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• Standards of practice is the minimum level of accepted performance, to ensure high-quality care.

Stressors

• Recognize signs of stress in patients through assessment and critical thinking.
• Ask about lifestyle changes to learn about stressors, that contribute to a patient's infection.

Clinical Decisions

• Consider the patient's perception, environmental factors, support systems, and coping mechanisms when making clinical decisions about stress.
• Identify potential stressors and cluster assessment data to determine appropriate nursing diagnoses focused on coping abilities.
• Develop tailored interventions for the underlying "related to" factors for each nursing diagnosis, and continuously eevaluate the patient's response and adjust the care plan.
• Effective stress management requires synthesizing knowledge, patient data, and clinical judgment.

Code of Ethics

• Incorporate personal values and ethics into practice
• Autonomy: Initiate independent nursing interventions without error.
• Accountability: Be responsible for professionally & legal nursing care which is provided.
• Caregiver: Help patients to maintain & regain health
• Advocate: Protect patents' human & legal rights
• Educator: Effectively improve patients knowledge, skills, self-care activities & make informed decisions
• Communicator: Provide high-quality care, and meet patients' needs, preferences, strengths & weaknesses
• Manager: Direct group of nurses by establishing an environment for collaborative patient-centered care, safe, evidence-based quality care w/ positive outcomes

Intellectual Standards

• Guide the manner in which a nurse pursues an assessment
• Precise: Be exact and specific (e.g., focusing on one problem and possible solution)
• Specific: To mention, describe, or define in detail
• Accurate: Be true and free from error, and be objective and subjective.
• Relevant: Be essential and crucial to a situation
• Plausible: Be reasonable or probable
• Consistent: Express consistent beliefs or values
• Logical: Engage in correct reasoning based on beliefs in a given instance to the conclusions that follow
• Deep: Contain complexities and multiple relationships
• Broad: Cover multiple viewpoints
• Complete: Be thorough in thinking and evaluating
• Significant: Focus on what is important and not trivial
• Adequate: Be satisfactory in quality or amount

Professional Standards

• Apply standard criteria, when assessing a patient.
• Compare the patients actual assessment findings, with what the standard sets as normal or abnormal.
• Registered nurses should integrate ethics in all aspects of practice, and demonstrate advocacy in all roles and settings.
• Practice with cultural humanity and inclusiveness, while communicating effectively in all areas of professional practice.
• Nurses should collaborate with health care consumers and key stakeholders, and provide leadership within the professional practice and the profession.
• Nurses should seek knowledge to improve their current nursing practice, and promote futuristic thinking.
• The registered nurse integrates scholarship, evidence, and research findings.
• The registered nurse contributes to quality nursing and evaluates one's own and others.
• The registered nurse utilizes appropriate resources to plan, provide, and sustain safe, effective, and fiscally responsible evidence-based nursing services while avoiding waste.
• Practices should advance environmental safety and health.

Critical Thinking

• Analyze assessment data objectively and from multiple perspectives.
• Question assumptions, and explore alternative explanations
• Recognize gaps in information, and seek clarification
• Synthesize knowledge from various sources to understand a clinical picture.
• Identify pertinent changes in the patient's condition over time.
• Evaluate the effectiveness of interventions, and modify the plan as needed.

Patient Assessment

• Inductive reasoning is obtained when a set of assessment facts (e.g., objective clinical findings, diagnostic test results) and observations lead to generalizations.
• Spend enough time during initial and follow-up assessments to observe patient, and improve knowledge.
• Determine what is important to the patient, and make a positive connection.

Reevaluation

• Helps decide whether to continue, discontinue, or revise the plan of care.
• Reassessment is necessary when there are unmet or partially unmet outcomes, or if you determine that perhaps a new problem has developed.
• Consider the SMART principles.
• Identify interventions, and redefine priorities of care.
• Ensure that the database is accurate and current, and reveals any missing links interfering with goal achievement.
• You sort, validate, and cluster all new data to analyze and interpret differences from the original database.

Critical Thinking Attitudes

• Guidelines for approaching problems and making correct decisions.
• Attitudes include:
  • Knowing when to obtain more information.
  • Knowing when information is misleading.
  • Recognizing knowledge limits.
  • Confidence
  • Thinking independently
  • Fairness
  • Responsibility and Authority
  • Risk Taking
  • Discipline
  • Perseverance
  • Creativity
  • Curiosity
  • Integrity
  • Humility

Critical Thinking Evaluation

• A part of the nursing process is used to methodically determine if nursing care approaches led to desired outcomes, reflecting competence.
• Indicators of competence includes the ability to:
  • Examine results of care per collected data.
  • Compare achieved effects or outcomes with expected outcomes.
  • Recognize errors or omissions.
  • Understand the patient's situation.
  • Reflect and correct errors.
• Nurses should apply evaluation objectively, using objective criteria such as expected outcomes, pain characteristics, and learning objectives to determine the effects of nursing actions and reflect on their behavior to determine if appropriate decisions were made.

Clinical Decision-Making Process

• Involves investigating and analyzing ALL aspects of a clinical problems, and then applying scientific and nursing knowledge to choose the best course of action.
• This process is initiated by the patient's healthcare needs, and requires Critical thinking, Evidenced based practice, and problem solving
• ADPIE is taken by nurses, while APs don't have the ability to analyze why.

Types of Data

• Objective Data: Findings resulting from observation of patient behavior and clinical signs, as well as direct measurement.
• Subjective Data: Patients verbal descriptions of health problems gathered during interviews.

Data Collection

• Involves gathering subjective and objective information about the patient, from various sources:
  • Interviews
  • Observations
  • Physical Assessments
  • Diagnostic Tests
  • Medical records
• Patient database: Electronic health record to store comprehensive patient data and record assessments, diagnoses, interventions, and evaluations.
• Allow the interprofessional team to access up-to-date patient information to guide clinical decision-making, coordinate care across settings, facilitate communication, medication reconciliation, and provides data for quality improvement efforts.

Patient Assessment

• Patient-centered interviews are conducted during a nursing history, and periodic assessments are conducted during ongoing contact.
• Confirm accuracy, by comparison with another source, and other nurses, healthcare team members, family and friends may also validate information.
• Opening the door for gathering more assessment data because it involves clarifying vague or unclear data.

Obtaining Data

• The patient (subjective) is a nurse's primary and best source of info, when conscious and alert.
• If the patient is unreliable, refer to caregiver or family (objective)
• Health literacy is assessed in English and Spanish with a short form.

Parts of Nursing Diagnosis

• Nursing diagnosis identifies the disease condition based on signs and symptoms.
• Medical diagnosis indicates increased vulnerability or potential.
• Collaborative problems require both medical and nursing interventions.
• There are 3 types Problem-focused Identify an problem the patient is experiencing. Risk nursing Indicate an increased cause of problem. Health promotion Helps the patient desire or motivation to enhance well-being.

Nursing Process

• Assessment: The registered nurse collects pertinent data and information relative to the healthcare consumer's health or the situation.
• Diagnosis: The registered nurse analyzes the assessment data to determine the actual or potential diagnoses, problems, and issues.
• Outcomes Identification: The registered nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation.
• Planning: The registered nurse develops a plan encompassing strategies to achieve expected outcomes.
• Implementation: The registered nurse implements the identified plan including coordination of Care, Health Teaching, and Health Promotion.
• Evaluation: The registered nurse evaluates progress toward attainment of goals and outcomes.
• Cycle is continuous

Parts of the Nursing Process

• Assessment: Record all relevant subjective (patient-reported) and objective (observed), include pertinent medical history, physical assessment findings, lab results, etc.
• Nursing Diagnosis: State the identified actual or potential health problems/needs using approved nursing terminology. Support diagnoses with clustered assessment data.
• Planning: Develop patient-centered, measurable goals. Outline evidence-based nursing interventions that address each diagnosis, considering patient preferences and circumstances.
• Implementation: Describe nursing actions taken, patient's response, and any modifications made to the plan. Document according to principles like accuracy, completeness, and timeliness.
• Evaluation: Objectively state if goals were met, partially met, or not met based on patient outcomes in relation to any areas requiring revision or continued care.

Prioritization

• Based on urgency, current condition and desired outcomes.
• Involves ordering of nursing diagnosis or patient problems to establish the preferred order in which you will implement.
• Prioritize nursing diagnoses by considering immediate needs based on ABC (airway, breathing, and circulation).
  • Highest priority) risk for violence, impaired gas exchange, impaired cardiac function.
  • Intermediate priority) nonemergent & not life threatening, such as risk for infection.
  • Low priority) not always directly related to specific illness or prognosis but includes long-term health care needs.

Data Analysis and Nursing Knowledge

• Prioritization of nursing diagnoses occurs when nursing and scientific knowledge is used to recognize patterns from a patient assessment.
• The action you need to take depends on the data.

Evaluation - Goal/Outcome

• Is done by the patient, and sometimes family member.
• The results help you to decide whether to continue, discontinue, or revise the plan of care.
• When the outcomes are unmet or partially met, reassessment is necessary, using the SMART acronym when writing the goal.

SMART Goals

• Specific: the objective statement is properly constructed and describes exactly what must be be accompished:
  • Begins with the word to
  • States a single result and defines target date for attainment
• Measurable: Provides the level of accomplishment of the end result and leaves no question as to what is expected.
• Achievable: All parties agree that the goals are attainable.
• Relevant: Objectives are within the realm of possibility and are results-based and reasonable.
• Time Bound: Establishes a time frame for which the activity or improvement will be achieved

Complete Database

• Involves gathering patient history (medical, surgical, family, social), review of systems, physical assessment findings, results from diagnostic tests, vital signs, psychological and spiritual assessments, environmental and economic factors, and current medications.

Infectious Process

• Incubation period, prodromal stage, illness stage, and convalescence.

Defenses Against Infection

• Normal flora, body system defenses, and inflammation

Interrupted Cycle

• Infection which can be prevented by patient self-care activities or appropriate nurse intervention

Infection Prevention

• Infection transmission is prevented through portals of exit, such as blood, skin, mucous membranes, respiratory tract, GU and GI tracts, and transplacental.
• Infection prevention reduces reservoirs of infection through bathing, dressing changes, disposal of contaminated articles and sharps, while keeping table surfaces clean and dry.
• Keep bottled solutions tightly capped and dated, and discard in 24 hours, while wearing gloves and eyewear.
• Empty and dispose of drainage bottles, and never raise a drainage system above the level of the site being drained.
• Private rooms are needed.

Risk Factors

• Organisms enter the body through the same route they use for exiting.
• Factors that affect susceptibility include age, sex, status and disease process.

Exogenous Infections

• Infections that comes from microorganisms which is not normal flora.
• Endogenous infections occurs when patient's flora is altered.
• Latrogenic infections are a type of HAl.

Body Defenses

• Natural defenses protect against infection.
• The body uses normal flora, body system defenses, inflammation, and systemic or local infection

Cleaning Different Surfaces

• Cleaning occurs before disinfection and sterilization procedures.
• Aseptic techniques are medical and surgical asepsis with medical techniques breaking the chain of infection.
• To ensure the object is cleaned:
  • rinse and wash with soap and warm water, use a brush for pores, rinse with warm water, and dry.

Disinfection

• Describes a process that eliminates many/all microorganisms with the exception of bacterial spores, from inanimate objects
• Hand washing, and PPE is used.

Critical Items

• Must be sterile since it interacts with tissue and vascular system. Ex: surgical intruments and implants
• Semi Critical- Items must be high level disinfected Items that interact with mucus. Ex: endoscope

PPE

• Disinfection eliminates many/all microorganisms, except the spores ones.
• When patient has a wound, a face shield is required to prevent direct exposure to fluids.

Contact Precautions

• PPE involves gowns and gloves and is used for direct and indirect contact

Droplet Precautions

• Focus on disease that are transmitted within 3 feet.
• PPE surgical mask, proper hygiene
• ex) influenza Airborn precautions- Focus on disease that are transmitted, which remain in the air.
• The Healthcare provider uses a high efficient particulate air filter every time.

Protective Environment

• Focuses on patient population, all of whom are highly susceptible.
• The airflow should be set higher, and all air is filtered.

PPE Equipment

• Gowns prevent soiling clothes during contact with an infected patient.
• Masks protect the respiratory system.
• Gloves and eye protection is needed whenever it is possible to be exposed with fluids.

Vital Signs

• Temperature
• Pulse
• Pulse Oximetry SpO2
• Respirations
• Blood Pressure
• Capnography (EtCO2)

Ranges For Adults

• Temperature range: 36° to 38°C
• Pulse: 60 to 100 beats/min
• Pulse Oximetry Normal: ≥95%
• Respirations: 12 to 20
• Blood Pressure: Systolic <120 mm Hg Diastolic <80 mm Hg
• Capnography Normal: 35-45 mm Hg

Measurement Times

• On admission, during care visits, after invasive procedures, before or after transfusion, and when changes are made in any condition.

Fever/Hyperthermia

• Increase heat loss, reduce heat production, and prevent complication.

Pulse sites

Temporal, carotid brachial, radial, femoral, popliteal, posterior tibial

Febrile Patients

• Obtain cultures of body fluids.
• Minimize heat production: Reduce activity and allow rest periods.
• Maximize heat loss: Reduce covering
• Control environment
• Identify onset and duration
• Health teaching as indicated
• Control environmental temperature to 21° to 27°C

Heat strokes- what to do

• What to do with heat stroke- moving patient to cooler environment. Also administer IV fluids, irrigating stomach and lower bowel with cool solutions, and applying hypothermia blankets.

Alterations in Breathing

• Bradypnea: slow
• Tachypnea: fast
• Hyperpnea: labored/increased depth
• Apnea: stops for several seconds
• Hyperventilation: rate and depth increases
• Hypoventilation: respiratory is abnormally low
• Biot's breathing: Respirations are abnormally shallow for two to three breaths, followed by irregular period of apnea.