Test 2.docx

Objectives: 15, 16, 17, 18 Chapter 15 (Assessing) Five Types of Nursing Assessments Initial Focused Quick priority Emergency Time-lapsed Triage Patient-Centered Assessment Method (PCAM) Characteristics of Nursing Assessments NURSING ASSESSMENTS ARE: -Systematic and continuous collection, ana...

Objectives: 15, 16, 17, 18 Chapter 15 (Assessing) Five Types of Nursing Assessments Initial Focused Quick priority Emergency Time-lapsed Triage Patient-Centered Assessment Method (PCAM) Characteristics of Nursing Assessments NURSING ASSESSMENTS ARE: -Systematic and continuous collection, analysis , validation, and communication of patient data. *data reflects how health functioning is enhanced by health promotion or compromised by illness/injury. *database includes all the pertinent patient information collected by the nurse and other health care professionals. ***The database enables the nurse to partner with patients to develop a comprehensive and effective care plan. CHARACTERISTICS OF NURSING ASSESSMENTS: *PURPOSEFUL * PRIORITIZED *COMPLETE *SYSTEMATIC *FACTUAL AND ACCURATE *RELEVANT *RECORDED IN A STANDARD MANNER Initial Assessment -is when a pt is initially admitted. (collect data on all aspects of pt’s health) focus on whole pt. Focused Assessment -focused on a specific area: example: child comes in pulling on ear, check ear first (focused) gather data about a specific problem already identified. Performed at urgent care. Quick Priority Assessments- short, focused, prioritized assessments completed to gain the most important information needed first. Can flag existing problems. Emergency Assessment- these assessments are performed when a crisis is present like the ER; to identify life threatening problems. Main thing to always keep in mind is ABC’s Airway, breathing, circulation. Time-Lapsed Assessment- performed to compare a pt’s current status to the baseline data obtained earlier. Performed to reassess health status and make any necessary revisions in care plan. Think of a timeline. Their baseline earlier was here and now its here. Triage Assessment- can be completed on the phone or in person. A screening assessment to determine the extent and severity of pt problems and recommend appropriate follow-up. Triage nurses need highly specialized nursing knowledge and clinical reasoning and judgement skills. Patient-Centered Assessment Method – tool used by healthcare practitioners to assess patient complexity using social determinants of health. Helps ask questions to gain understanding about the pt’s health and wellbeing, social environment, health literacy, and communication skills. (patient safety and examining pt as a WHOLE) always ask how the pt is interpreting his/her health. Ask how they feel, how their symptoms make them feels and if they are taking anything to help with their current condition. Establishing Assessment Priorities (what are some of the priorities when assessing a patient??) -Health orientation: how much the pt knows about their actual health? Do they know what’s really going on right now or they don’t? -Developmental stage: is it a child that isn’t really going to understand the questions we are asking? Or is it an adult that can cooperate with us in the assessment? -Culture: are there any culture needs we should be aware about when we are assessing this patient? -The Need for nursing Objective Data vs. Subjective Data Objective Data- observable and measurable data that can be seen, heard or felt by someone other than the person experiencing them. EXAMPLE: elevated temperature, skin moisture, vomiting. Subjective Data-Information perceived only by the affected person. EXAMPLE: pain experience, feeling dizzy, feeling anxious, nausea. Sources of Data: (ALWAYS TRY TO GET INFORMATION FROM THE PATIENT FIRST) *PATIENT *Family & significant others *Patient record *Medical history, physical examination, progress notes *Consultations *Reports of laboratory and other diagnostic studies *Reports of therapies by other health care professionals *Nursing and other healthcare literature Assessment Methods Inspection – The process of performing deliberate, purposeful observations in a systematic manner. Palpation- use of the sense of touch to assess skin temperature, turgor, texture, and moisture as well as vibrations within the body. Percussion- the act of striking one object against another to produce sound. Auscultation- the act of listening with a stethoscope to sounds produced within the body. Validating Inferences- (inferences is a conclusion reached on the basis of evidence and reasoning.) -performing a physical examination using proper equipment and procedure -using clarifying statements -sharing inferences with other team members -checking findings with research reports -comparing cure to knowledge base of normal function -checking consistency of cues Documentation of data -Immediately give verbal reporting of data whenever a critical change in the patient’s health status is assessed. -Enter initial database into computer or record ink on designated forms the same day patient is admitted. All information is entered into a computer unless computer system is down but other than that, always enter into a computer. -summarize objective and subjective data in concise, comprehensive, and easily retrievable manner -use good grammar and standard medical abbreviations -whenever possible, use patients own words -avoid nonspecific terms subject to individual interpretation or definition Chapter 16 (diagnosis / problem identification) Purposes of the Diagnosing Step- - The purpose of the diagnosing step is to identify how an individual, group, or community responds to actual or potential health and life process. -Identify factors that contribute to, or cause, health problems (etiologies). -Identify resources or strengths on which the individual, group, or community can draw to prevent or resolve problems. ** The Diagnosing step will help you determine what your patient needs in your care. For example: if a patient had a surgery and had a big scar left, you can say that the patient has disturbed body image related to the incision scar. Diagnosing- can help us improve communication not only with our patient but with other nurses that are also caring for this patient. Also allows the nurses to keep an open mind and ensure that data is accurate and complete when formulating a nursing diagnosis. ALSO for Nursing Diagnosis you want to: Recognize safety and infection transmission risks and addressing these immediately Identifying human responses—how problems, signs and symptoms, and treatment regimens impact on patients’ lives—and promoting optimum function, independence, and quality of life Anticipating possible complications and taking steps to prevent them Initiating urgent interventions. You should not wait to make a final diagnosis if there are signs and symptoms indicating the need for immediate treatment (LOOK AT NURSING CAREPLAN HANDBOOK FOR BREAKDOWN OF NANDA) ** PPMP means to PREDICT, PREVENT, MANAGE AND PROMOTE. (NURSING DIAGNOSIS HELP US TO PREDICT, PREVENT, MANAGE AND PROMOTE HEALTH WITHIN OUR PATIENTS) In the presence of known problems, predict the most common and most dangerous complications and take immediate action to (a) prevent them, and (b) manage them in case they cannot be prevented Whether problems are present or not, look for evidence of risk factors (things that evidence suggests contribute to health problems). If you identify risk factors, aim to reduce or control them, thereby preventing the problems themselves In all situations, ensure that safety and learning needs are met and promote optimum function and independence and a sense of well-being Patient Problems & Medical Diagnoses- the differences between patient problems and medical diagnosis. -Patient problems can change from day to day as the patients responses change. They focus on unhealthy responses to health and illness. -Medical Diagnosis identifies diseases and describe problems for which the physical or advanced practice nurses directs the primary treatment; Medical diagnosis remains the same as long as the disease is present. Steps of Data Interpretation and Analysis -Recognizing significant data: comparing data to standards -Recognizing patterns or clusters -Identifying strengths and current or potential problems -Identifying potential complications -Reaching conclusions -Partnering with the patient and family members (to see the NANDA that you have created and see how your nursing interventions can help the patient) TYPES of NURSING DIAGNOSES: 3 main ones are Problem-focused, Risk, and health promotion Formulation of Nursing Diagnoses- in order to formulate a nursing diagnosis, you have to have the three main components present which are: -Problem- identifies what is unhealthy about the patient. -Etiology- Identifies factors maintaining the unhealthy state. -Signs and symptoms *An example a nursing diagnosis with its three components would be: impaired bed mobility related to musculoskeletal impairment as evidenced by impaired ability to reposition his/herself in bed. Validating Nursing Diagnoses- in order to validate your nursing diagnosis, you need to ask yourself some questions like: Is my patient database (assessment data) sufficient, accurate, and supported by nursing research? Does my synthesis of data (significant cues) demonstrate the existence of a pattern? Are the subjective and objective data I used to determine the existence of a pattern characteristic of the health problem I defined? Is my tentative problem statement based on scientific nursing knowledge and clinical expertise? Is my degree of confidence above 50% that other qualified practitioners would formulate the same statement based on my data? Common Errors in Writing Nursing Diagnoses- -premature diagnoses based on an incomplete database. -erroneous (incorrect) diagnoses resulting from an inaccurate database or a faulty data analysis. -routine diagnoses resulting from the nurse’s failure to tailor data collection and analysis to the unique needs of the patient. -errors of omission meaning leaving out something important that should not have been left out. Chapter 17 (outcome identification and planning) Goal of Outcome Identification and Planning Step -Establish Priorities -Identify and write expected patient outcomes -Select evidence-based nursing interventions -Communicate the nursing plan of care *always remember to listen to your patient is telling you. For example if your patient has anxiety; the first thing you have to do is resolve their feelings before moving onto another intervention. *Also think about ABC’s when it comes to priority with your patients. ABC- Airway, Breathing, Circulation A Formal Care Plan Allows the Nurse Individualize care that maximizes outcome achievement Set priorities Facilitate communication among nursing personnel and colleagues Promote continuity of high-quality, cost-effective care Coordinate care Evaluate patient response to nursing care Create a record used for evaluation, research, reimbursement, and legal reasons Promote nurse’s professional development Three Elements of Comprehensive Planning Initial Ongoing Discharge Initial Planning- -developed by the nurse who performs the nursing history and physical assessment. -addresses each problem listed in the prioritized problem list. -identifies appropriate patient goals and related nursing care. Ongoing Planning -carried out by any nurse who interacts with the patient -keeps the plan up to date, manages risk factors, and promotes function. -states problem statements more clearly -develops new problem statements -makes outcomes more realistic and develops new outcomes as needed -identifies nursing interventions Discharge Planning -Carried out by the nurse who worked most closely with the patient -Begins when the patient is admitted for treatment -Uses teaching and counseling skills effectively to ensure that home care behaviors are performed competently Establishing Priorities (ONE OF THE MAIN THINGS FOR OUTCOME IDENTIFICATION AND PLANNING IS ESTABLISHING PRIORITIES) -Maslow’s hierarchy of human needs -Patient preference (patient centered care) -Anticipation of future problems -Critical thinking/ clinical reasoning and judgement *ALWAYS THINK AIRWAY, BREATHING, CIRCULATION WITH EVERY SINGLE PATIENT* Maslow’s Hierarchy of Human Needs Physiologic needs Safety needs Love and belonging needs. Self-esteem needs Self-actualization needs Parts of a Measurable Outcome (all of these components need to be present in order to have a measurable outcome. For every single patient we take care of) Subject Verb Conditions Performance criteria Target time Categories of outcomes: Cognitive: describes increases in patient knowledge or intellectual behaviors Psychomotor: describes patient’s achievement of new skills Affective: describes changes in patient values, beliefs, and attitudes IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care include: -Safety: Avoid Injury -Effective: Avoiding overuse and underuse -Patient-Centered: Responding to patient preferences, needs and values (incorporate patients family and needs as well) -Timely: Reducing waits and delays -Efficient: Avoiding waste -Equitable: Providing care that does not vary in quality to all recipients Types of Nursing Interventions Nurse-initiated: autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes Physician-initiated: actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders Collaborative: treatments initiated by other providers and carried out by a nurse EXAMPLES OF Nurse-Initiated Interventions include: Monitor health status Reduce risks Resolve, prevent, or manage a problem Promote independence with ADLs Promote optimum sense of physical, psychological, and spiritual well-being Give patients information needed to make informed decisions and be independent Chapter 18 (Implementing) Purposes of Implementation. Implementations help: -Help the patient achieve valued health outcomes -Promote health -Prevent disease and illness -Restore health -Facilitate coping with altered functioning -Educating the patient about the benefits of following a patient-centered care treatment Focus of Nursing Implementation -Planned nursing actions are carried out during the implantation step of the nursing practice -we also focus on the scope of practice which is your: who, what, where, when, and why -care coordination and continuity of care *Alfaro’s rule: ASSESS, REASSESS, REVISE, RECORD Types of Nursing Interventions Those providing direct and indirect care. Independent and collaborative interventions Protocols and standing orders, which are written plans that are developed that specify nursing actions for that skill. Care bundles Supportive interventions; assist the patient with their current need/difficulties. Implementing the Plan of Care #1 -Determine the patient’s new or continuing need for assistance -Promote self-care -Assist the patient to achieve valued health outcomes -Reassess the patient and review the plan of care -Use patient boards or whiteboards -Plan ahead and organize resources -Clarify prerequisite nursing competencies Implementing the Plan of Care #2 -Anticipate unexpected outcomes and solutions -Ensure quality and patient safety -Promote self-care: teaching, counseling, and advocacy -Assist patients to meet health outcomes -Promote communication within healthcare professionals Common Reasons for Noncompliance for the plan of care Lack of family support Lack of understanding about the benefits Low value attached to outcomes Adverse physical or emotional effects of treatment Inability to afford treatment Limited access to treatment Five Rights of Delegation Right task Right circumstances Right person Right directions and communication Right supervision and evaluation Checklist for Organizing Student Clinical Responsibilities -Patient profile and name by which patient is addressed -Patient’s chief complaint and reason for admission -Patient’s current health status -Routine assistance to meet basic human needs -Priorities for nursing care and special daily events -Special teaching, counseling, or advocacy needs -Special family needs -Plan for unexpected outcomes