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1 Chapter 10: Blended Competencies, Clinical Reasoning, and Processes of Person-Centered Care 1) Thoughtful Practice a) Considerate and Compassionate b) Patient always at the center to promote i) Humanity, dignity, and well-being c) Seek to establish powerful partnerships d) Thoughtful Person-Centered Practice i) Patient Centered Nursing Process (1) Assessing (2) Diagnosing (3) Planning (4) Implementing (5) Evaluating ii) Reflective practice leading to personal learning iii) Clinical reasoning, judgment, and decision making iv) The nurses personal attributes, knowledge base, and clinical experience e) Guiding Principals of Person- Centered Care i) All team members are considered caregivers ii) Care is based on continuous healing relationships iii) Care is customized and reflects patient needs, values, and choices iv) Knowledge and information are freely shared between and among patients, care partners, physicians, and other caregivers v) Care is provided in a healing environment of comfort, peace, and support vi) Families and friends of the patient are considered and essential part of the care team vii) Patient safety is a visible priority viii) Transparency is the rule in the care of the patient ix) All caregivers cooperate with one another through a common focus on the best interests and personal goals of the patient x) The patient is the source of control for their care 2) Theories of Caring a) Therapeutic Relationship- when the relationship between the carer and the cared for is use for promoting or restoring the health and well-being of people within the relationship 3) The Professional Nurse a) Personal Attributes i) Open-mindedness ii) Profound sense of the value of the person iii) Self-awareness and knowledge of one’s own beliefs and values iv) Sense of personal responsibility for actions v) Motivation to do what you do to the best of your ability because you care about the well-being of those entrusted in your care vi) Leadership skills vii) Bravery to question the system b) Knowledge Base c) Blended Competencies i) Manage patient’s care scientifically, holistically, and creatively (1) Nurses need many cognitive, technical, interpersonal, and ethical/legal competencies

4) Developing Cognitive Competencies a) Critical Thinking- systematic way to form and shape one’s thinking

2 i) It is a thought that is disciplined, comprehensive, based on intellectual standards, and well reasoned b) 5 types of consideration to lead to critical thinking i) Purpose of Thinking- helps discipline your thinking ii) Adequacy of Knowledge iii) Potential Problems- learn to flag and remedy pitfalls to sound reasoning iv) Helpful Resources v) Critique of Judgment/Decision vi) Focused Critical Thinking Guides 5) QSEN Competencies a) Provides future nurses with the knowledge, skills, and attitudes necessary to improve the quality and safety of the healthcare systems in which they work b) Patient Centered Care c) Teamwork and collaboration d) Evidence based practice e) Safety f) Informatics 6) Clinical Reasoning, Judgments, and Decision Making a) Critical Thinking- reasoning outside and inside the clinical setting b) Clinical Reasoning- ways of thinking about patient care issues c) Clinical Judgment- the result of critical thinking or clinical reasoning d) Critical Thinking and Critical Reasoning i) Is purposeful, informed, and outcome focused thinking ii) Is driven by patient, family, and community needs iii) Is based on principles of nursing process and scientific method iv) Uses both intuition and logic, based on knowledge, skills, and experience v) Requires strategies that make the most of human potential vi) Is constantly reevaluating, self-correcting, and striving to improve 7) The Nursing Process a) Systematic method that directs the nurse and patient, as together they accomplish the following i) Assess (1) Assess the patient to determine the need for nursing care ii) Nursing Diagnosis (1) Determine nursing diagnosis for actual and potential health problems iii) Outcome Identification and Planning iv) Implementing v) Evaluate the results 8) Characteristics of the Nursing Process a) Systemic i) Part of an ordered sequence of activities ii) An activity depends on the accuracy of the activity that precedes it and influences the actions b) Dynamic i) Great interaction and overlapping among the five steps c) Interpersonal i) The human being is always at the heart of nursing d) Outcome Oriented i) Nurses and patients work together to identity outcomes ii) Determine which outcomes are most important to the patient and match them with appropriate nursing actions e) Universally Applicable i) A framework for all nursing activities

3 9) Documenting the Nursing Process a) Accurate, precise, and relevant documentation provides all members of the healthcare team with a picture of the patient b) Patient record is the chief form of communication c) Nursing action not documented did not occur 10) Benefits of the Nursing Process a) Patient i) Scientifically bases, holistic, individualized patient care ii) Continuity of care iii) Clear, efficient, cost-effective plan of action b) Nurse i) Opportunity to work collaboratively with other healthcare workers ii) Satisfaction of making a difference in lives of patients iii) Opportunity to grow professionally as they evaluate the effectiveness of interventions and variables that contribute positively or negatively to the patient’s outcomes

Chapter 11: Assessing 1) Assessing a) Assessing is the systematic, dynamic and continuous collection, organization, validation, and communication of patient data or information and is used in ALL phases of the process b) Collecting patient data is a vital part assessing c) Assessment is critical for safety, accuracy, and efficiency d) Nurse make an initial and ongoing assessment i) Alerts nurses of changes in the patient’s responses to health and illness and suggest necessary changes e) Assessing includes physiological, Sociocultural, spiritual, economic, and life-style factors f) Primary source of information is from the patient g) Nursing assessments focus on a client’s responses to a health problem and should include the clients perceived needs, health problems, related experience, health practices, values, and lifestyles 2) Characteristics of Nursing Assessments a) Purposeful b) Prioritized c) Complete d) Systematic e) Factual and Accurate f) Relevant g) Recorded in a standard manner 3) Types of Nursing Assessments a) Initial Assessment i) Shortly performed after patient is admitted to the health care facility ii) Most institutions have a time frame in which they must be completed iii) Purpose of this assessment is to establish a complete database for problem identification and care planning b) Focused Assessment i) Information gathered about a diagnosed condition ii) May be done during an initial assessment if the patients health problems surface iii) Identify new or overlooked problems iv) QPA- Quick priority assessments are short, focused, prioritized assessments you do to gain the most important information you need to have first c) Emergency Assessment

4 i) When a physiological or psychological crisis presents done to identify the life threatening problem ii) Ex. a patient brought into the ER that is bleeding from a stab wound d) Time-lapse Assessment i) Compared a current assessment to a baseline assessment ii) Can be comprehensive or focused 4) Data Collecting- gathering information systematically to establish assessment priorities a) Database: contains all client info including the nursing health history, physical assessment, primary care provider’s history and physical examination, lab/test results, and material contributed by other health personnel. b) Purpose i) Health Status ii) Health Problem Identification c) Types i) Subjective (1) Information perceived only by the affected person (a) Can not be perceived or verified by another person (2) For example experience, feeling dizzy, feeling anxious (3) Also called symptoms or covert data ii) Objective (1) Observable and measurable data that can be seen heard, or felt by someone other than the person experiencing them (2) For example elevated temperature, skin moisture, vomiting (3) Also called signs or overt data d) Methods of Collection i) Examination (1) Examination of the patient for objective data that may better define the patient’s condition and help the nurse plan care (2) Normally follows the history and interview and may verify data (3) Focuses on the patients functional abilities (4) The purpose is appraisal of health status, the identification of health problems, and the establishment of a database for nursing interventions (5) Review of systems ii) Observation (1) Determines the patient’s current responses (a) Physical (b) Emotional (2) Determine the patient’s current ability to manage care (3) Determine the immediate environment and its safety (4) Determines the larger environment (a) Hospital (b) Community iii) Interviewing (1) Interview techniques (a) Focus on the patient (b) Listen attentively (c) Ask about the main problem first (d) Pose questions and comments in an appropriate manner (e) Avoid comments and questions the impede communication (f) Use silence and touch appropriately (2) Types of interview questions (a) Open ended- allow patient to verbalize freely (b) Closed- elicit specific information (c) Validating- validate what is heard

5 (d) Clarifying- avert misconceptions (e) Reflective- encourage patient to elaborate on thoughts and feelings (f) Sequencing- place events in chronological order (g) Directing- obtain more patient information e) Characteristics i) Purposeful ii) Complete iii) Factual and Accurate iv) Relevant f) Sources i) Patient- primarily and usually the best source (1) Data recorded unless stated otherwise is assumed to have come from the patient ii) Family/Significant other (1) Very important when patient is a child or has limited capacity to share information iii) Patient Record (1) Allows for comprehensive nursing care iv) Other healthcare professionals v) Nursing and healthcare literature 5) Reporting and Recording Data a) Timing i) Data should be reported verbally immediately whenever assessment findings reveal a critical change b) Documentation i) Enter initial database into computer or record in link on designated forms the same day as patient is admitted ii) Summarize objective and subjective data in concise, comprehensive, and easily retrievable manner iii) Use good grammar and standards medical abbreviations iv) Document as soon as possible v) Subjective data should be recorded using patients own words vi) Avoid nonspecific words

Chapter 12: Diagnosing 1) Diagnosing a) Begins after the nurse has collected and recorded the patient data b) Purpose i) Identify how a person, group, or community responds to actual or potential health and life processes ii) Identify factors that contribute to or cause health problems (etiologies) iii) Identify resources or strengths that the person, group, or community can draw on to prevent or resolve problems 2) Nursing Concerns and Responsibilities a) 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 can not be prevented b) Look for evidence of risk factors i) If identified aim to reduce or control them c) Ensure safety and learning needs are met, and promote optimum function and independence 3) Types of Diagnosis a) Nursing diagnosis i) Describes patient problems nurses can treat independently ii) Focus on unhealthy responses to health and illness iii) May change day to day depending on the patient b) Medical diagnosis i) Describes problems for which the physician directs the primary treatment

6 ii) Identifies diseases iii) Remains the same for as long as a disease is present c) Collaborative Problems i) Managed by using physician-prescribed and nursing-prescribed interventions ii) Primary responsibility of nurses iii) PC- potential complication 4) Steps of Data interpretation & Analysis a) Recognizing Significant Data i) Compare data to standards ii) Standard- norm or generally acceptable rule, measure, pattern, or model to which data can be compared in the same class or category b) Recognizing Patterns or Clusters i) Data cluster- grouping of patient data or cues that points to the existence of a health problem ii) Nursing diagnosis should always be derived from a cluster not a single cue c) Identifying Strengths and Problems i) If the patient meets the standard the nurse concludes that the patient has strength in that particular area ii) Patient strengths might include: (1) Healthy physiologic functioning, emotional health cognitive abilities, coping skills, interpersonal strengths, and spiritual strengths iii) A person who does not meet a certain health standard probably has a limitation in that area and may benefit from professional care iv) Nurses also identify potential health problems (1) Ex. patient has signs of a wound but their white blood cell count is normal the nurse then predicts the patient likely to have a longer healing period d) Identify potential complications i) Research potential complications e) Reaching Conclusions i) The nurse researches one of four basic conclusions after interpreting and analyzing patient data (1) No problem (a) No nursing response is indicated (b) Reinforce patients health habits (2) Possible Problem (a) Collect more data (3) Actual or potential nursing diagnosis (a) Begin planning, implanting, and evaluating (b) If patient denies treatment make sure the patient understands possible outcomes of this (4) Clinical problem other than nursing diagnosis (a) Consult with appropriate HCP 5) Types of Nursing Diagnosis a) Actual Nursing Diagnosis i) Represent problems that have been validated by the presence of major defining characteristics ii) 4 common components (1) Label (2) Definition (3) Defining characteristics (4) Related factor b) Risk Nursing Diagnosis i) Clinical judgments that a person, family, or community is more vulnerable to develop the problem than others in the same or similar situation c) Possible Nursing Diagnosis i) Statements describing a suspected problem for which additional data are needed (1) Additional data used to confirm or rule out the suspected problem

7 d) Wellness Diagnosis i) Clinical judgments about a person, group, or community in transition from a specific level of wellness ii) More beneficial in settings that work with healthy patients e) Syndrome Nursing Diagnosis i) Comprise a cluster of actual or risk nursing diagnosis that are predicted to be present because of a certain even or situation (1) Ex. post trauma syndrome, post rape syndrome 6) Parts of Nursing Diagnosis Statements a) Problem- identifies what is unhealthy about a patient i) Addresses the human response ii) NANDA nursing diagnosis b) Etiology- identifies factors maintaining to unhealthy state i) Physiologic, psychological, sociologic, spiritual, and environmental factors ii) Related to (r/t) c) Defining characteristics- identifies the subjective and objective data that signal the existence of a problem i) As evidence by (AEB) d) Ex. Acute pain r/t myocardial ischemia AEB C/O of radiating chest pain to neck and left jaw 7) Guidelines for Writing a Nursing Diagnose a) Phrase as a patient problem or alteration in health state rather than as a patient need b) Make sure patient problem precedes etiology and the two are linked “related to” c) Define characteristics d) Write in legally advisable terms e) Use nonjudgmental language f) Make sure problem statement indicates what is unhealthy g) Avoid using defining characteristics, medical diagnoses, or something that cannot be changed h) Reread the diagnosis

Chapter 13: Outcome Identification and Planning 1) Outcome Identification and Planning a) Nurse works in partnership with the patient and family to: i) Establish priorities ii) Identify and write expected patient outcomes iii) Select evidence-based nursing interventions iv) Communicate the plan of nursing care b) Goal- aim or an end c) Patient outcome- expected conclusion to a patient health problem, or in the event of a wellness diagnosis, an expected conclusion to a patients health expectation d) Expected Outcome- is used to refer to more specific, measurable criteria used to evaluate the extent to which a goal has been met e) Patient, family, and nurse need to work together in this phase 2) Goal of Outcome Identification & Planning Step a) Establish priorities b) Identify and write expected patient outcomes c) Select evidence based nursing interventions d) Communicate the plan of care 3) A formal plan of care: allows the nurse a) Individualize care that maximizes outcome achievement b) Set priorities c) Facilitate communication among nursing personnel and colleagues

8 d) e) f) g) h)

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 seasons Promote nurse’s professional development

4) Unique Focus of Nursing Outcome Identification and Planning a) Primary purpose is to design a plan of care with and for the patient that, once implemented, results in the prevention, reduction, or resolution of patient health problems and the attainment of the patient’s health expectations, as identified in the patient outcomes 5) Elements of Comprehensive Planning a) Initial Planning i) Developed by the nurse who performs the nursing history and physical assessment ii) Addresses each problem listed in the prioritized nursing diagnosis iii) Identifies appropriate patient goals and related nursing care iv) Standardized care plans- prepared plans of care that identity the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem b) Ongoing Planning i) Carried out by any nurse who interacts with patient ii) Keeps the plan up to date to facilitate the resolution of health problems, manage risk factors, and promote function iii) States nursing diagnoses more clearly iv) Develops new diagnoses v) Makes outcomes more realistic and develops new outcomes as needed vi) Identifies nursing interventions to accomplish patient goals c) Discharge Planning i) Carried out by the nurse who worked most closely with the patient ii) In acute care this begins when the patient is admitted for treatment iii) Uses teaching and counseling skills effectively to ensure home care behaviors are performed competently 6) Establishing Priorities a) A nurse needs guidelines for ranking diagnosis b) High priority diagnosis- poses a great threat to the patients health and well being c) Medium Priority- not life threatening d) Low Priority- diagnosis that are not specifically related to the current level of health or well being e) Three helpful guides are: i) Maslow’s Hierarchy of Human Needs ii) Patient Preference iii) Anticipation of Future Problems (1) Maslow’s Hierarchy of Human Needs (a) Basic needs must be met before a person can focus on higher ones, patient needs must be prioritized according to the following hierarchy (i) Physiological needs (ii) Safety needs (iii)Love and belonging needs (iv) Self-esteem needs (v) Self-Actualization needs (2) Patients Preference (a) Directs you to first meet the needs that the patient thinks are most important, as long as this order does not interfere with other vital therapies (3) Anticipation for Future Problems (a) Nurses must tap their knowledge base to consider the potential effects of different nursing actions

9 7) Deriving outcomes from Nursing Diagnoses a) Outcomes are derived from the problem statement of the nursing diagnosis b) At least one outcome is created for each nursing diagnosis c) Other outcomes may be written d) Nursing Outcome Classification (NOC)- presents the first comprehensive standardized language used to describe the patient outcomes that are responsive to nursing interventions e) Long Term vs. Short-term outcomes i) Long term outcomes require a longer period to be achieved than short term (1) They may also be used as discharge goals 8) Determine Patien...