RESULT FOR "NUR 111 FUNDAMENTALS OF NURSING TEST"

RESULT FOR "NUR 111 FUNDAMENTALS OF NURSING TEST" Steps of the Nursing Process 1. Assessment 2. Diagnosis 3. Planning 4. implementation 5. Evaluation Components of a health hx biographical data, chief complaint, hx of present illness, past hx, family hx, lifestyle, and social data. Assessment Collecting, organizing, and validating data; documenting the pt assessment data; the purpose is to establish a database about the patients' response to health concerns or illness and their ability to manage their needs. Nursing Dx Analyzing and synthesizing data. The purpose is to identify a client's strengths and health problems that can be prevented or resolved by collaborative and nursing interventions. Planning Determining how to prevent, reduce, or resolve the identified priority client problems; determine how to support the client's strengths; determine how to implement the nursing interventions in an organized, individualized, and goal-directed manner. The purpose is to develop individualized plans of care that specify a client's goals or desired outcomes that are related to the priority nursing interventions. Implementation carrying out or delegating and documenting the planned nursing interventions. The purpose is to assist the client in meeting their desired goals or outcomes, to promote wellness, to prevent illness and disease, to restore health, and to facilitate the client with coping with altered functioning. Evaluation Measuring the degree to which the client's goals or outcomes have been met or have NOT been met. The purpose is to determine whether to modify, terminate, or continue the client's plan of care. Subjective Data Symptoms; the client's perception of their health problems. This information is only apparent to the client. Examples include pain, nausea, anxiety, and itching. Objective data Signs; observations or measurements made by the collector. Examples include vitals, wound size, vomiting, diarrhea, rash, and edema. Types of Nursing Dx Actual, risk, wellness, health promotion, and syndrome PES Components of a nursing Dx; 1. Problem, 2. Etiology (R/T), 3. signs/symptoms (AEB) SMART The guidelines for writing goals or outcomes are specific, Measurable, Attainable, Relevant, and Time-limited. Types of nursing interventions Independent, dependent, collaborative Independent intervention Nurse initiated; I/O, Teaching, Vitals, Emotional support, Assessments, Turns, cough, and deep breathing. Dependent intervention Physician-initiated; Medications, IV, Dressings, and Hot and Cold applications. Collaborative intervention interdependent; PT, OT, Respiratory therapist, social workers, dietitians. Cognitive Skills Problems solving, critical thinking, decision making Interpersonal skills good communication Technical skills psycho-motor; motor skills, coordination Implementation action words teach, administer, measure, obtain, institute Short term goal less than a week long term goal longer than a week Types of care plans Standardized, concept mapping, critical pathway Communication Process 1. Sender 2. Message 3. Channel 4. Receiver 5. Response Verbal communication guidelines pace and intonation (Speed and tone), simplicity, clarity and brevity, congruence (verbal and nonverbal behaviors need to match), timing and relevance, adaptability, credibility, and humor (when appropriate). Nonverbal Communication Guidelines Body language (gestures, movements, use of touch) Essential Skills for Communication Observation, interpretation, and gestures. Effective Written Communication appropriate language and terminology, correct spelling, punctuation, and grammar, logical organization, and the appropriate use and citation of resources. Factors that influence that communication process? Development and gender, sociocultural characteristics, values and perceptions, personal space and territoriality, roles and relationships, environment, congruence, and attitudes. Elderspeak Similar to baby talk; conveys disrespect. Making accommodations that include producing shorter, less complex sentences, using simpler vocabulary, filler words, fragmented sentences, lexical filters, and repetition. Personal Space space that an individual feels comfortable with; 1 to 4 feet. Intimate Space close and touching Social Space the space that an individual is comfortable in during a social interaction with many people. Example: Teaching Public Space what a person is comfortable within an area with those that he or she does not know. Example: Public concerts or parks. Barriers to communication stereotyping, agreeing and disagreeing, being defensive, challenging, probing, testing, rejecting, changing topics, unwarranted reassurance, passing judgment, and giving common advice. Types of communication Aggressive, Passive, and Assertive Aggressive communication focuses on their own needs; loud, blaming, and demanding. Passive communication focuses on the needs of others; concealing, denying, and avoiding. Assertive communication declare and affirm opinions; respecting, balancing, and acknowledging. Assertive communication techniques "I" statements, fogging, negative assertion, repetition, confidence, management of nonverbal communication, avoiding apologizing, preform post conversation evaluation. Sensory deficits ability to see, hear, feel, and smell could be diminished. Check for medic alert bracelets, hearing aids, reading lips, and sign language. Cognitive impairments Diminished cognitive abilities. CVD, Alzheimer's disease, brain tumor or injury, medications that influence function. Structural deficits cleft palate, artificial airways, extreme dyspnea Providing support for those with deficits or impairments convey encouragement, let the client know if you don't understand, keep questions open-ended, and provide touch if it is appropriate. Support for HOH speak 3-6 ft from the client, speak into a good ear, free environment from competing noise, make sure that the client can see you, and speak at a natural rate. Characteristics of Effective groups accomplish goals, maintain cohesion, and develop and modify structure to improve effectiveness. SOLER Therapeutic communication techniques; Sit facing the client, observe an open posture, Lean in towards the client, establish Eye contact, and Relax. Empathy the ability to understand and accept another person's reality. Purpose of client records communication, planning care, auditing health agencies, research, education, reimbursement, legal documentation, and health care analysis. Documentation systems Source-oriented record, Problem, interventions, and evaluation (PIE), Focus charting, Charting by exception, Electronic documentation, Case management, and Narrative documentation. SOAP Used by MD and NP; Subjective information, Objective information, Assessment, and Plan Nursing Care Plan Requirements Evidence of client assessment, nursing Dx, nursing interventions, client outcomes, and evidence of the current nursing care plan. Kardexes concise method for organizing records. May or may not be a part of the perminate record, can be done in pencil, organized in sections: Perminate information, Medications and IV fluids, TX and Procedures Flow sheet used for recording data quickly and concisely. Used for the graphic recording of I&O, MAR, SAR, and VS Progressive notes used to record progress, interventions, assessments, and data. General guidelines for documentation Date and time, Timing, Legibility, Permanence, Accepted terminology, Correct spelling, Signature, Accuracy, Observations and Facts, and appropriately record mistakes. Recording a mistake 1. draw a line through it 2. write initials and date and time (done by an edit in computer charting.) Do's of Charting chart changes, show follow-ups, read prior notes, be timely, objective, and factual information, correct errors, chart teaching, use quotes for responses from patients DON'Ts of charting leave blank spaces, use whiteout, chart in advance, use vague terms, chart for others, use "patient" or "client", alter a record or record assumptions Key elements of a change of shift report Give basic identifying information, the reason for admission, medical Dx, surgical procedures, and any tests that have been done or need to be completed. Be concise; present any significant changes in a patient's condition. Receiving Telephone Reporting Document the date, time, and caller's name. Give subject information and keep it concise. Sign the notation and repeat the information back to the caller for accuracy. Telephone Reporting to a Primary Care Provider Include; your name, relation to a patient, medical Dx, nursing assessment and changes and interventions, relate the patient VS to baseline VS, report significant lab data, and document the report date, time, and content. Be sure to have the client's chart in hand for any further information. SBARR Situation, Background, Assessment, Recommendation, and Response. Use for nurses calling the physician, handing off patients, and transferring patients. Domains of teaching and learning cognitive, affective, and psychomotor Cognitive learning thinking Affective learning feelings Psycho-motor learning tasks, active Task mastery the person or patient has mastered the desired task. Factors affecting learning motivation, readiness, timing, involvement, relevance, feedback, nonjudgmental support, repetition, environment, physiological events, emotions Telehealth use of telecommunication technology and computers to exchange information. 6 C's of Caring Compassion, competence, confidence, conscience, commitment, comportment Caring encounters knowing the client, nursing presence, empowering the client, compassion, and competence. caring for self adequate nutrition, activity and exercise, recreation, avoiding unhealthy practices Collaboration two or more people working toward a common goal by combining their skills, knowledge, and resources while avoiding duplication of effort. Basic competencies for collaboration good interpersonal skills, mutual respect and trust, giving and receiving feedback, decision-making skills, learning to value and manage diversity, developing good conflict resolution skills, and learning to create win-win situations. Mutual respect and trust occurs when two or more individuals show or feel honor or esteem toward one another. Trust occurs when an individual is confident in the actions of another individual. Role of a Nurse Plan care, teach, do nursing assessments, giving caring and competent care. Multidisciplinary Team Approach typically works together to deliver client care, single team member, usually the physician makes the treatment decisions. Characteristics of Effective Collaborations common purpose and goals, clinical competence of each provider, interpersonal competence, humor, trust, valuing and respecting diverse and complementary knowledge. Informatics science of using computer information systems in the practice of nursing Clinical information systems electronic health records, bedside medication administration, computerized provider order entry (COPE), client surveillance Advantages of nursing information systems better access to information, enhanced quality of documentation, improved quality of care, increased productivity, improved communication, reduced errors, reduced hospital costs, automatic billing, reminders, and prompts for charting. Intranet private computer networks; use internet protocols and technology, facilitate collaborative data sharing, fire-walled, email, conferencing, and access to clinical data. E-health health information, services, and products provided via the internet Ergonomic considerations study and design a work environment that will maximize productivity by reducing operator fatigue and discomfort. Managing Care describes the healthcare system when the goals are to provide cost-effective care that focuses on decreased costs and improved outcomes for groups of clients. DRG diagnosis-related group Case management Collaborative process of assessment, planning, facilitating, and advocating through communication and available resources to promote quality, cost-effective outcomes. HMO Health patient organizations; emphasize patient wellness; members choose primary care physicians, if their needs are not met they will be referred to a specialist. PPO Preferred provider organization; requires approval before being seen. Shared Governance Model encourages nurses at the bedside to assist in the decision-making process; and management from the bottom up; empowers staff to fix certain problems that they know exist; allows staff to evaluate their practice and change it to make it better. Nursing Care Delivery Methods Functional nursing, team nursing, and primary nursing. Functional nursing task-focused team nursing team members provide care under the supervision of the RN Primary nursing RN assumes a caseload of patients during their entire hospitalization. Public insurance Medicare, Medicaid, prospective payment system medicare federal/state insurance for older adults 65 and older and those with disabilities. Medicaid federal public assistance for those with low incomes; paid by the federal and state government prospective payment system paid by DRG; predetermined amount regardless of stay. Normal WBC 5000 to 10000 DME Durable medical equipment Mutual respect When two or more people show or feel honor or esteem toward one another. Normal WBC 5000 to 10000 DME Durable medical equipment Mutual respect When two or more people show or feel honor or esteem toward one another.