Funds exam 1 blue print PDF

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The Nursing Process Critical Thinking    

It is about asking the WHY!!!. And the WHATS!! What is happening with my patient and WHY? What is the skill needed and why do I do it like this? What do I need to assess and evaluate?

The profession requires you to be become a critical thinker; a professional who is not just a task doer but rather a person who critically thinks through processes and situations.    

Why did the doctor order this procedure? What do I need to do to prepare my patient for this procedure? Risks? Education needed?

Much of what we do as nurses is independent of anyone telling us what to do. It is the combination of art and science. How to do it? 

Doing it with:  Open-mindedness  Creativity  Confidence  Continual inquiry/Perseverance

 Restoration of function begins early in the care of patients whose ability to perform self-care is disrupted.  Encouragement, support, commitment, and perseverance are important attitudes in critical thinking for these patients.  Perseverance is necessary when caring for patients who depend on you for assistance with ambulation or exercise.  Creativity is necessary when designing interventions for improving activity tolerance and mobility skills. Levels of Critical thinking:   

Basic level – going step by step without changing them to specify the patients needs. Complex – as we graduate the program Commitment – having years under nursing license

Assessment (pg 209) 1. 2.  

Look at chart Talk to caregiver/ family Initial – by RN at first encounter, Complete database/ Gordon’s Health Patterns Problem Focused – part of episodic reassessment

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Emergency assessment – Airway, Breathing, Circulation

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Time-lapsed – Shift to shift report (Nurse  Nurse) Ex: they are coming out of surgery; I’m going to look at incision. Ex: they come in with chest pain, I’m focused on the heart. Table 16-1 example of problem-focused patient assessment: Pain

Complete database (box 16-3)   

Client Secondary sources: Family/ Wife/ Health care members/ Medical records Critical thinking: - Literature: what you’ve learned, can research - Nurse’s experience: what you’ve done

Validating Data   

Complete, Factual, Descriptive, and Accurate Cues: data directly seen or given by client to nurse (use senses) Inference: nurse’s conclusion based on cues.

Use of TC pg 213-217     

Establish a report Eye contact Active listening Open-ended questions Read the examples of open & close ended questions provided on p. 217 for nurses and pay particular attention to Box 16-4 CULTURAL ASPECTS OF CARE

Gordon’s Functional Health Patterns pg 212 box 16-1  

Way to organize assessment data that emphasizes health EX: nutrition; elimination; mobility

Nursing Diagnosis pg. 227-231-233   

Ex: altered tissue perfusion, pain; signs and symptoms that as a nurse we can treat SYMPTOMS OF DISEASE Actual Problems (PRIORITY) – Altered breathing pattern, acute pain High-risk – may or may not happen, but has a high risk of happening - EX: risk for falls, infection, suicide, aspiration

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1. 2. 3. 1. 2. 3. 4.

Wellness diagnosis – trying to improve diagnosis (knowledge deficit, bc patient doesn’t know how to take their medications at home) - Deficient knowledge, failure to thrive AIRWAY BREATHING CIRCULATION Problem (NANDA label) Etiology (Cause) – pathophysiology that is causing problem. Signs and symptoms (defining characteristics or AEB) Related to factors: objective/ subjective evidence (meds, lab work, pt statements)

This is referenced on pages 231 Data Interpretation – Formulating a Nursing Diagnosis as well as page 233 Related Factors and etiology. I will explain this more in class. Read the Table 17-1, 17-2 & 17-3 for Related Factors examples to the NANDA diagnoses.

Planning pg. 240  

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Establishing desired/ expected outcomes. What is going to kill the patient the fastest? - Patient is in pain, but that is not the priority if the patient cannot breathe. - Patient might not be eating great but that does not compare to their altered breathing pattern causing them to not get enough air. Planning addresses: - Involve patient in prioritizing - Severity of physiological needs - Congruency between disciplines of the health care team Establishing patient goals/ outcomes pg 242 - Long term goals – week to months - Short term goals - < 1 week Nursing care outcome: pg 244-245 - S: SPECIFIC - M: MEASURABLE - A: ATTAINABLE - R: REALISTIC - T: TIMED - Ex: - Client respiratory rate will be 12-18 breaths per minute with even, regular pattern by 1400. VS. Client’s breathing will be more regular before the end of the shift. - MUST BE MEASURABLE pg 244

Nursing interventions  

Dependent: requires physicians “ok”. Pg 246 Independent

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Collaborative: could include several disciplines to complete - Strategies must be SAFE, and APPROPRIATE, ACHIEVABLE, CONGRUENT, and based on nursing knowledge and standards of care. Pg 257  Primary = Prevent the problem, checking BP  Secondary = Maintain the problem so it doesn’t get worse (Pt has flu, giving them Tamiflu), taking meds for BP  Tertiary = Rehab, they already had problem and are in rehab  Care plan  Pick 2 problems  Have 3 interventions for each 1. Assess – check respiratory rate 2. Care – position them to help them breathe 3. Teach – teach them how to take their respiratory medications safely. EX:   

Nurse will assess respiratory status every 2 hours: 0800, 1000, 1200, 1400, to include rate, rhythm, depth, pain, temperature, and client perception of status. Rationale: Assessment of status allows proper planning of intervention revisions. (citation) Evaluation of intervention: RR 24, pattern regular, temp 99, client still anxious about pain.

Evaluation Process pg 270  

Identify if goals were met If the interventions were done by the nurse - Has expected outcome been met? - Does each intervention work for this problem? - If outcomes are met, then further interventions are not needed.  Discontinue plan of care - Share with patient - Verify goals are met and move on  Modifying care plan - Change in condition, needs, ability - Error in judgment - Failure to follow the appropriate steps  Reassess all steps and start over  Outcome management = Quality care!

Legal, Ethical Considerations 

Accountability* - ability to answer to one’s own actions

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Advocacy* – a person who speaks up for or acts on the behalf of the patient, protects the patients right to make own decisions, and upholds the principle of Fidelity (keep promises). (Pts needs/ wishes, questions) Autonomy – freedom to make own decisions free of external control; respect for this refers to the commitment to include patients in decisions about all aspects of care. Beneficence – taking positive actions to help others; DO GOOD; best interest of the patient is more important than self-interest Code of Ethics Confidentiality* - protection of patient information that is mandated by Health Insurance Portability and Accountability Act of 1996 (HIPPA) Ethics – distinguishing between right and wrong; study of conduct and character; determines what is valuable Futility of care Nonmalefcience – avoidance of harm; DO NO HARM - I know getting them up after surgery will make patient mad and is risky for pain and falls but the pros far outweigh the negatives; I will be safe follow protocol to prevent injury. Responsibility* - willingness to respect one’s professional obligation, do the right thing for my patient

Why must I know them? A nurse’s knowledge and understanding of the Code of Ethics for Nurses can arm a nurse with the power to be a major influencer in day-to-day decisions that are made regarding patient care outcomes. 13TH year in a row  Most honest profession  Highest ethical standards Ex: How will a nurse support patients’ autonomy? -

Supporting patient who have questions about medications Ensuring the questions are answered in a manner the patient understands

Resolution of an Ethical Dilemma  Step 1- Is this an ethical dilemma?  Step 2- gather info relevant to case  Step 3- clarify values; fact, opinion, and values  Step 4- verbalize problem; break it down  Step 5- ID possible course of action  Step 6- negotiate plan; understanding self and respecting others  Step 7- evaluate the plan over time

Not resolving a dilemma: = moral distress = burn out, substandard care, feelings begin impacting care -

Ethics committee Staff meetings 1:1 meeting

Legal Implications: Assault – any action that places a person in reasonable fear of harmful, imminent, or unwelcome contact. No actual contact is required for this to occur. EX: verbal Battery – any intentional touching without consent; this is physical Confidentiality – protects private pt information, HIPPA Defamation of character, p. 308 – the publication of false statements that damage a person’s reputation Durable power of attorney for health care (DPAHC), p. 305 – legal document that designates a person/ people to make health care decisions. False imprisonment, p. 308 – unjustified restraint of a person without a legal reason. Patient must be conscious of lack of freedom for it to qualify as false imprisonment. Informed consent – pts agreement to have procedure after receiving all the risks Living wills – can be changed (as long as the patient is not declared legally incompetent or lacks the capacity to make decisions). Document that directs treatment in accordance to pts wishes Malpractice – professional negligence; professional actions by professional people; failure to act in reasonable manner as a person with the same education experiences would in the same situation Negligence – lacking in care; care provided by non-professionals Nurse Practice Acts – describe and define the legal boundaries of nursing practice within each state. Occurrence report – investigation in an attempt to determine deviations from standards of care. Risk management – identifying possible risks, analyzing them, acting to reduce the risks, and evaluating the steps taken to reduce them. Slander – the action or crime of making a false spoken statement damaging a person reputation Standards of care – deviation from what a reasonable person would do in the same situation, minimal acceptable nursing care legally.

Quasi-intentional torts -

Invasion of privacy Defamation of character

 Slander – verbal  Libel – written Unintentional torts -

Negligence Malpractice

Misdemeanor = crime that causes injury but not serious harm -

Ex: failing to check bowel sounds after discontinuing NG suction and tube

Felony = serious offense = serious harm to person/society -

Ex: not reporting communicable disease Ex: taking a patient’s pain meds

DNR – still treat with compassion, still check on pt Insubordinate – refusal to accept an assignment by employer. -

The RN CANNOT delegate: EAT

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(1) assessment

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(2) interpretation of assessment data/information

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(3) evaluate the outcome or effectiveness of an intervention or nursing action

Nutrition BMI -

< 25 normal < 18.25 underweight 25-30 = overweight >30 = obese

Negative nitrogen = infection, burns wounds Consult with dietician if pt is malnourished Vitamin KADE – fat soluble ‘ Vitamin BC – water soluble Nutrition Risk Factors -

Diet history examples? Teeth, swallowing, amt/type of food, etc Medical history examples? Close pregnancies

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GI problems Medication history examples? Laxatives, antidepressants

The goal of the American Heart Association (AHA) dietary guidelines is to -

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reduce risk factors for the development of hypertension and coronary artery disease. Diet therapy for reducing the risk of cardiovascular disease includes balancing calorie intake with exercise to maintain a healthy body weight; eating a diet high in fruits, vegetables, and wholegrain high-fiber foods; eating fish at least 2 times per week; and limiting food and beverages that are high in added sugar and salt. The AHA guidelines also recommend limiting saturated fat to less than 7%, trans-fat to less than 1%, and cholesterol to less than 300 mg/day. To accomplish this goal, patients choose lean meats and vegetables, use fat-free dairy products, and limit intake of fats and sodium.

The nurse is assessing a patient receiving enteral feedings via a small-bore NG tube. Which assessment findings need further intervention? A. Gastric ph of 4.0 during placement check B. Weight gain fo 1 pound over a week C. Active bowel sounds in all quads D. Gastric residual aspirate of 350ml for the 2 nd consecutive time E. D- anything over 250ml on 2 consecutive checks is concerning. A patient is on enteral feedings through a NG tube. Which factors increase the risk of aspiration in the patient? (SATA) A. Coughing B. Diarrhea C. Lying flat D. Administration of prokinetic drugs E. Reflux disease F.

A, C and E...