NURS 3000 Clinical Judgment Model Part 2 PDF

NURS 3000 - Professional Nursing Clinical Judgment Model, Part 2 Clinical Judgment Model Part 2 Harding University - Active Learning Guide, Module 3 Instructions Complete the module active learning guide as you work through the module content. Take notes, answer the questions on the guide, and respo...

NURS 3000 - Professional Nursing Clinical Judgment Model, Part 2 Clinical Judgment Model Part 2 Harding University - Active Learning Guide, Module 3 Instructions Complete the module active learning guide as you work through the module content. Take notes, answer the questions on the guide, and respond to any case studies and client scenarios. All of these activities will assist in your preparation for exams, help you plan and implement care in the clinical setting, and facilitate your development as a Christian nurse servant. You will submit your completed guide to the instructor at the end of the week. The completed learning guide will be worth a maximum of 10 points. If you have questions or are unsure about your answers you may email your instructor for clarification. Note: The Active Learning Guide provides a general outline of topics covered in this module; it is not all-inclusive of all information needed for the exam. You are responsible for all content in readings and activities throughout the module. I. Planning/Generating Solutions: Chapter 12 1. What is planning? Purpose of planning? pg. 199 Planning is intentional and systematic stage of the nursing process that includes decision making and problem solving. In planning, the nurse relates to the client’s assessment data and diagnostic statements for guidance in formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client’s health problems 2. What is discharge planning and when does it begin? pg. 200 The process of anticipating and planning for needs after discharge, is a crucial part of a comprehensive healthcare plan and should be addressed in each client’s care plan. Effective discharge planning begins at first client contact and involves comprehensive and ongoing assessment to obtain information about the client’s ongoing needs. 3. Briefly compare these: Standardized care plan versus Individualized care plan versus collaborative care plan/critical pathway. pg. 200-203 Standardized care plan → is an “official” or proper plan that defines the nursing care for a determined or specific groups of clients with common needs. Example, all patients that suffer from myocardial infarction, will receive the standard interventiions. An individualized care plan → is utilized to meet the unique needs and circumstances of a specific client needs that are not addressed by the standardized plan. A collaborative or multidisciplinary care plan → is standardized and summarizes the care that is required for a group of clients that have simmilar, common and predictable medical conditions. This type of care is sequenced and the care must be NURS 3000 - Professional Nursing Clinical Judgment Model, Part 2 given each day during the projected time of stay for that specific type of condition. 4. Discuss differences between protocols, policies, and procedures. pg. 202 Protocols → are developed prior to indicate and determine the required actions to be taken for a specific segment of client population. Policies/Procedures → are developed to regulate or govern how frequently occurring situation are handled. Example, the specific number of visitors a patient can have is a policy. Policies/Procedures can be similar to protocols to determine what is to be done a case of cardiac arrest as an example. If policy covers a situation that is relevant or pertinent to healthcare it will be noted in the care plan. Example “Make social service referral according to Policy Manual.” The actual policy itself, does not make it into the care plan or patient’s permanent record. 5. Look at Guidelines for Writing Nursing Care Plans pp. 204-205 List them and describe. pg. 204-205 Date and sign the plan → The date the plan is written is essential for evaluation, review, and future planning. Used with S.M.A.R.T. The date is used to measure the progress of patients after implementation and used when evaluating. The nurse’s signature demonstrates accountability to the client and to the nursing profession, since the effectiveness of nursing actions can be evaluated. Use category headings → “Nursing Diagnoses,” “Goals/Desired Outcomes,” “Nursing Interventions,” and “Evaluation” are the common headings. Include a date for the evaluation of each goal. Used with S.M.A.R.T. Use standardized, approved medical or English symbols and key terms → rather than complete sentences to communicate your ideas unless agency policy dictates. Example, write “Turn and reposition q2h” rather than “Turn and reposition the client every two hours.” Or, write “Clean wound H2O2 bid” rather than “Clean the client’s wound with hydrogen peroxide twice a day, morning and evening.” Be specific → Because nurses are now working shifts of different lengths, 12s, and 8s, it is even more important to be specific about expected timing of an intervention. To limit confusion. If the intervention reads “change incisional dressing q shift,” it could mean either twice in 24 hours, or three times in 24 hours, depending on the shift time. This miscommunication becomes even more serious when medications are ordered to be given “q shift.” Writing down specific times during the 24-hour period will help clarify. NURS 3000 - Professional Nursing Clinical Judgment Model, Part 2 Refer to procedure books or other sources of information → rather than including all the steps on a written plan. Include a reference “according to Policy Manual“ or example, write “See unit procedure book for tracheostomy care,” or attach a standard nursing plan about such procedures as radiationimplantation care and preoperative or postoperative care. Tailor the plan → to the unique characteristics of the client by ensuring that the client’s choices, such as preferences about the times of care and the methods used, are included. This reinforces the client’s individuality and sense of control. For example, the written nursing intervention “Provide prune juice at breakfast rather than other juice” should indicate that the client was given a choice of beverages. Ensure that the nursing plan incorporates preventive and health maintenance aspects as well as restorative ones → For example, carrying out the intervention “Provide active-assistance ROM (range-of-motion) exercises to affected limbs q2h” addresses the goal of preventing joint contractures and maintaining muscle strength and joint mobility. Ensure that the plan contains ongoing assessment of the client (e.g., “Inspect incision q8h”). It is always an ongoing assessment. Include collaborative and coordination activities in the plan → For example, the nurse may write interventions to ask a nutritionist or physical therapist about specific aspects of the client’s care. Make sure it is a team effort that can influence and improve clients care with a multi-vector approach. Include plans for the client’s discharge and home care needs. The nurse begins discharge planning as soon as the client has been admitted. It is often necessary to consult and make arrangements with the community health nurse, social worker, and specific agencies that supply client information and needed equipment. Add teaching and discharge plans as addenda if they are lengthy and complex. 6. What activities are involved in planning/generating solutions? Describe all four activities. pg. 205 See Table 12.1 Setting priorities → process of establishing a preferential sequence for addressing nursing diagnoses and interventions. The nurse and client begin planning by deciding which nursing diagnosis requires attention first, which second, and so on. Maslow’s Hierarchy of needs is used to determine. High Priority, Life-threatening problems, such as impaired respiratory or cardiac function. Medium Priority, Health-threatening problems, such as acute illness and decreased coping ability. NURS 3000 - Professional Nursing Clinical Judgment Model, Part 2 Low Priority, one that arises from normal developmental needs or that requires only minimal nursing support. Establishing client goals or desired outcomes → The nurse and client set goals for each nursing diagnosis, these are called desired outcomes. These goals are what the nurse hopes will be attained (S.M.Attainable.R.T.) after implementing (A.D.P.Implementation.E) the nursing interventions. Other terms used for goals are, expected outcome, predicted outcome, outcome criterion, and objective. Selecting nursing interventions and activities → Nursing interventions and activities are the actions that a nurse performs to achieve client goals. The specific interventions chosen should focus on eliminating or reducing the etiology of the nursing diagnosis, which is the second clause of the diagnostic statement. Writing individualized nursing interventions on care plans → After choosing the appropriate nursing interventions, the nurse writes them on the care plan. Date nursing interventions on the care plan when they are written and review regularly at intervals that depend on the individual’s needs. Intensive care unit, the plan of care will be continually monitored and revised. Community clinic, weekly or biweekly reviews may be indicated. The format of written interventions is similar to that of outcomes: verb, conditions, and modifiers, plus a time element. The action verb starts the intervention and must be precise. “Explain (to the client) the actions of insulin” is a more precise statement than “Teach (the client) about insulin.” “Measure and record ankle circumference daily at 0900” is more precise than “Assess edema of left ankle daily.” 7. How can the nurse use Maslow’s hierarchy of human needs to prioritize the client’s hypotheses? In Maslow’s hierarchy, physiologic needs such as air, food, and water are basic to life and receive higher priority than the need for security or activity. Growth needs, such as self-esteem, are not perceived as “basic” in this framework. Thus, nursing diagnosis of altered respiratory status would take priority over nursing diagnoses such as anxiety or impaired coping. NURS 3000 - Professional Nursing Clinical Judgment Model, Part 2 1. Physiological needs are biological requirements for human survival, e.g., air, food, drink, shelter, clothing, warmth, sex, and sleep. 2. Safety needs – people want to experience order, predictability, and control in their lives. 3. Love and belongingness needs refers to a human emotional need for interpersonal relationships, affiliating, connectedness, and being part of a group. 4. Esteem needs are the fourth level in Maslow’s hierarchy and include self-worth, accomplishment, and respect. 5. Self-actualization needs are the highest level in Maslow’s hierarchy, and refer to the realization of a person’s potential, selffulfillment, seeking personal growth, and peak experiences. 8. Fill in the following information about Client Goals:  Definition → describes, in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions.  Purpose → To improve the well being of client by setting Specific, Measureable, Attainable, Releveant and Timely or time based.  Describe the information in Table 12.2 Deriving Outcomes from Nursing Diagnoses pg. 207 Nursig Diagnosis → a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community. Opposite Healthy Responses or goals → The improvement that the nurses and client would like to see. Generally opposite of the nursing diagnosis. Desired Outcomes: The client will → The measurable and timely goal or outcome to be attained. 9. What are the differences between short and long-term goals? Short-term goals → are useful for clients who (a) require healthcare for a short time or (b) are frustrated by long-term goals that seem difficult to attain and who need the satisfaction of achieving a short-term goal. In an acute care setting, much of the nurse’s time is spent on the client’s immediate needs, so most goals are short term. Example, “Client will raise right arm to shoulder height by Friday.” Long-term goals or outcomes → are used to guide planning for their discharge to long-term agencies or home care, especially in a managed care environment. Outcomes are often set for clients who live at home and have chronic health problems and for clients in nursing homes, extended care facilities, and rehabilitation centers. NURS 3000 - Professional Nursing Clinical Judgment Model, Part 2 10.What questions should the nurse ask when developing client goals? pg. 208 What is the client’s problem? What is the opposite, healthy response? How will the client look or behave if the healthy response is achieved? (What will I be able to see, hear, measure, palpate, smell, or otherwise observe with my senses?) What must the client do and how well must the client do it to demonstrate problem resolution or to demonstrate the capability of resolving the problem? 11.What are the components of a goal statement? Table 12.3 See examples. pg. 209 Subject → The subject, a noun, is the client, any part of the client, or some attribute of the client, such as the client’s pulse or urinary output. The subject is often omitted in goals; it is assumed that the subject is the client unless indicated otherwise. Verb → The verb specifies an action the client is to perform, for example, what the client is to do, learn, or experience. Verbs that denote directly observable behaviors, such as administer, show, or walk, must be used. Conditions or modifiers → Conditions or modifiers may be added to the verb to explain the circumstances under which the behavior is to be performed. They explain what, where, when, or how. Example: Walks with the help of a cane (how). After attending two group diabetes classes, lists signs and symptoms of diabetes (when). When at home, maintains weight at existing level (where). Discusses food pyramid and recommended daily servings (what). Conditions → need not be included if the criterion of performance clearly indicates what is expected. Criterion of desired performance→ The criterion indicates the standard by which a performance is evaluated or the level at which the client will perform the specified behavior. These criteria may specify time or speed, accuracy, distance, and quality. To establish a timeachievement criterion, the nurse needs to ask “How long?” To establish an accuracy criterion, the nurse asks “How well?” Similarly, the nurse asks “How far?” and “What is the expected standard?” to establish distance and quality criteria, respectively. Examples are: NURS 3000 - Professional Nursing Clinical Judgment Model, Part 2 Weighs 75 kg by April (time). Lists five out of six signs of diabetes (accuracy). Walks one block per day (distance and time). Administers insulin using aseptic technique (quality). See Guidelines for Writing Goals. Why is it important to be so specific when writing a goal? To be measured, an outcome must be made more specific by identifying the indicators that apply to a particular client. Ideas for interventions come more easily if the desired outcomes state clearly and specifically what the nurse hopes to achieve. S.M.A.R.T. II. Planning – Interventions 1. Describe the Types of Interventions: pg. 211  Independent → are those activities that nurses are licensed to initiate on the basis of their knowledge and skills. Includes physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management, and making referrals to other healthcare professionals.  Dependent → activities carried out under the orders or supervision of a licensed physician or other healthcare provider authorized to write orders to nurses.  Collaborative/Interdependent → are actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, and primary care providers. Collaborative nursing activities reflect the overlapping responsibilities of, and collegial relationships among, health personnel. 2. Describe Criteria for choosing interventions. pg. 212 Safe and appropriate for the individual’s age, health, and condition. Achievable with the resources available. For example, a home care nurse might wish to include an intervention for an older client to “Check blood glucose daily.” In order for that to occur, the client must have intact sight, cognition, and memory to carry this out independently, family who can assist with this task, or available and affordable daily visits from a home care nurse. NURS 3000 - Professional Nursing Clinical Judgment Model, Part 2 Congruent with the client’s values, beliefs, and culture. Congruent with other therapies (e.g., if the client is not permitted food, the strategy of an evening snack must be deferred until health permits). Based on nursing knowledge and experience or knowledge from relevant sciences (i.e., based on a rationale). For examples of rationales, refer to the Nursing Care Plan for Margaret O’Brien on pages 214–215. Within established standards of care as determined by state laws, professional organizations (e.g., American Nurses Association), accrediting organizations (e.g., The Joint Commission), and the policies of the institution. Many agencies have policies to guide the activities of health professionals and to safeguard clients. Rules for visiting hours and procedures to follow when a client has cardiac arrest are examples. If a policy does not benefit clients, nurses have a responsibility to bring this to the attention of the appropriate people and facilitate a modification of the policy. 3. Writing Nursing Interventions: What specific elements should be included in every intervention? pg. 212 The date on the care plan, format of written interventions is similar to that of outcomes: verb, conditions, and modifiers, plus a time element. The time element answers when, how long, or how often the nursing action is to occur. Examples are “Assist client with tub bath at 0700 daily” and “Administer analgesic 30 minutes prior to physical therapy.” The specific intervention itself. 4. Why is it important for interventions to be based on scientific rationale? What is rationale? pg. 203 Scientific based interventions are evidence based interventions that have been found to promote safe and effective patient care that leads to improved outcomes. Rationale → the evidence-based principle given as the reason for selecting a particular nursing intervention. III. Implementing and Evaluating: Chapter 13 1. Implementing/Taking Action involves what? Consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions. The nurse performs or assigns the nursing activities for the interventions that were developed in the planning step and then concludes the implementing step by recording nursing activities and the resulting client responses. 2. What should the nurse do before implementing/taking action? Reassessing the Client/Take Vitals NURS 3000 - Professional Nursing Clinical Judgment Model, Part 2 Just before implementing an intervention, the nurse must reassess the client to make sure the intervention is still needed. Even though an order is written on the care plan, the client’s condition may have changed. For example, a client has a nursing diagnosis of Impaired sleep related to anxiety and unfamiliar surroundings. During rounds, the nurse discovers that the client is sleeping and therefore defers the back massage that had been planned as a relaxation strategy. 3. Discuss the guidelines for implementing interventions. pg 221  Base nursing interventions on scientific knowledge, nursing research, and professional standards of care (evidence-based practice) when these exist. The nurse must be aware of the scientific rationale, as well as possible side effects or complications, of all interventions. Example, a client has been taking an oral medication after meals; however, this medication is not absorbed well in the presence of food. Therefore, the nurse will need to explain why this practice needs to be altered.  Clearly understand the interventions to be implemented and question any that are not understood. The nurse is responsible for intelligent implementation of medical and nursing plans of care. This requires knowledge of each intervention, its purpose in the client’s plan of care, any contraindications (e.g., allergies), and changes in the client’s condition that may affect the order.  Adapt activities to the individual client. A client’s beliefs, values, age, health status, and environment are factors that can affect the success of a nursing action. For example, the nurse determines that a client chokes when swallowing pills. The nurse consults with the primary care provider to change the order to a liquid form of the medication. Or, the nurse observes that some clients prefer to drink hot water rather than ice water and, after confirming this preference with a specific client, supplies this at the bedside.  Implement safe care. For example, when changing a sterile dressing, the nurse practices sterile technique to prevent infection; when giving a medication, the nurse administers the correct dosage by the ordered route.  Provide teaching, support, and comfort. See Chapter 17 for details on client teaching and Box 17.4 for examples of verbs used in writing learning outcomes. The nurse should always explain the purpose of interventions, what the client will experience, and how the client can participate. The client must have sufficient knowledge to agree to the plan of care and to be able to assume responsibility for as much selfcare as desirable. These independent nursing activities enhance the effectiveness of nursing care plans NURS 3000 - Professional Nursing Clinical Judgment Model, Part 2  Be holistic. The nurse must always view the client as a whole and consider the client’s responses in that context. For example, whenever possible, the nurse honors the client’s expressed preference that interventions be planned for times that fit with the client’s usual schedule of visitors, work, sleep, or eating.  Respect the dignity of the client and enhance the client’s self-esteem. Providing privacy and encouraging clients to make their own decisions are ways of respecting dignity and enhancing self-esteem.  Encourage clients to actively participate in implementing the nursing interventions. Active participation enhances the client’s sense of independence and control. However, clients vary in the degree of participation they desire. Some want total involvement in their care, whereas others prefer little involvement. The amount of desired involvement may be related to the severity of the illness; the client’s culture; or the client’s fear, understanding of the illness, and understanding of the intervention. 4. Delegation: See chapter 18 pp. 327-330  List and describe the Five Rights of Delegation 1. The nurse delegates the; 2. right task 3. right circumstances 4. right person 5. right directions and communication 6. right supervision and evaluation  What tasks are generally ones which may be delegated to unlicensed personnel? Box 18.4 pg. 328 1. Commonly Assigned 2. Taking of vital signs on stable clients 3. Basic hygiene techniques 4. Bedmaking 5. Client transfers and ambulation 6. Personal care 7. Food service 8. Documentation 9. Safety measures (including fire, safety, and disaster preparedness, and infection control) 10.Performing basic life support (cardiopulmonary resuscitation [CPR]) 11.Basic preventative and restorative care and procedures 12.Basic observation procedures such as weighing and measuring  Box 18.5 Principles Used by the Nurse in Delegating pg. 330 NURS 3000 - Professional Nursing Clinical Judgment Model, Part 2 1. The nurse must assess the individual client prior to delegating tasks. 2. The client must be medically stable or in a chronic condition and not fragile. 3. The task must be considered routine for this client. 4. The task must not require a substantial amount of scientific knowledge or technical skill. 5. The task must be considered safe for this client. 6. The task must have a predictable outcome. 7. Learn the agency’s procedures and policies about delegation. 8. Know the scope of practice and the customary knowledge, skills, and job description for each member of your team. 9. Be aware of individual variations in work abilities. Each individual caregiver has different experiences and may not be capable of performing every task cited in the job description. 10.When unsure about an assistant’s abilities to perform a task, observe while the individual performs it, or demonstrate it to the individual and get a return demonstration before allowing the individual to perform it independently. 11.Clarify reporting expectations to ensure the task is accomplished. 12.Create an atmosphere that fosters communication, teaching, and learning. For example, encourage staff members to ask questions, listen carefully to their concerns, and make use of every opportunity to teach.  Who has ultimate responsibility for the care of the client? It is important to note that the nurse is not held legally responsible for the acts of the AP but is accountable for the quality of the act of delegation and has the ultimate responsibility for ensuring that proper care is provided. IV. Evaluating Outcomes 1. Discuss the five steps in the evaluation process. pg. 223  Collecting data related to the desired outcomes (NOC indicators): Did the client improve or deteriorate compared to the previous evaluation? NURS 3000 - Professional Nursing Clinical Judgment Model, Part 2  Comparing the data with desired outcomes: What improvements have been made in client care?  Relating nursing activities to outcomes: Have the nursing interventions resulted in the attainment of outcomes?  Drawing conclusions about problem status: What outcomes have been attained?  Continuing, modifying, or terminating the nursing care plan: What changes are needed in the plan of care to attain outcomes? 2. What are the three conclusions the nurse must consider when evaluating client outcomes/goals? pg. 223 The goal was met; that is, the client response is the same as the desired outcome. The goal was partially met; that is, either a short-term outcome was achieved but the long-term goal was not, or the desired goal was incompletely attained. The goal was not met. 3. Review Table 13.1 Evaluation Checklist on pg 225. Memorize the steps. Write them down and rehearse if necessary. 4. See Nursing Care Plan pg. 228-230 for examples of evaluation statements and note linkage back to the hypothesis statement and client goals. If the client goal is met and the client is still under the care of the nurse, the nurse must develop a new goal.