Health Assessment-Module 9 Notes (Nursing process part 2) PDF

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Nursing process...

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Health Assessment Module 9: The Nursing Process (Part 2) Objectives:  Describe the nursing process and each of its 5 steps  Describe characteristics of the nursing process  Use ongoing data collection to determine how to safely and effectively implement a care plan  Understand why evaluation after a nursing intervention is important  Describe evaluation, it’s purpose and it’s relation to the other steps in the nursing process  Describe how to use the patient’s response to the plan of care to modify the plan accordingly  Describe guidelines for effective and thorough documentation  Identify measures to protect confidential patient information  Describe the purpose of patient records  Document patient data completely, accurately, currently, concisely and factually-avoiding legal problems  Describe the SBAR method of communicating with other healthcare professionals The Nursing Process: Implementation Purposes of Implementation  Help the patient achieve valued health outcomes  Promote health  Prevent disease and illness  Restore health  Facilitate coping with altered functioning Question: T/F? One of the advantages of using Nursing Intervention Classifications in nursing practice is to ensure appropriate reimbursement for nursing services. TRUE Aims of NOC Research  Identify, label, validate, and classify nursing-sensitive patient outcomes and indicators  Evaluate the validity and usefulness of the classification in clinical field testing  Define and test measurement procedures for the outcomes and indicators Clinical Reasoning and Implementing  Reassessing the patient for changes in status that might dictate a different set of interventions  Be sure that research supports the interventions you have selected and be open to between ways of addressing patient problems and issues  Always monitor the patient’s responses to your interventions so that you can modify the care plan if needed  Alfaro’s rule: “assess, reassess, revise, record.” 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

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Special family needs

Implementing Guidelines  Act in partnership with the patient/family  Before implementing, reassess the patient to determine whether the action is still needed  Approach the patient competently  Approach the patient caringly  Modify nursing interventions according to the patient’s 1. Developmental and psychosocial background 2. Ability and willingness to participate in the care plan 3. Responses to previous nursing measures and progress toward goal/outcome achievement  Check to make sure that the nursing interventions selected are consistent with standards of care and within legal and ethical guides to practice  Always question that the nursing intervention selected is the best of all possible alternatives  Develop a repertoire of skilled nursing interventions. The more options one can choose from, the greater the likelihood of success Types of Nursing Interventions  Those providing direct and indirect care  Those aimed at individuals, family, and community  Those for nurse-initiated and other provider-initiated treatments Question: Which one of the following nursing interventions is an indirect care interventions? A. A nurse explains available birth control measures to a young couple B. A nurse meets with the collaborative care team to plan nursing measures for a patient C. A nurse prays with a patient prior to surgery D. A nurse administers pain medication to a patient with end-stage renal cancer Rationale: An indirect care intervention is treatment performed away from the patient on behalf of a patient or group of patients, such as the example B, consulting with the collaborative care team. The remaining answer options are direct care interventions or treatment performed through interaction with the patient

Implementing the Care  Determine the patient’s new or continuing need for assistance  Promote self-care

Plan

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Assist the patient to achieve valued health outcomes Reassessing the patient and reviewing the care plan Clarifying prerequisite nursing competencies Organizing resources Anticipating unexpected outcomes/situations Preventing errors and omissions Promoting self-care: teaching, counseling, and advocacy Assisting patients to meet outcomes

Reassessing the Patient and Reviewing the Care Plan  Be sure that each nursing intervention is supported by a sound scientific rationale, as demanded by an evidence-based practice  Be sure that each nursing intervention is consistent with professional standards of care and consistent with the protocols, policies, and procedures of the institution or agency  Be sure that the nursing actions are safe for this particular patient and individualized to the patients preferences  Clarify any questionable orders Variables Influencing Outcome Achievement  Patient Variables o Developmental stage o Psychosocial background and culture  Nurse Variables o Resources o Current standards of care o Research findings o Ethical and legal guides to practice Question: Which example illustrates a nurse variable influencing patient outcomes? A. A patient in a nursing home refuses to take his medications B. A low-income family is unable to afford formula to their newborn infant C. An alcoholic patient is unwilling to participate in AA meetings D. A rape victim does not receive counseling in the emergency department because a counselor is not available Rationale: Nurse variables that influence the care plan include resources (answer D), current standards of care, research findings, and ethical and legal guides to practice. The remaining answer options are patient variables, which include the patient’s changing ability and willingness to participate in the care plan and personal responses to the nursing interventions implemented Common Reasons for Noncompliance  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

Question: T/F? When a patient fails to cooperate with the care plan despite the nurse’s best efforts, it is time to reassign the patient to another caretaker. FALSE. Rationale: When a patient fails to cooperate with the care plan despite the nurse’s best efforts, it is time to reassess the strategy Lecture # 2- Evaluating Evaluating Step  RN and patient together measure how well the patient has achieved the outcomes specified in the care plan  RN identifies factors that contribute to the patient’s ability to achieve expected outcomes and, when necessary, modifies the care plan  The purpose of evaluation is to allow the patient’s achievement of expected outcomes to direct future nurse-patient interactions Question: T/F? The purpose of evaluation is to allow the patient’s achievement of expected outcomes to direct future nurse-patient interactions. TRUE Rationale: The purpose of evaluation is to allow the patient’s achievement of expected outcomes to direct future nurse-patient interactions Actions Based on Patient Response to Care Plan  Terminate the care plan when expected outcome is achieved  Modify the care plan if there are difficulties achieving the outcomes  Continue the care plan if more time is needed to achieve the outcomes Question: Which action should the RN take when a patient has achieved each expected outcome in the care plan? A. Terminate the care plan B. Modify the care plan C. Continue the care plan Rationale: The care plan is terminated when the patient has achieved all of its goals. The care plan is modified when there are difficulties achieving outcomes. The care plan is continued if more time is needed to achieve the outcomes.

Four Types of Outcomes  Cognitive: increase in patient knowledge  Psychomotor: patient’s achievement of new skills  Affective: changes in patient values, beliefs, and attitudes

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Physiologic: physical changes in the patient

Question: Which example is a psychomotor outcome? A. A patient learns how to control his weight using the Choose MyPlate food guide B. A patient is able to test for glucose levels and inject insulin as needed C. A patient values his health enough to decide to quit smoking D. A patient is able to ambulate the hallway following knee surgery Rationale: Psychomotor outcomes involve the patient’s achievement of a new skill, such as controlling diabetes. Cognitive outcomes involve an increase in patient knowledge (Answer A). Affective outcomes pertain to changes in patient values (Answer C). Physiologic outcomes target physical changes in the patient (Answer D). 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 Question: T/F? Asking a patient to plan an exercise program to lower blood pressure based on information provided to the patient in an A/V presentation is an excellent method to evaluate a physiologic outcome. FALSE Rationale: Asking a patient to plan an exercise program to lower blood pressure based on information provided in an A/V presentation is an excellent method to evaluate a cognitive outcome. Five Classic Elements of Evaluation  Identifying evaluative criteria and standards  Collecting data to determine if criteria and standards are met  Interpreting and summarizing findings  Documenting judgement  Terminating, continuing, or modifying the plan Evaluative Criteria vs. Standards  Criteria: measurable qualities, attributes, or characteristics that specific skills, knowledge, or health status o Describe acceptable levels of performance by stating expected behaviors of nurse or patient  Standards: levels of performance accepted and expected by the nursing staff o Established by authority, custom, or consent

Variables Affecting Outcome Achievement  Patient o For example, a patient gives up and refuses treatment  Nurse o For example, a nurse is suffering from burnout

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Healthcare System o For example, inadequate staffing

Evaluative Statements  Decide how well outcome was met (met, partially met, or not met)  List patient data or behaviors that support this decision Revisions in the Care Plan  Delete or modify the nursing diagnosis  Make the outcome statement more realistic  Increase the complexity of the outcome statement  Adjust time criteria in the outcome statement  Change nursing interventions IOM’s 10 New Rules to Redesign and Improve Care 1. Care based on continuous healing relationships 2. Customization based on patient needs and values 3. The patient as the source of control 4. Shared knowledge and the free flow of information 5. Evidence-based decision making 6. Safety as a system priority 7. The need for transparency 8. Anticipation of patient’s needs 9. Continuous decrease in waste 10. Cooperation among clinicians Question: T/F? An outcome evaluation focuses on measurable changes in the health status of the patient or the end result of nursing care. TRUE Rationale: An outcome evaluation focuses on measurable changes in the health status of the patient or the end result of nursing care....