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Nursing 101 - exam #1 review

Monday, February 10, 2020
Nursing 101 - exam #1
Clinical Judgement
- Clinical Judgement: is “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
patients ’s response.”
- The concept of clinical judgement in general refers to interceptions and interferences
that influence actions in clinical practice
- All clinicians are expected to use the best evidence to inform practice
- Clinical judgement is inherently complex and influence by many factors related to the
particular patient and caregiving situation, and it therefore requires a holistic view
- Clinical judgement is circular, interactive, and moved fluidly between and among all of
the aspects of the process
- Clinical judgement involves reasoning and interpretation
- The model of clinical judgement is a comprehensive approach to clinical judgement
that was developed based on three decades of clinical judgement research and
through an extensive review of research done primarily with expert nurses in practice.
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- Noticing:
• a nurse notices things about a patient in the context of the nurses; s background
and experience, context of environment, and knowing the patient
• a nurse is looking for patterns that are consistent with previous experiences and
uses that information to guide care
- Interpreting:
• Interpreting is the process of assembling information to make sense of it
• Types of reasoning patterns tend to vary with the experience of the nurse
- novice nurses tend to rely on analytic reasoning
- Expert nurses draw from a variety of reasoning patterns - analytic, intuitive, and
- Responding:
• Reasoning is the implementation of actions and interventions, based on patient
• Depending on the level of expertise, the nurse may or may not be able to judge the
effectiveness of the intervention before initiating it
- Reflecting:
• Reflecting is the process of thinking and learning from experiences
- Reflection-in-action happens in real time while care is occurring
- Reflection-on-action happens after the patient care occurs
• Reflecting is critical for development of knowledge and improvement in reasoning
- Clinical judgement is an integral aspect of nursing care of all patients and patient
populations. Nurses in all specialty areas and practice settings - whether in public
health nursing, community-based nursing, long term care, or acute care - exercise
clinical judgement; thus it is considered an essential skill of the professional nurse.
- Clinical judgement, however, is not required for every patient care activity or
intervention. Some nursing actions are obvious
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- Clinical judgement, or thinking like a nurse, requires deep clinical knowledge and
several types of thinking
- Acquisition of clinical judgement is a developmental process
- Collaborative learning: in your learning groups, think about an area in which you
have a great deal of expertise
- Exemplars (examples of concepts):
• Clinical skills
• Urgent and emergent situations
• communication
• Medication management
• Management of care
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Community Based Overview
-Community based care if a philosophy of
•as a nurse you assume your patients
came from the community and will return to
•the more you know about the community
the better nurse you will be
-The goal is maintaining or improving
quality of life
•focus is not on curing the patient but rather
empowering patients to care for themselves
•focus on health promotion and disease
- Community based care is not defined by the setting
• the focus is on CONTINUITY of care in ALL settings
- Individuals and their families are the main recipients of community based care
• “The health of the individual is almost inseparable from the health of the larger
Infection Prevention & Control
- Infection: the invasion of a susceptible host by pathogens or microorganism,
resulting in disease
• entry and multiplication of organisms result in disease
• Colonization occurs when a microorganism invades the host but does not cause
- Symptomatic infection: if pathogens multiply and cause clinical signs and symptoms
- Asymptomatic infection: if clinical symptoms are not present
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- Hand hygiene is the most important technique to use in preventing and controlling
transmission of infection
- Chain of Infection
• infectious agent or pathogen
• reservoir or source for pathogen growth
• portal of exit
- after microorganism find a site to grow and multiply, they need to find a portal of
exit if they are to enter another host and cause disease
- Ex: skin/mucous membranes, respiratory and urinary tract, etc.
• mode of transportation
- direct or indirect contact, droplet, airborne, vehicles (ex: contaminated items), or
vectors (ex: mosquito)
• portal of entry
- organisms enter the body through the same routes they use for exiting
• susceptible host
- susceptibility to an infectious agent depends on an individual’s degree of
resistance to pathogens
- Immunocompromised: having an impaired immune system
- Virulence: ability to produce disease
- Aerobic bacteria: requires oxygen for survival and for multiplication sufficient to
cause disease
- Anaerobic bacteria: thrives where little or no free oxygen is available
- Bacteriostasis: prevention of growth and reproduction of bacteria
- Bactericidal: destructive bacteria
- Infectious process
• 1. incubation period
• 2. Prodromal stage (just dealing with it)
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• 3. illness stage (full symptoms)
• 4. Convalescence (no symptoms but achy)
• localized infection: right at the site of injury
• Systemic infection: broadened symptoms
- Defenses against infection
• Normal floras do not usually cause disease when residing in their usual area of the
body but instead participate in maintaining health
• A number of body organ systems have unique defenses against infection
• Inflammation: the cellular response of the body to injury, infection or irritation
- signs of local inflammation and infection are identical
- Health Care - Associated infections (HAIs)
• results from the delivery of health services in a health care facility
• Patients at a greater risk for HAIs
- Multiple illnesses
- Older adults
- poorly nourished
- lowered resistance to infection
• Types of HAIs
- Iatrogenic: from a procedure
- Exogenous: from microorganisms outside the individual
- Endogenous: when the patient’s flora becomes altered and an overgrowth
• Risk factors
- # of health care employees with direct contact with the patient
- types and # of invasive procedures
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- therapy received
- length of hospitalization
• major sites for HAIs
- Surgical or traumatic wounds
- urinary and/or respiratory tracts
- Bloodstream
- Factors influencing infection prevention and control
• Age
• Nutritional status
• stress
• disease process
• Treatments or conditions that compromise the immune system
**stress increases susceptibility to illness and infection**
The Nursing Process
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Nursing Assessment
- the first step of the nursing process, assessment, involves the gathering and analysis
of information about a patient’s health status
- As a nurse you learn to make clinical judgements from assessment data to identify a
patient’s level of wellness
- Nursing assessment includes 2 steps:
• collection of information from a primary source (patient) and secondary sources
(ex: family)
• the interpretation and validation of data t ensure a complete database
- Critical thinking is a vital part of assessment
- An assessment is necessary for you to gather information to make accurate
judgements about a patient’s current condition
- Cue: information that yo obtain through use of the senses
- Inference: your judgement or interpretation of these cues
- start by assessing a patient using all of the Gordon’s 11 functional health patterns
• Health perception - health management pattern
• Nutritional-metabolic pattern
• elimination pattern
• Activity-exercise pattern
• Sleep-rest pattern
• Cognitive-perceptual pattern
• Self-perception - self-concept pattern
• Role-relationship pattern
• Sexuality-reprodutive pattern
• Coping-stress tolerance pattern
• Value-belief pattern
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- the second approach for conducting a comprehensive assessment is problem
• focus is on the patient’s presenting situation
- Types of data:
• subjective data: patients’ verbal descriptions of their health problems
• objective data: observations or measurements of a patient’s health status
- EX: inspecting the condition of a surgical incision or wound, describing an
observed behavior, and measuring blood pressure
- objective data is measured on the basis of accepted standard
- when you collect objective data, apply critical thinking intellectual standards so
you can correctly interpret your findings
- Sources of data:
• Patient: usually your best source for information
• Family members & significant others: primary sources of information for infants
or children, critically ill adults, and patients who are mentally handicapped or have
cognitive impairment
- Patient centered interview:
• Relationship based
• Effective communication with patients during an assessment interview requires a
variety communication skills
• interview techniques
- observation
- Open-ended questions
- leading questions
- back channeling
- probing
- direct closed-ended questions
• Nursing health history: gathered during initial or early contact with a patient
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- requires a cultural competence
• involves self-awareness, reflective practice, and knowledge of patient’s core
cultural issues
Nursing Diagnosis
- Diagnosis: clinical judgement made on the basis of information
- medical diagnosis: identification of a disease condition based on a specific
evaluation of physical signs and symptoms, a patient’s medical history and the results
of the diagnostic tests and procedures
- Nursing diagnosis: clinical judgement concerning a human response to health
conditions/life processes, or vulnerability for that response by an individual, family, or
community that a nurse is licenses and competent to treat
- Collaborative problem: actual or potential physiological compilation that nurses
monist to detect the onset of changes in a patient’s health status
- Today the list contains several hundred diagnoses and continues to grow on the basis
of nursing research and the work of the members of the North American Nursing
Diagnosis Association International (NANDA-I)
- Types of nursing diagnoses:
• defining characteristics: observable assessment cues such as patient behavior,
physical signs…. they support each problem-focused diagnostic judgement
• a related factor allows you to individualize a problem-focused nursing diagnosis for
a specific patient need
• risk nursing diagnosis: clinical judgement concerning the vulnerability of an
individual, family, group, or community for developing an undesirable human
response to health conditions/life processes
- Critical thinking and the process
• the diagnostic process requires you to use critical thinking
• in the practice of nursing it is important for you to know the nursing diagnostic
labels, their definitions, the defining characteristics or risk factors for each
diagnoses, related factors pertinent to the diagnoses, and the interventions suited
for treating the diagnoses
• data cluster: set of cues, the signs or symptoms gathered during assessment
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• Diagnostic label: name of nursing diagnosis as approved by NANDA-I
• a complete diagnostic statement will also include a related factor (appropriate for
problem-based and some health promotion diagnoses). You identify the related
factor from the patient’s assessment data. the related factor is associated with a
patient’s actual or potential response to a health problem and can change by using
specific nursing interventions
Planning Nursing Care
- Goal: broad statement that describes a desired change in a patient's conditions,
perceptions, or behavior
- Expected outcome: the measurable change that must be achieved to reach a goal
- always partner with patients when setting their INDIVIDUALIZED goals
- Selecting goals and expected outcomes:
• A correct goal statement: “Patient will ambulate independently in 3 days.”
• A correct outcome statement: “Patient ambulates in the hall 3 times a day
by 4/22.”
• A common error is to write an intervention: “Ambulate patient in the hall
3 times a day.”
- Writing goals and expected outcomes:
• Specific or singular goal or outcome
• Measurable
• attainable
• Realistic
• timed
- Critical thinking in planning nursing care
• part of the planning process is selecting nursing interventions for meeting a
patient’s goals and outcomes. once you identify nursing diagnoses and select goals
and outcomes, you choose interventions individualized for a patient’s situation
• Independent nursing interventions: (nurse-initiated) actions that a nurse initiates
without supervision or direction from others
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• when developing a plan of care, review resources such as the scientific literature,
standard protocols, or guidelines, the NOC and NIC, policy or procedure manuals,
or textbooks
- Nursing Care plan: included nursing diagnoses, goals and/or expected outcomes,
specific nursing interventions, and a section for evaluation findings so any nurse is
able to quickly identify a patient’s clinical needs and situation
Implementing Nursing Care
- Nursing intervention: any treatment based on clinical judgement and knowledge
that a nurse preforms to enhance patient outcomes
- Clinical practice guideline: protocol is a systematically developed set of statements
that helps nurses, physicians, and other health care providers make decisions about
appropriate health care for specific clinical situations
- Standing order: preprinted document containing orders for routine therapies,
monitoring guidelines, and/or diagnostic procedures for specific patients with
identified clinical problems
- The NIC system developed by the University of Iowa differentiates nursing practice
from that of other health care disciplines by offering a language that nurses can use
to describe sets of actions in delivering nursing care.
- The NIC interventions offer a level of standardization to enhance communication of
nursing car across settings and to compare outcomes
- ANA Standards of Professional Nursing Practice
- QSEN Institute established standard competencies in knowledge, skills, and attitude
- Assessment is a continuous process that occurs each time you interact with a patient
- as a nurse, always stay alert for the risks posed by a patient’s illness and treatments
- Activities of daily living (ADLs): usually preformed in the course of a normal day;
they include ambulation, eating, dressing, bathing, and grooming.
- a patient’s need for assistance with ADLs is temporary, permanent, or rehabilitative
- Assistance with ADLs ranges from partial assistance to complete care
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- Evaluation: the final step of the nursing process - crucial to determine whether, after
application of the first 4 steps of the nursing process, a patient’s condition or wellbeing improves
• you conduct evaluative measures to determine if your patients met expected
outcomes, NOT if nursing interventions were completed
- Evaluation is an ongoing process that occurs whenever you have contact with a
- once you deliver intervention, you continuously examine results by gathering
subjective and objective data from a patient, family, and health care team members
- Outcomes are statements of progressive, step-by-step physical, emotional, or
behavioral responses that a patient needs to accomplish to achieve the goals of care
- when patients do not meet goals and outcomes, you identify the factors that interfere
with their achievement
- if a nursing diagnosis is unresolved or if you determine that perhaps a new problem
has developed, reassessment is necessary
- After reassessment determine which nursing diagnoses are accurate for the
situation… ask yourself whether you selected the correct diagnosis and if the
etiological factor is accurate and current
- when revising a care plan, review the goals and expected outcomes for necessary
- the evaluation of interventions examines 2 factors
• the appropriateness of the intervention selected
• the correct application of the intervention
- documentation and reporting are important parts of the evaluation because it is
crucial to share information about a patient’s process and current status
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Documentation and Informatics
- Documentation: nursing action that produces a written account of pertinent patient
data, nursing clinical decisions/interventions, and patient responses in a health record
- Diagnosis-related groups (DRGs): classifications based on a patient’s primary and
secondary medical diagnoses that are used as the basis for establishing Medicare
reimbursement for patient care
- Guidelines for quality documentation:
• Factual
• accurate
• complete
• current
• Organized
- Methods of documentation
- Subject
- Objective
- assessment
- plan
- Problem
- intervention
- evaluation
• Focus charting (DAB)
- data
- action response
- Problem-oriented medical record (POMR): a system of organizing documentation
to place the primary focus on patients’ individual problems
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• Ex: databases, problem list, care plan, and progress notes
- Case management: model of delivering care incorporates an inter professional
approach to documenting patient care
- Critical pathways: interprofessional care plans that identify patient problems, key
interventions, and expected outcomes within an established time frame
- Variances: unexpected outcomes, unmet goals, and interventions not specified within
the critical pathway
- Standardized care plans: facilitate the creation and documentation of a nursing and
or interprofessional plan of care
• also know as clinical practice guidelines (CPGs)
- Acuity ratings: used to determine the hours of care and number of staff required for
a given group of patients every shift or every 24 hours
- Computerized provider order entry (CPOE): used by nurses to enter either
telephone (TO) or verbal (VO) orders
- Health informatics: application of computer and information science in all basic and
biomedical sciences to facilitate the acquisition, processing, interpretation, optimal
use, and communication of health related data
- nursing informatics: se of information and computer technology to support all
aspects of nursing practice, including direct delivery of care, administration,
education, and research
• The medical record is also a financial record that serves as the basis for
• All information contained in the medical record is confidential; access to patient
records is limited to individuals involved in the care of the patient.
• Interdisciplinary communication among members of the health care team is essential,
and the medical record is one tool that supports and facilitates that communication.
• Accurate record keeping requires an objective interpretation of data with precise
measurements, correct spelling, and proper use of abbreviations.
• To keep medical records accurate, any change in a patient's condition warrants
immediate documentation about the event and the action that was taken to address
the change.
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• A nurse's electronic or handwritten signature on an entry in a record designates
accountability for the contents of that entry.
• Protection of the confidentiality of patients' health information and the security of
computer systems are top priorities that include log-in processes, audit trails, firewalls,
data-recovery processes, and policies about handling and disposing of data to protect
patient information.
• POMRs are organized by the patient's health care problems.
• Long-term care documentation is interdisciplinary and closely linked with fiscal
requirements of outside agencies.
• Always verify patient care information communicated to providers through telephone
orders by using and documenting use of the “read-back” process.
• A hospital information system consists of two major types of information systems: CIS
and administrative information systems.
• Nursing informatics facilitates the integration of data, information, and knowledge to
support clinical decision making of nurses and other providers in all roles and settings.