NRSG139 Prac B notes PDF

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ƒNRSG139 – Practical B Clinical reasoning - Judgement - Assessment - Reasoning/rationale  Patient outcomes

What do we need to know? -

History taking (from pt) Patient chart info Handover Visual obs – assessment Cues Vital signs/obs

Student worksheet -

16 year old high school student, lives at home Presents to ED with a primary complaint of acute abdominal pain and fever Female adolescent in school uniform, slightly overweight, shy and reluctant to maintain eye contact, some hesitation to answer triage questions Identify unknown terminology - P,HR – heart rate - T – Temperature - BP – Blood pressure - RR – Respiratory rate - Sp02 – oxygen levels (RA – room air) (NP – nasal prongs) - GCS – anything less than an 8 is critical, 15 is the highest - PEARL – pupils’ reaction to light -

CRC stage one – consider the patient Describe or list facts - Duration of pain - Area of pain - Type of pain - Duty of care – respecting confidentiality - Privacy - School age (child bearing age) CRC stage two – collect cues and information Review current information, gather new information, recall knowledge - Acute abdominal pain - High school student - Slightly overweight - Slightly hesitant What do we need to know? - Any family medical history - Area of pain - Duration of pain CRC stage three – process information - Health assessment - UTI - STI - Previous medical and surgical history - Abdomen spilt into quadrants NRSG139 lecture notes Expectations 1 – engage and participate 2 – punctual 3 – professional 4 – be responsible for your learning -

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The aim of this first ‘Integrating Practice’ unit is to provide the foundations on which clinical assessments are based and model the way in which you will contextualize your theoretical knowledge through clinical practice. The purpose is to provide you with core foundational skills in preparation for clinical practicum in Semester 2.

1. Written Assignment (health assessment and critical practice) - Monday 1st April 2019 6pm - 30% - conduct a short health interview with a person (adolescent or older) - following the interview construct a written essay using the structured Clinical Reasoning Cycle (CRC) framework provided - Ax 1 Instructions document and marking rubric (unit outline) guide your work - All docs on LEO 2. Reflection on ANSAT (understanding clinical assessment) - Friday 19th April 2019 6pm - 30% - reflect on what you have learnt this semester related to a specific aspect of health assessment (health interviewing, measurement of TPR, or measurement of BP),

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as it relates to your developing ability to meet Criteria 4 of the ANSAT tool “Comprehensively Conducts Assessment” Ax 2 Instructions document, marking rubric (unit outline) and NMBA standards doc to guide your work

3. Objective Structured Clinical Examination (OSCE) - Teaching Week 9 or 10 during practical (simulation) class - 40% - in-class Week 9 or 10. Only come to the Week in which you are allocated. - I will randomly allocate and post the list for all students, about mid-semester. - instruction list for students attached (please read this particularly the Additional Points at the bottom of the document) - Marking criteria (attached) for your reference, students have access to this Leo resources MARKS WILL NOT BE RETURNED TO STUDENTS AT THE TIME OF ASSESSMENT. This is ACU policy that students do not have access to marks for all of the assessment tasks prior to finalisation and release of unit grades. Marks for the OSCE will be released to students after the release of Results for the unit. - a version of the marking criteria (i.e with the marks removed) is explicitly used in the Weeks 5, 6 & 7 lab classes as well. What must I do this week  Timetable – 1 lecture, 1 Practical Simulation (labs), 1 Practical Simulation (Classroom).  Nrsg139 LEO site https://leo.acu.edu.au/course/view.php?id=29049  Nrsg139 Unit Outline – find, read and understand  Assessment Task 1 - read it and start to plan  Health Simulation Centre MANDATORY Orientation Clinical assessment Collection of data (information) about an individual’s health - Subjective data – measured - Objective data – described Continuing (cyclical) process Purpose of Clinical Assessment - Complete patient assessment - Focused Assessment o Targeting assessment on a particular area - Follow-up assessment o Coming back to re-access after some time - Emergency assessment Principles of nursing assessment How do we collect information? - Interview o formal o Informal - Physical assessment

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Diagnostic testing Review of medical records

Gathering information - Structured - Objective - Purposeful - Accurate

The nursing process Nurses care for people of varying ages, experiencing physical or mental illness in a range of clinical contexts (Forbes & Watt, 2016). We do this by: - Assessment – gathering of information - Planning – clinical reasoning to guide decisions - Implementation – the ‘doing’ - Evaluation – re-assessment (Forbes & Watt, 2016; Holland, 2008). This is known as the nursing process – and can be further understood by drilling down into critical thinking and clinical reasoning frameworks.

Contexts for Clinical Assessment -

What is health? Health (and illness) is subjective and varies from person to person. How an individual defines health (and illness) can and does change over time and in different contexts. It is shaped by our cultural upbringing, personal (lived) experiences), level of health literacy, and the broader social determinants of health to which we are subjected. Therefore: conducting health assessment must consider the individuals definition of health (and illness), and the social and environmental contexts of their circumstances.

Person-centred care A philosophical approach in the provision of health care. People (i.e. patients/consumers) are involved in and are central to their care. Terminology: - Personhood - Percent-centredness - Person centered care Personal attributes required to provide person-centred care: - Open mindedness - Profound sense of value for the individual - Self-awareness and reflectivity - Personal responsibility for actions (moral agency) - Motivation to do the role to the best of your ability - Leadership - Courage to question **

Watch (0:00-6:50): Victoria State Government. (2015). Part 2 Person-centred care. https://www2.health.vic.gov.au/about/news-and-events/videos/patient-experience-2 Consider: - What are the patients saying is vital to care delivery? - Why would a disconnect between what is wanted and what is given, exist?

How do nurses make clinical decisions Requires critical thinking: - A active process of questioning, reflecting & interpreting It combines logic, intuition, and creativity - It is thinking that assesses itself with a view to improving it It is purposeful, reasoned & goal directed thinking that strives to problem solve patient care issued through the use of clinical reasoning (Estes, 2016 p3) Uses clinical reasoning: - Systematic and cyclical process that guides decision making (LevettJones, 2018 pg 4). - An advanced form of decision making implemented in clinical practice settings (Estes, 2013). This is the basis of the nursing process.

Clinical reasoning ‘a process by which nurses (and other clinicians) collect cues, process the information, come to an understanding of patient problems or situation, plan and implement intervention, evaluate outcomes and reflection and learn form the process’ Clinical reasoning cycle - Framework for thinking - Eight steps o Steps may merge or soften the boundaries between – they are presented here a discrete separate step. - It is dynamic – meaning ever changing - It is a continuous (cyclical) process. CRC & Person-Centred Care - Critical thinking uses clinical reasoning as an active process in making clinical decisions for all people in our care. - This is set on the backdrop of the principle of person-centred care. - The Clinical Reasoning Cycle is a dynamic framework of think and clinical decision making. In summary

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People (i.e. patients/consumers) are involved in and are central to their care. Clinical assessment is an on-going, cyclical process. . Processing new and changing information, within the context of the individual, is a difficult skill.

Practical B notes What is an individual health assessment? Comprises - Health assessment - Physical assessment Consideration - Therapeutic communication - Environment - Confidentiality - Note taking - Time/length duration - Biases and preconceptions - Diversity Health history - Subjective and objective information - Emergency/focused/comprehensive/ongoing Physical assessment - Uses ‘IPPA’ - Consists of: o General safety survey o Vital signs o Structured approach – head to toe, body system, RLT, Gordons functional health patters etc… o Diagnostics and laboratory information Trigger questions for exploration and discussion 1. What is assessment? And how does critical thinking fit into this? 2. Health assessment interview – techniques 3. Health assessment – history 4. Health assessment – physical assessment 5. Health assessment structure approaches – HTT, body systems, GFHP, RLT Health assessment – history Through the health history, the nurse elicits a detailed, accurate, and chronological health records seen from the client’s perspective. Types of questions  Previous operations  Medication  Allergies  Use of illicit substances  Immunisations

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Individual medical history and family history Sexual activity Living conditions Occupation Patient history as a child Health activities – sleep and exercise Reason of visit Date and time Biological information – DOB, gender etc…

NRSG139 – lecture week 2 Health sociology Health problems have social origins (Germov, 2014) ‘Health sociology’ helps us understand a wide range of health issues, that focus on the difference in health status between groups. For example: - Men and women - Poor and wealthy - Indigenous and non-indigenous It seeks the social patterns of health – rather than biomedical or psychological explanation (Germov, 2014) Diversity ‘All of the similarities and differences that make each individual unique, including characteristics a person is born with and those determined by social factors’ Often driven by groups we identify with: - Race & ethnicity - Gender - Sexual identity - Age and generation - Socioeconomic status/Class - Disability - Religion, faith and other beliefs - Education Culture The values, beliefs, behaviour, practices and material objects that constitute people’s way of life ‘A shared set of values, perceptions and assumptions based on shared language and other learned experiences Cultural diversity Australia is ethnically diverse - Immigrants: refers to those in a population born in another country (Germov, 2014). - Ethnic communities: ethnic groups that have established organisation to provide shared context for interaction between members (Germov, 2014). - Cultural stereotypes: shared image of members of ethnic group, often negative or simplistic (Germov, 2014).

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Racism: based on genetic traits, new racism includes cultural factors

Multiculturalism to cultural competence Multiculturalism is a policy term that refers to: - The expectation that all members of society have the right to services - Recognizes past and present cultural diversity promoting potential equality Ethnospecific services: services established to meet the needs of ethnic groups Mainstreaming: policy term that contrasts ethno specific services – providing access to services to all people Multiculturalism to cultural competence – not safety (yet) Cultural competence: ‘A set of behaviours, policies, and structures that enables the health care system to deliver the highest quality care to patients regardless of race, ethnicity, culture or language proficiency’ Four dimensions of cultural competency exist: - Systemic - Organizational, - Professional - Individual Cultural responsiveness: health care services that are respectful of, and relevant to, the health beliefs, health practices, culture and linguistic needs of diverse consumer/patient populations and communities. That is, communities whose members identify as having particular cultural or linguistic affiliations by virtue of their place of birth, ancestry or ethnic origin, religion, preferred language or language spoken at home Cultural safety - Principled term utilised to define new approaches to health care and community healing, adopted by aboriginal people and some organisations - Precise meaning and concept remain vague and elusive Evolutionary phase - This space is evolving within academia and government policy development – and is still a concept, and lacking outcomes Now more fully developed - Sits along the cultural continuum – cultural competency, cultural responsiveness, cultural safety In summary - Diversity can be looked at by thinking about all the ways in which we differ – some changeable and some not. - Dimensions of diversity exist and can intersect - Culture is defined as the values, beliefs, behaviour, practices and material objects that constitute people’s way of life – with cultural diversity prevalent in Australia - Cultural competency is a policy, behaviours that enable health care systems to deliver care regardless of ethnic differences.

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Cultural safety is a new and evolving principle along the cultural competence continuum.

Professional & therapeutic communication Professional communication: based on professional relationship where proficient communication skills are required to function as a member of an interprofessional team which in turn to effectively provide quality person centred care Therapeutic communication: based on a therapeutic relationship that is professional and interpersonal, between nurse and patient to achieve health related goals Communicating as a professional and with colleagues Levels of communication: - Intrapersonal - Interpersonal - Group communication o ISBAR - Group dynamics Forms: - Verbal o Language - Non-verbal o Touch o Facial expression o Posture o Gait o Gestures o Appearance o Dress/grooming o Sounds & silence The health assessment interview - Health history is first step of patient assessment - The health assessment interview is the meeting between you and the person seeking health care - It is is a purposeful, time-limited, goal directed, verbal interaction - Collects subjective data – what the person says about themselves Communication factors - Internal factors: o Liking others o Empathy o Listening o Biases & preconceptions - External factors: o Privacy

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Interruptions/time/duration Environment Dress Notes & note taking

Stages of the interview process Stage I – Joining stage or orientation phase: - Introductions – self, interview - Establishment of trust, building of rapport - Define relationship and set goals. Stage II – Working stage : - Bulk of the patient data is collected - Nurse’s responsibility to keep interview goal-directed. - Open ended and closed/direct questions Stage III – Termination stage: - Last stage: Summary and validation - Opportunities to give additional information and make comments or statements Factor affecting good communication Effective communication - Using open-ended questions - Using closed questions - Facilitating - Using silence - Grouping of techniques Factors affecting communication - Listening – particularly active listening - Non-verbal communication - Distance - Personal space Communication techniques Listening responses – received, processed and responded to messages: - Making observations - Restating - Reflecting - Clarifying - Interpreting - Sequencing - Encouraging comparisons - Summarizing Action responses – stimulate change in thinking or behaviour - Focusing - Exploring - Presenting reality

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Confronting Informing Collaborating Limit setting Normalising

Interview techniques to avoid Problematic techniques - Requesting an explanation/justification - Probing - Offering false reassurance - Giving approval or disapproval - Defending - Advising - Posing leading questions - Interrupting the patient - Neglecting to ask pertinent questions - Using multiple questions - Using medical jargon - Being authoritative - Having hidden agendas Types of health interview - Complete/comprehensive health history - Focused history - Ongoing history - Emergency health history In summary Professional and therapeutic communication is based on our relationships with each other and people in our care There are levels of communication and techniques used as a goal to illicit health care information The comprehensive health history is undertaken by health interview of people, with consideration for special populations Professional boundaries and awareness of self-discloser traps promote professional, empathetic and trusting relationships for the nurse and people in their care. Week Three Prac B Documentation/taking notes Relevant, accurate, complete and timely information about a patient’s care is documented in the healthcare record to support safe patient care - Legal record of your encounter with person - Represents persons health and history – be careful and confidential - Used by all members of health care team - Document in a professional and legally acceptable manner, follow institutions documentation system - Its ok to take notes, let the person know that is what your doing

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Electronic medical records (EMRs) are a paperless system of documentation o EMRise o Nursing informatics

O/E – on examination NKA – nil known allergies PMH – previous medical history PSH – previous surgical history Consider the patient - 18-year-old male - Fit and healthy - Nil known allergies - Walk in - Alert orientated - With mum - State of mind – distress/anxiety Collect cues - Nil known allergies - Left arm laceration approx. 5 cm long - Fingers pink limited movement - Bleeding freely when pressure moved - Pain on movement - No PMH PSH - Social family history (DV/abuse) - Wound assessment - Pain assessment - IV access - Vaccination HX Process information - Loss of blood - Recreation basketball wants to return to play - Laceration scarring/wound closure options - Pain issue/resolution - Neurovascular consult/imaging tests - A recovery health option Identify problems and issues - Pain management - Achieve haemostasis - Potential for OR Notes from video – just a routine operation - Communication failure - Lack of leadership - Focused on one thing - Lack of situational awareness - Nurses could have advocated for ICU P – probe A – Alert

C – Challenge E – Emergency NRSG139 lecture Semester 2 – NRSG140 Integrating Practice 2 -

Professional Practice Experience Nursing Handbook on the Professional Practice LEO Page 2019. 80 hours (2 week block) Mandatory documentation www.wil.acu.edu.au

Types of health interview - Complete/comprehensive health history - Focused history - Ongoing history - Emergency health history Approach to planning the interview Gather all available patient information and review Seek out an appropriate setting and time: - Professional approach - 30 – 60 minutes for full history –less for focused history - Positioning and comfort Assess yourself for problematic thoughts or feelings. Professional boundary/personal space Stages of the interview process Stage I – Joining stage or orientation phase: - Introductions – self, interview - Establishment of trust, building of rapport - Define relationship and set goals. Stage II – Working stage : - Bulk of the patient data is collected - Nurse’s responsibility to keep interview goal-directed. - Open ended and closed/direct questions Stage III – Termination stage: - Last stage: Summary and validation - Opportunities to give additional information and make comments or statements Beginning the interview - Begin the interview with a friendly introduction. - Introduce yourself by name ...