Separating the Professional from the

sharpfartsΤεχνίτη Νοημοσύνη και Ρομποτική

8 Νοε 2013 (πριν από 3 χρόνια και 9 μήνες)

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Separating the Professional from the
Technical


“the active, organized, cognitive process
used to examine one’s own thinking and
the thinking of others”



Using reflection, intuition, and previous
experiences to make sound decisions



Requires a habit of asking questions,
remaining well informed, a willingness to
reconsider, and avoiding premature
decision making


Knowledge base


Theoretical


Experiential


Experience


Practice making decisions


Technical Skills & Competencies


Attitudes and behaviors


Self aware


Genuine / authentic


Effective


communicator


Curious & inquisitive


Alert to context


Analytical & insightful


Logical and intuitive


Confident & resilient


Honest


Responsible &


autonomous



Careful & prudent


Open & fair minded


Sensitive to diversity


Creative


Realistic and practical


Reflective & self
-
corrective


Proactive


Courageous


Patient & persistent


Flexible


Improvement oriented



The Nursing Process: a systematic problem
solving approach consisting of;


Assessment


Diagnosis


Planning


Implementation


Evaluation


Nursing involves both thinking and doing


Nursing deals with complex issues



Brings together


Critical thinking


Nursing process


Nursing knowledge


Patient situation



Types of Assessment


Comprehensive



Focused


Special needs



Initial


Ongoing



Types of Data


Subjective



Objective



Sources of Data


Primary data


Client



Secondary data


Family


Health Records


Health Team Members



Methods of collection


Observation


Use all 5 senses



Physical assessment



Interview


Health history


Performed after nursing history


Collection of objective data


Ht., Wt., V.S.


General Survey


Head to toe exam


Inspection


Palpation


Percussion


Auscultation


Olfaction



Biographical Data


Reason for Seeking Health Care / Chief
complaint


Client’s Expectations


History of Present Illness


Past Health History


Family History / social history


Medications


Review of body systems



To ensure data is


accurate


Complete


Factual


And you are not jumping to conclusions



When to validate


Subjective and objective data do not agree


Patient’s statements differ at different times


Data falls outside normal range


Systematic


Usually controlled by agency forms



Body systems framework


Maslow’s Hierarchy of Needs


Gordon’s functional patterns


Orem’s Self care model


Roy Adaptation Model


NANDA nursing diagnosis Taxonomy II


Organizing data into meaningful clusters



A set of signs or symptoms grouped
together into logical order



Groupings of associations



Helps you recognize significant cues



Utilizes critical thinking to



Judge the value or significance of the
data



Validate and verify assumptions with
client and other health care team
members



Identify patterns in data and draw conclusions about
client’s status



Describes client’s actual or potential response to a health
problem



A statement of client health that nurses can identify,
prevent, or
treat independently



Stated in terms of unique human responses to diseases,
injuries, or stressors



Must be accurate because it provides direction for nursing
care


Actual
(3
-
part statement)


Presently exists


Risk
(2
-
part statement)


Likely to develop in vulnerable patient


Possible
(2 or 3
-

part statement)


Suspect on intuition but don’t have enough data yet


Syndrome
(1 part statement)


Collection of nursing diagnoses that occur together


Wellness
(1
-
part statement)


Not a health problem, wants to move to higher level of wellness



Diagnostic Label (title or name)


Approved by NANDA



Related Factors


Etiology must be in nurses domain to intervene


Don’t use medical diagnoses



Defining Characteristics


Cues from assessment data


must support diagnosis



Eg
. Impaired mobility R/T lack of
peripheral sensation
AEB

inability to walk
from bed to chair.


Data collection


Omitted, incomplete, inaccurate, disorganized


Data analysis & interpretation


Inaccurate interpretation of cues, conflicting cues,
incorrect judgments of inferences


Data clustering


Incorrectly clustered or not clustered at all


Diagnostic Statement


Problem & etiology must be in scope of nursing to

treat


Identify client’s response not medical
diagnosis


One symptom is insufficient for problem
identification


Nursing interventions directed at correcting
etiology of problem


Identify client response to equipment not
the equipment itself


Client problems
not
nurse problems


Develop in cooperation with client


Nursing diagnosis


Defines nursing needs of clients related to the
medical diagnoses



Medical Diagnosis


Reflects specific disease, illness, or injury


Goal


prescribe treatment


Place in order of importance or urgency



Maslow’s Hierarchy of Human Needs


Physiological


Safety and security


Love and belonging


Self
-
esteem


Self
-
actualization


A,B,C’s


Nursing Process


Client centered goals / outcomes


Specific measurable objective


Are precise, descriptive, clearly stated


Reflects highest level of wellness


Should be realistic


Observable client behavior


Measurable criteria for each goal


Projected time frame for goal achievement


Provide a guide for selecting interventions


Short term goals


Achieve in hours or days, less than 1 week


Long term goals


Achieved over weeks or months


Subject


The client


Action verb


Action that will be performed by client


Performance criteria


Specific measurement to be evaluated


Target time


When action should be achieved


Special conditions


Amt. of assistance, what equipment, resources
needed


Client centered…


Singular factors/ criteria…


Observable factors…


Measurable factors…


Time limited factors…


Mutual factors…


Realistic factors…


Serves as Written guidelines for client care


Communicates care


Enhances continuity


Organizes information


promotes efficiency


Involves client and family


Meets requirements of accrediting agencies



Care plans help students learn problem
solving, skills of written communication,
organizational skills, and application of
theory



AKA Nursing


Actions


Measures


Strategies


Activities



Actions based on clinical nursing judgment and
knowledge that nurses perform to achieve client
outcomes


Include activities of observation/assessment,
prevention, treatment, & health promotion



Independent


Nurse initiated interventions


In realm of independent nursing practice


No MD order required



Dependent


Physician initiated interventions


Require MD orders



Collaborative (interdependent) interventions


Coordination of multiple professionals


Include activities of


Observation/assessment


Prevention


Therapeutic Treatments


Health promotion


Activities of daily living


Teaching


Discharge planning



Flow from Client goals/outcomes / orders



Individualize standardized interventions



Nursing Orders


Instructions on care plan describing implementation
of interventions


Include


Date


Subject


Action verb


Times and limits


Signature


Standing Orders


Protocols


Critical Pathways


Evidence Based Practice


Nursing action nonspecific


Fail to indicate frequency


Fail to indicate quantity


Fail to indicate method


Fail to indicate person to perform



Implementation


The action phase of the nursing process


You will perform or delegate planned
interventions


Implementation ends when you record the
nursing actions on chart


Evolves into evaluation as you record resulting
client responses


Check your knowledge and abilities


Organize your work


Prepare the patient


Implement the plan


Coordinate/collaborate


Delegate appropriately


Right task


Right circumstance


Right person


Right directions / communication


Right supervision


Planned


Ongoing


Does not end the nursing process


Systematic




Make judgments about


Client’s progress toward expected outcomes/goals


Effectiveness of nursing care plan


Quality of nursing care delivered


Ongoing evaluation


At each contact with patient



Intermittent evaluation


At outcome evaluation specified times



Terminal evaluation


At time of discharge


Review Outcomes


Collect Reassessment Data


Judge Goal Achievement


Achieved (met)


Partially achieved (partially met)


Not achieved (unmet)


Record evaluative statement


Revise care plan if indicated


Begin with assessment data and go through entire
nursing process


Written evidence of interactions


Health professionals


Clients


Families


Health care organizations


Diagnostic tests


Treatments


Education


Client results/responses


Correct client record


Client name on each page


Document immediately


Date and time each entry


Sign each entry with name and professional
credentials


No space between entries


Never change another’s entry


Use “quotes” for client statements


Chronological order


Use appropriate vocabulary / terminology


Only approved abbreviations / symbols


Use organized and logical sequence


State only factual not inferences


Use correct spelling, legible writing


Protect client confidentiality by not releasing
records to anyone without patient permission


Write neatly, legibly, & in ink


Use concrete specific terms


Follow agency guidelines



Source
-
Oriented Records


Separate sections for each discipline



Problem
-
Oriented Records


Consists of database, problem list, plan of care, &
progress notes


Narrative



SOAP



PIE



Focus



Charting by exception



Computerized