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Sheryl Abelew MSN RN
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Chapter 4
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Important step in the critical thinking process
Includes effective time management Steve Covey (1989) states you should
be “putting first things first”. There are three categories “must do, should do, and nice to do”.
Develop a time frame for priorities.
***Review box 4-2 Time Management Procedures
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Use Maslow’s hierarchy of needs Five levels of needs
Physiologic needs Sleep, food, water, movement, comfort
Psychological needs Safety and security
Love and belonging Affiliation, affection, intimacy
Self-esteem Sense of self worth, self respect, dignity
Self-actualization Recognition of potential growth, health, autonomy
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Place in level of priority High, Medium, and Low
High Life threatening, threats to pt safety, pain,
and anxiety, unstable or changes in condition Medium
Problems that could result in unhealthy consequences, like emotional or physical impairment, but no threat on life
Low Problems that can be resolved with minimal
intervention and have little potential to cause dysfunction
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Four levels of priority according to Rubenfeld and Scheffer (1999) Life Threatening Issues
ABC’sSafety
Protecting the patient from injury, practicing within scope of nursing, doing no harm
Patient Priorities Plan of care based on patient activities and
conditionNursing Priorities
Examine all the patients strengths and health concerns, moral and ethical and Maslow’s hierarchy of needs
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Setting priorities is not linear Addresses multiple concerns at the
same time Learning to take charge and make
efficient use of time is key in time management
Making a to do list will help with multitasking
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Assessment Obtain complete information and sort and ID
problems Analysis
Prepare list of needs and diagnosis Outcome Identification
Have measureable goals based on Maslow, and prioritize diagnosis
Plan Select diagnosis and activities
Implementation Perform immediate actions to prevent harm first.
Highest priority to lowest priority Evaluation
May require reevaluation and/or adjustments
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Priorities may change Inadequate assessment of clients needs Failure to differentiate priority and non
priority tasks Accepting others priorities without
seeing the big picture Performing tasks that were identified
first vs. those that are a priority Completing the easiest task first instead
of the priority
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Chapter 5
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“Nursing Process is considered to be a specialized form of systematic inquiry or problem solving process used in drawing conclusions about the patient’s problems and the corresponding nursing actions to resolve problems.” Saucier, Stevens * Williams (2002).
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Allows for a consistent use of standards and standardized language providing for a way to measure and quantify the effects of nursing care and interventions
In order to keep terms consistent, ANA recognizes NANDA as the official language of nursing diagnosis, NIC for interventions classification, and NOC for outcomes classifications
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Assessment Analysis (Diagnosis) Outcome Identification Plan Implementation Evaluation
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Collect data Identify pertinent data Recognize deviations from normal Validate data Sort and Organize data in a logical order Identify patterns in the data
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Examine for unmet needs and strengths and health concerns
Focus on problems the nurse can change
Develop diagnosis based on facts Validate the diagnosis Establish priorities
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Establish outcomesRealisticAchievableMeasureable
Collaborate to review goals to meet needs
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How to develop your strategies for meeting nursing interventions
Use NIC for nursing interventions Write plan of care using standardized
language Collaborate for planning delivery of care
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Initiate actions to accomplish goals Manage care in order of priority Delegate care based on caregiver,
acuity, needs and plan of care Intervene as necessary Document interventions and response
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Compare actual vs. expected outcomes Communicate findings Record attainment of goal Review and modify POC based on needs
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Written documentation of the nursing process
See Box 5-3 for care plan formation
See Table 5-5 for sample care plan scenario
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Chapter 6
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Transferring tasks to a competent individual
Used most commonly with a skill mix based on scope of practice
Consider job description when delegating
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Right Task Right Circumstance Right Person Right Direction and Communication Right Supervision and Evaluation
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Delegator reluctant to take the risk and give up control
Subordinate fails to take responsibility Workplace issues
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Assessment List patients need and assessment findings
Analysis Level of care and acuity
Outcome identification Establish priorities
Plan Nurse specifies nature of tasks and skill required
Implementation Delegation of tasks
Evaluation Compare outcomes with the POC
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Chapter 7
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Three levels of CommunicationSocial
Interactions for building relationshipsTherapeutic
Nurse listens to patient problems and focuses on needs
Collegial Enhancing relationships with colleagues,
improved pt care, and better documentation
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Nursing Personnel Delegating Report Interdisciplinary Conflict resolution Physician notification Receiving phone calls
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DocumentationOne way to validate critical thinkingKeep confidentialAccurate and objectivePerformed promptly
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Chapter 8
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Goal directed based on rationale thought processes
Involves critical thinking Approached analytically
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4 areas must be assessedWhat the patient needs to learnCharacteristics of the patientPatients preferred learning styleWhether patient is ready/willing to learn
Conduct a learning needs assessment Assess cultural background Developmental stage consideration Literacy
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Analyzing needsValidate with the patient
Outcome identification ID goals, clear objectives
Planning the lesson Instructional methods
Traditional i.e. lecture, discussion Non traditional i.e. role-playing, simulations, etc
Implementing educational session Evaluating the educational process
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Chapter 9
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When processing data, continually evaluate reasoning
Examine the evidence to determine what else is needed
Obtain and clarify data Examine logic and give reasons for
conclusions Review the consequences of possible
actions and draw conclusions if desired outcome can be obtained
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Use professional standards as guidelines to decision making when evaluating patient circumstances, and then consider the textbook data, current diagnostic test findings, and assessments of the nurse
Nurses need to follow the regulations set forth according to scope of practice and standards of practice as well as the code of ethics for nurses when making decisions
Review box 9-2 pg 199
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Nurse collects information and uses skill of interpretation to define what the patient is presenting as
Nurse establishes expected outcomes for interventions to determine if the problem will be resolved
After implementation, nurse will evaluate on an ongoing basis progress towards goals
After recognizing effects from intervention, nurse will offer rationale for the result
Lastly, nurse will reexamine thinking
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Quality implies evaluation Evaluation requires standards which
define the acceptable levels of care Nurse must evaluate actions to the
professional practice standards from the ANA
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Indicators that identify impossible workloadFailure to monitor when indicated by
patients condition Inadequate treatment for circumstancesExcessive delay of treatmentsFailure to provide ongoing care and
treatmentsLack of time to provide patient teaching
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Use clinical reasoning to monitor patients change of condition and respond with the appropriate intervention
Two examples of monitoring the patients conditionCalling the physician
When there is a change in condition Pain without ordered meds that manage the pain Acute elimination problems Lab values that require orders Risk to safety
Interpreting lab values Are the findings abnormal and expected Are the findings abnormal and unexpected Are the findings normal
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Failure to use appropriate decision making skills
Failing to assess, report, or omissions Failure to assess for changing of
condition Nurse fails to perform duties
appropriately results in negligence
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Chapter 10
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Ethics deals with the principles of right and wrong
Foundation of ethics is standards of conduct and moral judgment
Nurses must be aware of their own value system
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ChoosingAllows for free choice identifying
alternatives and selecting alternatives Prizing
Individual satisfaction with choice of verbalization to others
Acting (Internalization and repetition)
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Ethical PrinciplesAutonomy
Right to self-determinationNonmaleficence
Directs the nurse does no harmBeneficence
Doing good on the patients behalf Justice
Moral obligation to treat people fairly and equally Fidelity
Keeping your word and acting in the patient’s best interest
Veracity Telling the truth
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ANA as developed a code of ethics Nine statements define this code Review pg 233 Box 10-3
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Assessment Analysis Outcome Identification Plan Implementation Evaluation
**
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Gather information to determine the facts that will have the most affect on the situation
Develop sensitivity to recognize ethical situation and its essence to nursing
Identify risks to the patients
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Determine the values in conflict Become aware of the relevant
information Values clarification Generate multiple alternatives and rank
in order of what is right and wrong Explore emotional, social and physical
risks to patient and staff
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Providing safe nursing care Expected outcome should serve as a
guide in making decisions Use clearly stated outcomes for success
to be measureable
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Decision maker should choose the best options for prioritizing of needs to achieve the desired outcome
Organize information and alternatives that represent various moral views
Be prepared to defend your choice Stay focused on the outcome to stay
focused on the real problem
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Implement the moral action selected to resolve the dilemma
Follow chain of command Support a blame free environment
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Were the actions ethical? Did the solution generate the desired
outcome? Can you justify the consequences? Do the benefits outweigh the risks?
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Hospitals and long term care facilities have groups of individuals who discuss, clarify, and resolve issues related to patient care welfare
Goal is to support objectivity in difficult patient care decisions
Best when whole team and patient and families are involved
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Self-Determination Professional Caregiver Issues
Risk for injury Usually with the demented, depression, or
delirium Inadequate staffing
Staffing appropriate for acuity of patients Nurses practicing out of their specialty or
knowledge baseBiomedical advances
Transplants, in vitro, etc.
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Disregard for othersUsing others without considering them
Inappropriate application of standardsMaking decisions that another prudent
professional would not make Personal gain
Having ulterior motives Conflict of values
Responding to needs without concern for those affected
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Chapter 11
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A skill required in choosing how to meet the needs of a group of patients
RequiresProblem solvingPriority settingDecision makingGood application of the nursing processAbility to identify variations in patientsStrong knowledge base Sound nursing decisions
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First level prioritiesLife threateningUnstable, worsening of condition
Second level prioritiesDelay may cause untoward resultsNonemergent
Scheduled meds, mental status changes, acute pain
Third level prioritiesDeficits that can easily be resolved or do
not affect normal function Bathing, grooming, emotional support
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Review implications if care/treatment were to be delayed
Develop and action planScheduled activities should be primary
consideration Determine who can do it
Consider the roles of available UAPEvaluate competency of staff
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Nurses should not refuse because of a lack of skill
Focus on what they can do and what they can help with being supervised
Educational preparation is ideal Review pg 264 Box 11-3 Review pg 264 box 11-4 If an assignment is out of scope of
practice submit an occurrence report and request additional training
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ED nurses Coronary intensive care nurses Pediatric nurses Obstetric nurses Oncology nurses Psychiatric nurses Medical/surgical nurses
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Consider circumstances and need Gender LOC Acuity Special needs Age Medical dx Staffing Family requests
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Failure to use nursing judgment Inability to gather data Inadequate decision making Inability to prioritize Incompetent application of cognitive
skills Failure to ID impact of action on an
outcome