Test 3 NUR166.docx

Objectives: Chapters 19, 20, 21, 28 Chapter 19 Five Classic Elements of Evaluation -Identifying evaluate criteria and standards -collecting data to determine whether criteria and standards are met. -interpreting and summarize findings -documenting judgements -terminating, continuing, or modifying t...

Objectives: Chapters 19, 20, 21, 28 Chapter 19 Five Classic Elements of Evaluation -Identifying evaluate criteria and standards -collecting data to determine whether criteria and standards are met. -interpreting and summarize findings -documenting judgements -terminating, continuing, or modifying the plan. *time is a huge thing for planning! Is the outcome time frame reasonable? Four Types of Outcomes Cognitive- increase the patients knowledge Psychomotor- patient’s achievement of new skills Affective-changes in patient’s values, beliefs and attitudes Physiologic-physical changes in the patient Evaluating Outcomes Cognitive: asking patient to repeat information or apply new knowledge Psychomotor: asking patient to demonstrate new skill Affective: observing patient behavior and conversation Physiologic: using physical assessment skill to collect and compare data Evaluative Statements -Decide how well outcome was met (met, partially met, or not met)example: I chopped my leg off, lajesus says dr.jimenez is going to walk 15 steps. And dr. jimenez walks 15 steps, then is met. Stays met as long as the goal is met within the timeframe. Partially met: say dr. jimenez, walks the 15 steps so lajesus adds things to promote health and says -List patient data or behaviors that support this decision Short term goals – are within about 7 days Long term goals- for when patient goes home Actions Based on Patient Response to Care Plan -Delete or modify the diagnosis/problem -Make the outcome statement more realistic -Adjust Time criteria in outcome statement -Change nursing interventions Four Steps Crucial to Improving Performance Discover a problem. HOW DO U DISCOVER A PROBLEM W UR PATIENT? “how r u today? What brought u in to the ER today?” Plan a strategy using indicators. What is gonna be your strategy if I tell you I have right lower quadrant pain? Your gonna start planning in your head.. maybe its appendicitis?? Implement a change. Assess the change and/or plan a new strategy if outcomes are not met. Example: if its not appendicitis, what else could be? Seven Crucial Conversations in Health Care Broken rules Mistakes Lack of support Incompetence Poor teamwork – one of the biggest during interview is “what is the turnover rate?” if its high- do not take that job. Disrespect Micromanagement Chapter 20 Documentation -Written or electronic legal record of all pertinent interactions with the patient -Includes data related to assessing, diagnosing, planning, implementing, and evaluating -Facilitates quality, evidence-based patient care -Serves as financial and legal record -Helps in clinical research -Supports decision analysis If you didn’t document it, it didn’t happen. You must document everything. Characteristics of Effective Documentation Consistent with professional and agency standards example: if they say check vitals every 15 mins, it better be listed in that chat every 15 mins. Complete Accurate Concise Factual Organized and timely – say you performed an assessment at 9 am, you should document it at 9am not 6pm at end of shift, it marks it and saves it as documented at that time and looks bad on you as a nurse. Legally prudent Confidential Elements of Documentation Content Timing Format Accountability Confidentiality – everything is confidential Everything in the hospital is done on military time. Learn military time. What Is Confidential? -All information about patients written on paper, spoken aloud, saved on computer Name, address, phone, fax, social security number Reason the person is sick Treatments patient receives Information about past health conditions Methods of Documentation -Computerized documentation/Electronic health records (EHRs) -Source-Oriented Records Progress notes; narrative notes -Problem-Oriented Medical Records SOAP notes SOAP-Subjective, Objective, Assessment and Plan -PIE Charting: Problem, Intervention, Evaluation -Focus Charting -Charting by Exception Formats for Nursing Documentation -Initial nursing assessment -Care plan; patient care summary -Critical collaborative pathways -Progress notes -Flow sheets and graphic records -Medication administration record -Acuity record is how you get charged. -Discharge and transfer summary -Home health care documentation -Long-Term care documentation Hand-off Communication/ISBARR -Identity/Introduction -Situation -Background -Assessment -Recommendation -Read back of orders/response Change of shift/handoff reports Basic identifying information about each patient: name, room number, bed designation, diagnosis, and attending and consulting physicians Current appraisal of each patient’s health status Current orders (especially any newly changed orders) Abnormal occurrences during your shift Any unfilled orders that need to be continued onto the next shift Patient/family questions, concerns, needs Reports on transfers/discharges Conferring about Care -Consultations and referrals -Nursing and interdisciplinary team care conferences -Nursing care rounds -Purposeful rounding Eight Behaviors of Purposeful Rounding -Use Opening Key Words (C-I-CARE) with PRESENCE / C is for connecting the I is for Ask for permission for the A. -Accomplish scheduled tasks -Address four Ps : Potty, Pain, Personal Belongings and Position -Address additional personal needs, questions -Conduct environmental assessment -Ask “Is there anything else I can do for you? I have time.” -Tell the patient when you will be back -Document the round Chapter 21 Meaningful Use of Electronic Health Record -Improve quality, safety, efficiency, and reduce health disparities -Engage patients and family -Improve care coordination and population and public health -Maintain privacy and security of patient health information Components of System Development Lifecycle (SDLC) -Analyze and plan -Design and develop -Test -Train -Implement -Maintain -Evaluate Analyze and Plan #1 -What is the purpose of this new technology or change to the current technology? -What problem do we hope to solve? -What data do we have to indicate the current state of the issue (how bad is the problem)? -How will its use be incorporated into the current workflow of the nurse? Analyze and Plan #2 -Will it streamline nursing documentation, or will it increase the burden of documentation? -Will it improve the overall usability and experience with the EHR? -What technologic options are available if there are more than one? Design and Develop -What should the screen display look like? How should it be laid out to be consistent with other screen layouts? -Can the design support or improve the nurse’s workflow as mapped out during the analysis and planning phase? -Is there evidence supporting the effectiveness of the new technology and, if so, does it provide recommendations for the design? -Can we use standard nursing terminology in the electronic system to better capture nursing’s contribution to care delivery and patient outcomes? Testing Unit testing- testing certain small portions; not testing the whole thing yet. Small portions Function testing- does it work? Does it function? Is it working the way I told you? Integration testing- integrating little by little ; not just throwing someone in there to the wolves. Performance testing- if its working in the designed area. User acceptance testing- is it accepted? Telehealth and Mobile Technologies Telehealth: the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration Telemedicine: the use of telecommunications technologies to support the delivery of all types of medical, diagnostic, and treatment-related services, usually by physicians or nurse practitioners Telecare: refers to technology that allows consumers to stay safe and independent in their own homes   24. Examples of technology Evaluation steps: -Determine what will be evaluated -Determine the question -Conduct a literature search -Determine the needed data -Determine the study type -Determine the data collection method and sample size -Collect, analyze, and display data -Document your outcome evaluation Uses of Patient Portals #1&2 -Access medical history and other health information -Complete various forms and questionnaires online -Communicate securely and conveniently with providers -Request prescription refills -Pay bills -Review lab results -Schedule appointments -Receive reminders for appropriate screenings -Enter clinical data, such as blood pressure, glucose levels, weight, Fitbit data, and other activity tracking data -Review progress notes -Access educational materials based on diagnosis or procedure Benefits of Patient Portals -Better health outcomes -Chronic condition management -Timely access to care -Patient retention -Patient-centered medical home recognition Chapter 28 Factors Affecting Safety Developmental considerations Patient environments Functional ability Developmental Considerations #1, 2, & 3 -Neonate and Infant Fetal considerations Mobility Car seats -Toddler and preschooler Environment Poisoning Asphyxiation Child abuse -School Age Accidents Child abduction Bullying -Adolescent Driving Substance use, misuse, and abuse Piercings and tattoos Firearms Internet and social media Sex trafficking -Adult Drug use and poisoning Intimate partner violence -Older Adult Falls Motor vehicle accidents Fire Polypharmacy and poisoning Elder abuse Safety Consideration for Adults -Remind them of effects of stress on lifestyle and health -Enroll in defensive driving course -Counsel about unsafe health habits (reliance on drugs and alcohol) -Evaluate workplace for safety -Counsel about domestic violence Safety Considerations for Older Adults -Identify safety hazards in the environment -Modify the environment as necessary -Attend defensive driving courses or courses designed for older drivers -Encourage regular vision and hearing tests -Ensure hearing aids and eyeglasses are available and functioning -Have operational smoke detectors in place -Objective document and report any signs of neglect and abuse Factors That Contribute to Falls -Poor gait and balance -Strength issues -Visual impairment -Problems with feet -Comorbidities -Use of medications that increase fall risk -Orthostatic hypotension -Hazards in the home or community -Vitamin D deficiency Patient Safety -Orienting the Person to Surroundings -Preventing Falls in the Health Care Facility -Using Restraints in Health Care Facilities Physiologic Hazards Associated with Restraints -Increased possibility of serious injury due to fall -Skin breakdown -Contractures -Incontinence -Depression -Delirium -Anxiety -Aspiration and respiratory difficulties -Death RACE R—Rescue anyone in immediate danger. A—Activate the fire code and notify appropriate person. C—Confine the fire by closing doors and windows. E—Evacuate patients and other people to safe area Safety Event Reports -Must be completed after any accident or incident in a health care facility that compromises safety -Describes the circumstances of the accident or incident -Details the patient’s response to the examination and treatment of the patient after the incident -Completed by the nurse immediately after the incident -Is not part of the medical record and should not be mentioned in documentation Health Teaching in the Schools -Monitor the child’s use of the Internet -Get involved in school activities and ask pertinent questions -Volunteer for safety committees that include staff and parents -Ensure that the school’s emergency preparedness plan is current