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NUR 324 > WK 5 Nursing Process, Clinical Judgement Model, and SBAR > Flashcards

WK 5 Nursing Process, Clinical Judgement Model, and SBAR Flashcards

(55 cards)

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1
Q

nursing process -1950s

A

guide and promote safe, competent, quality pt care

NCBSN

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2
Q

clinical judgment - 2019

A

NCBSN

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3
Q

the nurse is conducting an interview of a pt admission. which datum should the nurse document as subjective data?

A

nausea, light-headedness, discomfort in the stomach

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4
Q

which statement describes a characteristic of clinical judgment in nursing practice?

A

it is the foundation of safe, competent practice

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5
Q

nursing interventions: what are those?

A

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

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6
Q

independent vs. dependent

A

independent: assessment, monitor and teaching = VS, IO, height, weight

dependent: requires HCP = labs, meds, treatments needed

collaboration is unique

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7
Q

more about nursing intervention

A

need a timeframe and always speak to rationale

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8
Q

time frame for nursing interventions examples

A

assess VS q4 hours

teach about IS use and encourage use of q1 hour x15

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9
Q

the nursing process

A

assessment
diagnosis
planning
implement
evaluate

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10
Q

assessment

A

gather info ab the pt condition

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11
Q

diagnosis

A

identify the pt problems

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12
Q

planning

A

set goals of care and desired outcomes

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13
Q

implement

A

perform the nursing actions identified in planning

assess, monitor, implement, collaborate, teach, psychosocial

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14
Q

evaluate

A

determine if goals and expected outcomes are achieved

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15
Q

clinical judgement model

A

recognize cues
analyze cues
prioritize hypotheses
generate solutions
take actions
evaluate outcomes

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16
Q

recognize cues

A

identify and recognize relevant clinical data

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17
Q

analyze cues

A

be able to interpret cues, organize, and recognize patterns in order to link the pt clinical presentation to a problem

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18
Q

prioritize hypotheses

A

narrow problems down to the most pressing problem

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19
Q

generate solutions

A

determine desired outcomes and the best solutions

determine what resources you may need

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20
Q

take action

A

implement nursing interventions based on your plan

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21
Q

evaluate outcomes

A

compare observed outcomes to the desired/expected outcomes

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22
Q

assessment is

A

recognize cues

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23
Q

diagnosis is

24
Q

planning is

Study These Flashcards
A

prioritize hypotheses and generate solutions

25
implementation is
take actions
26
evaluation is
evaluate outcomes
27
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
28
what step in the clinical judgement model was she in?
analyzing cues
29
T/F: clustering of cues is the evidence of the nursing problem
truw
30
how do you prioritize problems?
use the ABCs and what is pressing RIGHT NOW
31
planning etc.
develop a goal with outcome criteria
32
implementation etc.
what interventions can you do do you need the HCP for additional support can you collaborate with the interdisciplinary team
33
evaluation etc.
determine if the goal is met, or not
34
what happens when something unexpected happens? how do you communicate this?
SBAR
35
SBAR
situational background assessment recommendation
36
SBAR continued
a structured communication technique used clinically and is designed to convey a great deal of info in a succinct and brief manner
37
SBAR is a technique/process of delivering info no matter what:
emergent issue, FYI issue
38
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
39
two types of SBAR
problem based pt focused
40
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
41
pt focused SBAR
when you are giving report to night shift or to the unit where the pt is being transferred
42
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
43
step 2 of SBAR
identify focused assessment that will add info to the conversation what is there and maybe what isn't there
44
step 3 and SBAR
know their medical history and how it may play a role in the problem
45
step 4 and SBAR
look for trend data in chart
46
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
47
situation
briefly describe the situation, give a succinct overview
48
background
briefly state pertinent history. what got us to this point?
49
assessment
summarize the facts. what do you think is going on?
50
recommendation
what are you asking for? what needs to happen next?
51
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
52
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
53
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
54
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
55
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

NUR 324 (7 decks)

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