior or response

Question 64

collaborate

Answer 64

Collaborate with the patient and family. Use evaluative measures. - ex. can patient walk 100 ft? Interpret and summarize findings. Document results. Revise plan of care.

Question 65

documentation

Answer 65

Legal and professional responsibility, Requires accurate and approved terminology and abbreviations

Question 66

Data Documentation

Answer 66

Record all observations succinctly. Factual and as descriptive as possible on what you: Hear See Feel Smell

Question 67

in SOAPIE, do not use

Answer 67

the word appears, or any vague statements.

Question 68

document SOAPIE in

Answer 68

third person. Don't use I statements.

Question 69

Nursing care plans

Answer 69

A product of the planning component. Involve nursing dx, goals, specific nursing activities and strategies, and expected outcomes. It is a written guideline for client care.

Question 70

what can be delegated?

Answer 70

some interventions, vital signs, ambulating, meds, to an LVN if there are parameters - like notify nurse of abnormal findings.

Question 71

what is the point of nanda?

Answer 71

just to standardize nursing language

Question 72

during implementation, you're still doing what?

Answer 72

assessing. You're assessing the steps, the outcome, etc.

Question 73

interventions - physician initiated

Answer 73

Physician initiated Dependent—Require an order from a physician or other health care professional – pain medication given by RN, inserting indwelling catheter, medications – requires an MD order

Question 74

interventions - Collaborative

Answer 74

Interdependent—Require the combined knowledge, skill, and expertise of multiple health care professionals – Both RN and MD and other interdisciplinary collaborate- teamwork ex - physical therapy

Question 75

incentive spirometer - independent or dependent action?

Answer 75

independent as long as no contraindications

Question 76

what senses do you document?

Answer 76

what you hear, see, feel, and smell

Question 77

What is the analysis part in ADPIE?

Answer 77

the nursing diagnosis

Question 78

how can you cluster info?

Answer 78

clustered data according to body systems, risk factors, family/social factors, emotional factors, etc.

Question 79

what should interventions include?

Answer 79

teaching and learning

Question 80

when do you cluster data?

Answer 80

during the assessment and diagnosis