Exam (elaborations) NR 226 Final Exam Study Outline

Exam (elaborations) NR 226 Final Exam Study Outline The Nursing Process o The purpose of the nursing process is to diagnose and treat human responses (e.g., patient symptoms, need for knowledge) to actual or potential health problems. Use of the process allows nurses to help patients meet agreed-on outcomes for better health. o The nursing process requires a nurse to use the general and specific critical thinking competencies described earlier to focus on a particular patient's unique needs. The format for the nursing process is unique to the discipline of nursing and provides a common language and process for nurses to “think through” patients' clinical problems  5 Steps of the Nursing Process (ADPIE) o Assessment  Phases of interview/assessment  An interview is an approach for gathering subjective and objective data from a patient through an organized conversation. An initial interview involves collecting a nursing health history and gathering information about a patient's condition  1. Orientation and Setting an Agenda o Begin an interview by introducing yourself and your position and explaining the purpose of the interview. Explain why you are collecting data and assure patients that all of the information will be confidential. o Your aim is to set an agenda for how you will gather information about a patient's current chief concerns or problems. Remember, the best clinical interview focuses on a patient's goals, preferences, and concerns and not on your agenda.  2. Working Phase-Collecting Assessment or Nursing Health History o Start an assessment or a nursing health history with openended questions that allow patients to describe more clearly their concerns and problems. For example, begin by having a patient explain symptoms or physical concerns and describe what he or she knows about the health problem or ask him or her to describe health care expectations. NR 226 Final Exam Study Outline Updated 2021 o Use attentive listening and other therapeutic communication techniques that encourage a patient to tell his or her story.  3. Terminating an Interview o Termination of an interview requires skill. You summarize your discussion with a patient and check for accuracy of the information collected. Give your patient a clue that the interview is coming to an end. For example, say, “I have just two more questions. We'll be finished in a few more minutes.” o This helps a patient maintain direct attention without being distracted by wondering when the interview will end.  Methods of obtaining data  An assessment is necessary for you to gather information to make accurate judgments about a patient's current condition. Your information comes from:  The patient through interview, observations, and physical examination.  Family members or significant others' reports and response to interviews.  Other members of the health care team.  Medical record information (e.g., patient history, laboratory work, x-ray film results, multidisciplinary consultations).  Scientific and medical literature (evidence about disease conditions, assessment techniques, and standards).  Subjective Data  Subjective data are your patients' verbal descriptions of their health problems. For example, Mr. Lawson's self-report of pain at the area where his incision slightly separated is an example of subjective data. Subjective data include patients' feelings, perceptions, and self-report of symptoms.  Only patients provide subjective data relevant to their health condition. The data often reflect physiological changes, which you further explore through objective review of body systems.  Objective Data  Objective data are observations or measurements of a patient's health status. Inspecting the condition of a surgical incision or wound, describing an observed behavior, and measuring blood pressure are examples of objective data.  Objective data is measured on the basis of an accepted standard such as the Fahrenheit or Celsius measure on a thermometer, inches or centimeters on a measuring tape, or a rating scale (e.g., pain).  When you collect objective data, apply critical thinking intellectual standards (e.g., clear, precise, and consistent) so you can correctly interpret your findings. o Diagnosis  Identify components of the nursing diagnostic statement  The diagnostic reasoning process involves using the assessment data you gather about a patient to logically explain a clinical judgment, in this case a nursing diagnosis.  The diagnostic process flows from the assessment process and includes decision-making steps. These steps include data clustering, identifying patient health problems, and formulating the diagnosis.  Identify assessment findings, goals, interventions, evaluations appropriate to a specific nursing diagnosis.  Be able to recognize the difference between each category. Context clues like “The Patient will…” means it is a goal. o Planning  Components of goal/outcome statement  A patient-centered goal reflects a patient's highest possible level of wellness and independence in function. It is realistic and based on patient needs, abilities, and resources. A patient-centered goal or outcome reflects a patient's specific behavior, not your own goals or interventions.  Goals and expected outcomes direct your nursing care. Once you set a patient-centered goal for a nursing diagnosis, the expected outcomes provide the desired physiological, psychological, social, developmental, or spiritual responses that indicate resolution of the patient's health problems.  Usually you develop several expected outcomes for each nursing diagnosis and goal. For a patient to resolve a goal, several measurable outcomes are needed to ensure that the goal is met. In the case of Mr. Lawson's diagnosis of Risk for Infection, Tonya knows that more than one outcome is needed to ensure that the patient is infection free.  The SMART acronym (Specific, Measurable, Attainable, and Realistic, Timely) is a useful approach for writing goals and outcome statements more effectively. o Implementation  Independent nursing interventions  Nurse-initiated interventions are the independent nursing interventions or actions that a nurse initiates without supervision or direction from others.  Examples include positioning patients to prevent pressure ulcer formation, instructing patients in side effects of medications, or providing skin care to an ostomy site. Independent nursing interventions do not require an order from another health care provider.  Dependent nursing interventions  Health care provider–initiated interventions are dependent nursing interventions, or actions that require an order from a health care provider. The interventions are based on the health care provider's response to treating or managing a medical diagnosis.  Advanced practice nurses who work under collaborative agreements with physicians or who are licensed independently by state practice acts are also able to write dependent interventions.  As a nurse you intervene by carrying out the health care provider's written and/or verbal orders. Administering a medication, implementing an invasive procedure (e.g., inserting a Foley catheter, starting an intravenous [IV] infusion) and preparing a patient for diagnostic tests are examples of health care providerinitiated interventions.  Direct care activities  Direct care interventions are treatments performed through interactions with patients. For example, a patient receives direct intervention in the form of medication administration, insertion of a urinary catheter, discharge instruction, or counseling during a time of grief.  Indirect care activities  Indirect care interventions are treatments performed away from a patient but on behalf of the patient or group of patients (e.g., managing a patient's environment [e.g., safety and infection control]), documentation, and interdisciplinary collaboration. o Evaluation  Elements of the evaluation process  Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the first four steps of the nursing process, a patient's condition or well-being improves.  You conduct evaluative measures to determine if your patients met expected outcomes, not if nursing interventions were completed. The expected outcomes established during planning are the standards against which you judge whether goals have been met and if care is successful.  You examine the results of care by using evaluative measures, which are assessment skills and techniques (e.g., observations, physiological measurements, use of measurement scales, patient interview).  In fact, evaluative measures are the same as assessment measures, but you perform them at the point of care when you make decisions about a patient's status and progress. The intent of assessment is to identify which, if any, problems exist. The intent of evaluation is to determine if the known problems have remained the same, improved, worsened, or otherwise changed.  Professional Practice o Delegation  5 rights 1. Right task – ones that are repetitive and require little supervision, relatively noninvasive, results that are predictable, minimal risk (ex: specimen collection, ambulating stable pts, prepping room for pt. admit) 2. Right Circumstances – patient setting, available resources 3. Right person – make sure that the tasks match the person’s level of expertise 4. Right Direction / Communication – give clear, concise descriptions of the task including its objective, limits, and expectations 5. Right Supervision/ Evaluation – provide appropriate monitoring, evaluation, intervention when needed, and feedback  supervision o Prioritization of care – organization of vison of desired outcomes for a patient  High Priority – immediate threat to patient’s survival or safety (ex: obstructed airway, loss of consciousness, psychological episode of anxiety attack, ABC’s)  Intermediate Priority – non-emergency, nonlife threatening actual or potential needs that a pt. and family members are experiencing (ex: teaching needs of pt. related to a new drug, taking measures to decrease post-operative complications)  Low Priority – actual or potential problems that are not directly related to a patient’s illness or disease. (ex: developmental needs or long-term health care needs such as self-care at home) o Nursing care delivery model 1. Traditional Models  Team nursing – developed in response to severe nursing shortage  Primary nursing – developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members  Patient and family centered – mutual partnerships among the patient, family, and health care team are formed to plan, implement and evaluate the nursing and health care delivered  Four core concepts 1. Respect and dignity – ensuring that care provided is given based on a pt.’s and family’s knowledge, values, beliefs, and cultural backgrounds 2. Information sharing – health care providers communicate and share information, so patients and families receive timely, complete, and accurate information to effectively participate in care and decision making 3. Participation – pts and families are encouraged and supported in participating in care and decision making 4. Collaboration – demonstrated by health care leaders collaborating with patients and families in policy and program development, implementation, and evaluation and patients who are fully engaged in their health care o Management of patient care  Organization – combine and utilize effective use of time (doing the right things) and efficient use of time (doing things right), approaches any procedure or situation as well prepared as possible  Time management – involve learning how, where, and when to use your time; remain goal oriented and use it wisely; use pt. goals to identify priorities (ex: priority to do list)  Utilization of resources – resources include all members of the health care team, pt. care occurs more smoothly when staff members work together; more help can ensure a more comfortable and safer procedure/environment for the pt.  Evaluation – ongoing task; compares actual patient outcomes with expected outcomes; reveals the need to continue current therapies for a longer period, revise approaches to care, or introduce new therapies o Leadership  Characteristics of effective leader  Effective communicator  Consistent in managing conflict  Knowledgeable and competent in all aspects of delivery of care  Role model for staff  Uses participatory approach in decision making  Shows appreciate for a job well done  Shows appreciation for a job well done  Delegates work appropriately  Sets objectives and guides staff  Displays caring, understanding, and empathy for others  Motivates and empowers others  Is proactive and flexible  Focuses on team development  Ethics o Code of Ethics a set of guiding principles that all members of a profession accept. It is a collective statement about the group's expectations and standards of behavior. The American Nurses Association (ANA) established the first code of nursing ethics decades ago. The ANA reviews and revises the code periodically; but principles of responsibility, accountability, advocacy, and confidentiality remain constant. o Understand, give examples of terms Advocacy Advocacy refers to the support of a particular cause. As a nurse you advocate for the health, safety, and rights of patients, including their right to privacy and their right to refuse treatment. Responsibility The word responsibility refers to a willingness to respect one's professional obligations and to follow through. An example is following an agency's policies and procedures. Accountability Accountability refers to the ability to answer for one's actions. You ensure that your professional actions are explainable to your patients and your employer. Confidentiality Federal legislation known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates confidentiality about and protection of patients' personal health information. The legislation defines the rights and privileges of patients for protection of privacy. Social Networking The online presence of social networks presents ethical challenges for nurses. On one hand social networks can be a supportive source of information about patient care or professional nursing activities. Social media can provide you emotional support when you encounter hardships at work with colleagues or patients. On the other hand, the risk to patient privacy is great. Patients need to be confident that their most personal information and their basic dignity will be protected by the nurse. Issues – quality of life, genetic screening, futile care Quality of life represents something deeply personal. Health care researchers use quality-of-life measures to define scientifically the value and benefits of medical interventions. Quality-of-life measures may take into account the age of a patient, the patient's ability to live independently, his or her ability to contribute to society in a gainful way, and other nuanced measures of quality. Futile Care Difficult emotional and spiritual challenges resulting in moral distress can characterize the management of care at the end of life. The term futile refers to something that is hopeless or serves no useful purpose. In health care discussions the term refers to interventions unlikely to produce benefit for a patient. The concept is slippery when applied to clinical situations. If a patient is dying of a condition with little or no hope of recovery, almost any intervention beyond symptom management and comfort measures is seen as futile. In this situation an agreement to label an intervention as futile can help providers, families, and patients turn to palliative care measures as a more constructive approach to the situation. o Guidelines for ethical decision making Deontology proposes a system of ethics that is perhaps most familiar to health care practitioners. Deontology defines actions as right or wrong on the basis of their “right-making characteristics” such as fidelity to promises, truthfulness, and justice. It specifically does not look at consequences of actions to determine right or wrong. Instead, deontology examines a situation for the existence of essential right or wrong. Deontology depends on a mutual understanding of justice, autonomy, and goodness. But it still leaves room for confusion to surface.  Legal issues in nursing o Nurse Practice Acts describe and define the legal boundaries of nursing practice within each state. The Nurse Practice Act of each state defines the scope of nursing practice and expanded nursing roles, sets education requirements for nurses, and distinguishes between nursing and medical practice. o Regulatory law, or administrative law, reflects decisions made by administrative bodies such as State Boards of Nursing when rules and regulations are passed.  An example of a regulatory law is the requirement to report incompetent or unethical nursing conduct to the State 303Board of Nursing. HIPAA o Standards of care are the legal requirements for nursing practice that describe minimum acceptable nursing care. Standards reflect the knowledge and skill ordinarily possessed and used by nurses actively practicing in the profession. o The American Nurses Association (ANA) develops standards for nursing practice, policy statements, and similar resolutions. These standards outline the scope, function, and role of the nurse in practice. o Nursing standards of care are described in the Nurse Practice Act of every state, in the federal and state laws regulating hospitals and other health care agencies, by professional and specialty nursing organizations, and by the policies and procedures established by the health care agency where nurses work o Errors  The best way for nurses to avoid malpractice is to follow standards of care, give competent care, and communicate with other health care providers. You also avoid malpractice by developing a caring rapport with the patient and documenting assessments, interventions, and evaluations fully.  Nurses need to know the current nursing literature in their areas of practice. Know and follow the policies and procedures of the agency where you work. Be sensitive to common sources of patient injury such as falls and medication errors.  Finally, communicate with the patient, explain all tests and treatments, document that you provided specific explanations to him or her, and listen to his or her concerns about treatments. You are accountable for timely reporting of any significant changes in the patient's condition to the health care provider and documenting these changes in the medical record. o ADA  The Americans with Disabilities Act (ADA) of 1990 and as amended in 2008 is a civil rights statute that protects the rights of people with physical or mental disabilities.  The ADA prohibits discrimination and ensures equal opportunities for people with disabilities in employment, state and local government services, public accommodations, commercial facilities, and transportation.  As defined by the statute and the U.S. Supreme Court, a disability is a mental or physical condition that substantially limits a major life activity, including seeing, hearing, speaking, walking, breathing, performing manual tasks, learning, caring for oneself, and/or working.  Under the ADA employers are required to construe the definition of a person's disability to the maximum intent allowed under the ADA.