Checking accuracy and reliability
Actions based on inaccurate or unreliable information could cause patient harm
Comparing and Contrasting
the
... [Show More] process of looking for similarities and differences between situations
Clustering related information
Grouping together information with a common theme to determine issues, problems, or concerns.
Recognizing inconsistencies
realizing when pieces of information contradict each other
Distinguishing relevant from irrelevant
Deciding what information is pertinent to the patient
Determining the importance of information
Ability to determine importance or significance of patient information to current situation
Judging how much ambiguity is acceptable
Nursing judgement based on acceptable normal ranges may vary depending on a patient situation
Determining legal, ethical, and professional guidelines
Made with ethical, legal and professional guidelines
Managing potential complications
Planned nursing interventions to decrease the risk of future complications.
Identifying signs and symptoms
Indicates when a situation is normal, abnormal, or has changed.
Gathering complete and accurate data
Data collected from all available sources is used as the basis for identifying issues, problems, and concerns
Assessing systematically and comprehensively
Use a systematic method of assessment so no important information is missed
Predicting (and managing) potential complications
Look at the big picture to prepare for potential future complications
Identifying assumptions
Arriving at a conclusion without supporting evidence
Nursing Process
five-step systematic method for giving patient care; involves assessing, diagnosing, planning, implementing, and evaluating
Aces tool
Assess function/expectation
Coordinate/manage care
use Evolving knowledge
make Situational decisions
Planning matches with?
Interpreting
Diagnosing matches with?
Interpreting
Assessing matches with?
Noticing (recognizing cues)
Evaluating matches with?
Reflecting (evaluate the outcome)
Competent nurse
has been practicing for 2-3 years; can prioritize and cope with various contingencies; requires assistance working through various situations not yet experienced
proficient nurse
understands a patient situation as a whole rather than as a list of tasks, attends to an assessment data pattern, and acts without consciously labeling it
PQRST
provocative
quality
region/radiation
severity
timing
Responding aligns with?
Implementing (carry out the plan)
Interpreting aligns with?
Diagnosing/planning
Noticing aligns with?
Assessment
Expert nurse
They make decisions using an advanced level of intuition and analytical ability.
They do not need to rely on rules to comprehend a situation and take action.
impartial
Principle of justice, what is ethically right!
Reflecting aligns with?
Evaluating
SBAR
Situation
Background
Assessment
Recommendation
Six types of coordination
Care coordination
Case management
Care management
Discharged planning
Integrated care
Medical home care
KATZ tool
Used for lower function of patients similar to adls
self-management
Patient engagement (plan of care) prioritize things.
SPICES tool
Sleep disorders
Problems with eating or feeding
Incontinence
Confusion
Evidence of falls
Skin breakdown
Types of Assessment
-the patient-centered interview during a nursing health history.
-a physical examination.
-the periodic assessments you make during rounding or administering care.
American Nurses Association (ANA)
Professional organization that represents all registered nurses.
emanating
Any substance that flows out/ comes from a source of origin.
Implementing match with?
Responding (take action)
Diagnosing match with?
Interpreting
4 effective communication skills (4 c's)
Courtesy
Comfort
Connection
Confirm
9 parts of interpreting
Interpreting: thinking skills
1. Comparing and Contrasting 2. Clustering Related Information 3. Recognizing Inconsistencies 4. Checking Accuracy and Reliability 5. Distinguishing Relevant From Irrelevant 6. Determining the Importance of Information 7. Judging How Much Ambiguity Is Acceptable 8. Determining Legal, Ethical, Professional Guidelines 9. (Predicting and) *Managing Potential Complications
nursing scope of practice
Tasks or procedures that the nurse can perform within the state the nurse is working in.
clinical judgement
an interpretation or conclusion about a patient's needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient's response
clinical thinking
the ability to interpret arguments, evidence, raw information in a logical and unbiased fashion (problem solve)
Attributes of a nurse [Show Less]