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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”

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Presentation on theme: "Separating the Professional from the Technical.  “the active, organized, cognitive process used to examine one’s own thinking and the thinking of others”"— Presentation transcript:

1 Separating the Professional from the Technical

2  “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

3  Knowledge base ◦ Theoretical ◦ Experiential  Experience ◦ Practice making decisions  Technical Skills & Competencies  Attitudes and behaviors

4 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

5  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

6 ◦ Brings together  Critical thinking  Nursing process  Nursing knowledge  Patient situation

7 ◦ Types of Assessment  Comprehensive  Focused  Special needs  Initial  Ongoing

8  Types of Data ◦ Subjective ◦ Objective  Sources of Data ◦ Primary data  Client ◦ Secondary data  Family  Health Records  Health Team Members

9  Methods of collection ◦ Observation  Use all 5 senses ◦ Physical assessment ◦ Interview  Health history

10  Performed after nursing history  Collection of objective data ◦ Ht., Wt., V.S. ◦ General Survey ◦ Head to toe exam  Inspection  Palpation  Percussion  Auscultation  Olfaction

11  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

12  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

13  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

14  Organizing data into meaningful clusters  A set of signs or symptoms grouped together into logical order  Groupings of associations  Helps you recognize significant cues

15  Utilizes critical thinking to ◦ Judge the value or significance of the data ◦ Validate and verify assumptions with client and other health care team members

16  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

17  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

18  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.

19  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

20  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

21  Nursing diagnosis ◦ Defines nursing needs of clients related to the medical diagnoses  Medical Diagnosis ◦ Reflects specific disease, illness, or injury ◦ Goal – prescribe treatment

22  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

23  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

24  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

25  Client centered…  Singular factors/ criteria…  Observable factors…  Measurable factors…  Time limited factors…  Mutual factors…  Realistic factors…

26  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

27  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

28  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

29  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

30  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

31  Nursing action nonspecific  Fail to indicate frequency  Fail to indicate quantity  Fail to indicate method  Fail to indicate person to perform

32  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

33  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

34  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

35  Ongoing evaluation ◦ At each contact with patient  Intermittent evaluation ◦ At outcome evaluation specified times  Terminal evaluation ◦ At time of discharge

36  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

37  Written evidence of interactions ◦ Health professionals ◦ Clients ◦ Families ◦ Health care organizations ◦ Diagnostic tests ◦ Treatments ◦ Education ◦ Client results/responses

38  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

39  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

40  Source-Oriented Records ◦ Separate sections for each discipline  Problem-Oriented Records ◦ Consists of database, problem list, plan of care, & progress notes

41  Narrative  SOAP  PIE  Focus  Charting by exception  Computerized


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