Clinical Reasoning & Nursing Health Promotion PDF

The nursing process - The common thread uniting diff types of nurses who work in varied areas is the nursing process -the essential core of practice for reg nurses to deliver holistic patient focused care - ADPIE (Assesment, diagnosis, pllanniing, impllementation, evaluation)...

The nursing process - The common thread uniting diff types of nurses who work in varied areas is the nursing process -the essential core of practice for reg nurses to deliver holistic patient focused care - ADPIE (Assesment, diagnosis, pllanniing, impllementation, evaluation) 6 functions of clinical judgment - Recognize cues (what matters most?), analyze cues (what does it mean?), priorittize hypothesis (where do i start), generatr solutions (what can I do?), take action (what will I do?), evaluate outcomes (did it help?) Benifits of Nursing Process - Provides an orderly and systemic method for planning and providing care - Enhances nursing effiecinys by standardizing nursing practice - Facilitates documation of care - Provides unity of lang for nursing profession - Economical - Stresses the independent function of nurses - Increases care quality through the use of deliberate actions - Provides continuity of care and prevents duplication CHaracteristics of nursing process: - Interactive purposeful and systemic (organized) - Client centered - Goal directed, outcome focused - Prioritizing needs - The steps are interrelated and dependent on the accuracy of each of the preceding steps - It is used to identify, diagnose, and treat human responses to health and illness - Used to identify diagnose and treat human responses to health and illnesses ASSESSEMNET (first step of the nursing process) - Can be defined as collect organizing validating and documenting client data - During this phase the nurse gathers info about a cliences psychological, physiological, and sociologica and spiritual status through observation, interviewing, physical examinations, health records, and family members - Nursing assessments do not duplicate medical assessments (which target to pathologic conditions) but focus on clients responses to health problems or potential health problems - Identify assessment priorities determined by the purpose of the assessment and the client’s condition - Organize or cluster the data that ensure systemic collections - Establish the database - Continuously update the database - Validate data - Communicate data ASSESSMENT SKILLS - observation - Interview: a convo with purose to get ot give info to teach and provide support - Physical examination: sysetmec data collection method by inspection, palpatation, percussion, and auscultation - Intuition (insight): use of insight, instinct and clinical experience to make clinical judgments about the client ASSESSMENT Activies - Collect data (subjective data: data that the patient or family rep[orts or data that the nurse makes as an inference, conclusion, or assumption should be in clients own words. Objective data: data that the nurse can see toch smell or hear or is reproduclble such as vital signs. - Validate data: double checking the data to confirm accuracy - organize data: grouping data using Head to Toe model, systemic review, etc - document data (secondary/primary data): documents subjective data in client own words and objective using medical terms, abbreviations, etc THE NURSING PROCESS - DIAGNOSIS - Interpret and analyze patient data - Identify patient strngths and health - Formulate and validate diagnoses - Develop a prioritized list of diagnoses - Detect and refer signs and symptoms that may indicate a problem beyond nursing experiences THE NURSING PROCESS- PLANNING This step of the nursing process includes formulation of guidelines that establish the proposed course of nursing action in the resolution of nursing diagnoses & the development of the client’s plan of care Planning consists of 3 stages: - Initial planning: done by the nurse who performs admission assessment in order to prioritize problems, identify goals and correlate nursing care to resolve the problems - On-going planning: involves continuous updating of the client’s plan of care. Every nurse who cares for the client is involved in ongoing planning - Discharge planning: involves anticipation & planning for the client’s needs after Prioritixing the problem/diagnosis Formulate goals/desired outcomes - Short term - Long term Select interventions Write interventions THE NURSING PROCESS- implementation Implantation consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions or nursing orders Nursing skills required during implementation: - Cognitive skills: : including problem solving & decision making - Interpersonal skills: : include verbal & non-verbal response, communication - Technical skills: includes hand on skills needed to perform procedures such as administering injections, drugs, lifting, moving THE NURSING PROCESS - Evaluation The last phase of the nursing process which includes the judgment of the effectiveness of nursing care to meet client goals based on the clients behavioral responses The step determines the success/effectivnetss of the whole nursing process and the decision either continue, modify, or repeat depends on evaluation - The goal was met - The goal was partially met - The goal was not met CLINICAL JUDGEMNET vs CLINICAL REASONING Clinical judgement - The observed outcome of critical thinking and decision making. It is an iterative process that uses nursing knowledge to observe and access presenting situations, identify a prioritized client concern, and generate the best possible evidence based solutions in order to deliver safe client care Clinical reasoning - A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this info, and weigh alternative actions. INTERPROFESSIONAL STRUCTURED COMMUNICATION - SBAR SBAR components - Structured communication tools such as SBAR can enhance communication between members of the healthcare team - SBAR provides a vehicle for individuals to speak up and express concern in a concise manner - SBAR is useful for framing any conversation, especially critical ones requiring a team's immediate attention and action, such as when a patient's condition is rapidly deteriorating. It may also be useful with providers who are not part of the core team, such as remote consultants or mental health providers - Situation states what is currently happening with the patient. It usually begins with the identifity of the person communicating the SBAR, patient identifiers such as age and gender, and a brief statement of the current problem or situation - Background covers clinical background such as paitent history related to the current situation, signs and symptoms of the presenting complaint, and any test results such as lab or imaging reports - Assessment reports what the person communicating the SBAR thinks the problem is. It states what the nurse or other provider has assessed based on the background  information, patient history, and observations. Assessment asks what else it can be, provides sense making, considers sources of other information to provide clarity, and relates actions to consequences. Assessment can also include objective data such as vital signs - Repeat-back recommendations and requests states an initial recommendation, what is needed and when, and repeats back the stated response from the other provider or patient to ensure accuracy