question

What is nursing process?

answer

A framework that provides an organized systematic approach to nursing care, thereby improving the probability of positive outcomes for individuals and groups.

question

In your own words, define nursing process.

answer

Critical thinking process that nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness. It is the fundamental blueprint for how to care for patients.

question

What are the 5 steps of nursing process?

answer

The five steps of the nursing process are assessment, diagnosis, planning, implementation and evaluation.

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Nursing Assessment

answer

1. Collection of information from a primary source (the patient) and secondary sources (e.g., family members, health professionals, and medical record.) 2. The interpretations and validation of data to ensure a complete database.

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Nursing Diagnosis

answer

A clinical judgement about individual, family or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat.

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Planning

answer

Involves setting priorities, identifying patient-centered goals and expected outcomes and prescribing individualized nursing interventions. Ultimately during implementation your interventions resolve the patient's problems and achieve the expected goals and outcomes.

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Nursing Implementation

answer

Formally begins after a plan of care is developed. The nurse initiates interventions that are designed to achieve the goals and expected outcomes needed to support or improve the patient's health status.

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Nursing Evaluation

answer

Determines whether, after application of the nursing process, the patient's condition or well-being improves.

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Nursing Intervention

answer

Any treatment based on clinical judgement and knowledge that a nurse performs to enhance patient outcomes.

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Why do nurses need to understand nursing process?

answer

Clearly defining your patient's problems provides the basis for planning and implementing nursing interventions and evaluating the outcomes of care.

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Why should you learn to "do" nursing process?

answer

-Complexity -Organization -Delegation -Coordination -State law mandate

question

What does the acronym NANDA mean?

answer

North American Nursing Diagnosis Association

question

What does NANDA do?

answer

Works on a classification system for computerization. Members DO NOT develop nursing diagnoses. But do research/review and work to approve them. Clinical nurses submit diagnoses to NANDA for approval.

question

Sources of data for Assessment

answer

-Patient ALWAYS primary source -Family/Significant Other -Charts and Records -Other Health Care Providers -Other records and Scientific Literature -Nurses Experience

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How are assessments done?

answer

-Through use of all senses -Interviewing/Interactions -Observations -Physical Examination: Inspection, auscultation, palpation, percussion.

question

Who is responsible for assessments?

answer

The nurse and the patient

question

Subjective data

answer

It is your pt verbal descriptions of their health problems; only pt can provide; data usually include feelings,perceptions, and self-report of symptoms. Not measurable. e.g. nausea, pain, hungry, worry about pain affecting life.

question

Objective data

answer

are observational or measurements of a pt health status; what you observe by inspecting, percussing, palpating, and auscultating during physical examination; measurement based on accepted standard of Fahrenheit/Celsius, inches/cm, or known characteristics of behaviors (fear,anxiety). e.g.inspecting condition of surgical incision or wound, describing an observed behavior, measuring BP, vomiting

question

Examples of subjective data

answer

I feel sick to my stomach I have a stabbing pain in my side He said "I ate all my breakfast"

question

Examples of objective data

answer

Red rash on right arm You saw him eat all of his breakfast Urinated 150 ml clear yellow urine

question

What types of data do you want to validate? And why?

answer

Measurable and Observable All healthcare diagnoses,decisions, and treatments are based on data you gather during assessment so you need to be factual and complete with what you gather. The more accurate and thorough you are with your gathering, the better you will be able to help the pt.

question

How do you validate data?

answer

1. recheck data/information 2. look for factors (has this happened before physiological, emotional etc.) that may be present 3. ask someone else if they see or hear what we are seeing 4. compare subjective/objective data 5. clarify

question

Cue

answer

Info obtained through more than one sense; information gathered by using the senses eg odors, crying, coughing, etc.

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Inference

answer

interpretation or judgement of the cues (ex:smell of urine = incontinence, crying = fear/sadness, coughing = cold/smoker)

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Example of cue & inference

answer

cue: i'm worried about my bowels. inference: Tony may be constipated.

question

Gordon's Functional Health Patterns

answer

1. Health Perception-Health Management Pattern 2. Nutritional-Metabolic Pattern 3. Elimination Pattern 4. Activity-Exercise Pattern 5. Sleep-Rest Pattern 6. Cognitive-Perceptual Pattern 7. Self-Perception-Self Concept Pattern 8. Role-Relationship Patterns 9. Sexuality-Reproductive Pattern 10. Coping-Stress Tolerance Patterns 11. Value-Belief Pattern

question

Critical thinking skills

answer

1. Interpretation 2. Analysis 3. Inference 4. Evaluation 5. Explanation 6. Self-regulation

question

Interpretation

answer

Be orderly in data collection. Look for patterns to categorize data. Clarify any data you are uncertain about.

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Analysis

answer

Be open-minded as you look at information about a patient. do not make careless assumptions. Does the data reveal what you belief is true, or are there other options?

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Inference

answer

Look at the meaning and significance of findings. Are there relationship between findings? Does the data abut the patient help you see that a problem exists?

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Evaluation

answer

Look at all situations objectively. Use criteria (e.g., expected outcomes, pain characteristics, learning objectives.) to determine results of nursing actions. Reflect on your own behavior.

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Explanation

answer

Support your findings and conclusions. Us knowledge and experience to choose strategies to use in the care of patients.

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Self regulation

answer

Reflect on your own experiences. Identify the ways you can improve your own performance. What will make you belief that you have been successful?

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Concepts for a critical thinker

answer

1. Truth seeking 2. Open-mindedness 3. Analyticity 4. Systematicity 5. Self-confidence 6. Inquisitiveness 7. Maturity

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Truth seeking

answer

Seek the true meaning f a situation. Be courageous, honest and objective about asking questions.

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Open-mindedness

answer

Be tolerant of different views, be sensitive to the possibility of your own prejudices, respect the right of others to have different opinions.

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Analyticity

answer

Analyze potentially problematic situations; anticipate possible results or consequences; value reason; use evidence-based knowledge.

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Systematicity

answer

Be organized, focused; work hard in any inquiry.

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Self-confidence

answer

Trust in your own reasoning processes.

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Inquisitiveness

answer

Be eager to acquire knowledge and learn explanations even when applications of the knowledge are not immediately clear. Value learning for learning's sake.

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Maturity

answer

Multiple solutions are acceptable. Reflect on your own judgements; have cognitive maturity.

question

Open-Ended Questions

answer

Prompts patients to describe a situation in more than one or two words.

question

Back channeling

answer

Encourages the patient to give more details by using active listening prompts such as "all right," "go on," or "uh-huh."

question

Probing

answer

Encourage a full description without trying to control the direction the story takes. Use further open-ended statements.

question

Closed-ended questions

answer

Limit answers to one or two words such as yes or no.

question

Examples of open ended questions

answer

1. Tell me how you are feeling 2. Tell me how your health has been. 3. Describe how your wife has been helping you. 4. Give me an example of how you get relief from your pain at home.

question

Examples of closed ended questions

answer

1. Do you think the medication is helping you? 2. Who helps you at home? 3. Do you understand why you are having the x-ray examination? 4. Are you having pain now? 5. On a scale of 0 to 10, how would you rate your pain?

question

Evidence-based knowledge

answer

Knowledge based on research or clinical expertise.

question

Levels of critical thinking

answer

Level 1: Basic Level 2: Complex Level 3: Commitment

question

Components of critical thinking

answer

Specific Knowledge base Experience Competencies Attitudes Standards

question

Scientific Method

answer

1. Identifying the problem 2. Collecting data 3. Formulating a question or hypothesis 4. Testing the question or hypothesis 5. Evaluating results of the test or study

question

Effective problem solving

answer

Involves evaluating the solution over time to make sure that it is effective. It becomes necessary to try different options if a problem recurs.

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Decision making

answer

Is a product of critical thinking that focuses on problem resolution.

question

Diagnostic reasoning

answer

It is the analytical process for determining a patient's health problems.

question

Clinical decision making

answer

Is a problem-solving activity that focuses on defining a problem and selecting an appropriate action. Requires careful reasoning (i.e., choosing the options for the best patient outcomes on the basis of the patient's condition and the priority of the problem).

question

Critical thinking attitudes and applications in nursing practice

answer

1. Confidence 2. Thinking Independently 3. Fairness 4. Responsibility and authority 5. Risk taking 6. Discipline 7. Perseverance 8. Creativity 9. Curiosity 10. Integrity 11. Humility

question

Concept map

answer

A visual representation of patient problems and interventions that shows their relationships to one another. The primary purpose of concept mapping is to better synthesize relevant data about a patient, including assessment data, nursing diagnosis, health needs, nursing interventions, and evaluation measures.

question

How does Concept Mapping 'fit in' with nursing diagnoses?

answer

-It is a technique that can help organize data analysis. -It uses diagrams to demonstrate the relationship of one concept or piece of information to other concepts pieces of information -Its a visual representation of patient problems and interventions that shows their relationship to one another (P&P p.202)

question

Nursing health history

answer

The history is a major component of assessment. Most health history forms are structured. However, based on information you gained from your patient's story (during the patient-centered interview) , you learn which components of the history to explore fully and which require less detail.

question

Components of a patient's health history

answer

1. Physical & Developmental 2. Intellectual 3. Spiritual 4. Social 5. Emotional

question

Physical & Developmental

answer

-Perception of health status -Past health problems and therapies -Present health therapies -Risk factors -Activity and coordination -Review of systems -Developmental stage -Effect of health status on developmental stage -Members of household marital problems -Growth and maturation -Occupation -Ability to complete activities of daily living (ADL's)

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Intellectual

answer

-Intellectual performance -Problem Solving -Educational level -Communication patterns -Attention span -Long-term and recent memory

question

Spiritual

answer

-Beliefs and meaning -Religious experiences -Rituals and practices -Fellowship -Courage

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Social

answer

-Financial status -Recreational activities -Primary language -Cultural heritage -Community resources -Environmental risk factors -Social relationships -Family structure and support

question

Emotional

answer

-Behavioral and emotional status -Support systems -Self-concept -Body image -Mood -Sexuality -Coping mechanisms

question

Concomitant symptoms

answer

Does the patient experience other symptoms along with the primary symptom? For example, does nausea accompany pain?

question

Review of systems (ROS)

answer

A systematic approach for collecting the patient's self-reported data on all body systems.

question

What does clustering data mean?

answer

A set of signs or symptoms gathered during assessment that you group together in a logical way.

question

How is clustering used when identifying a nursing diagnosis?

answer

Data clusters are patterns of data that contain defining characteristics, the clinical criteria that are observable and verifiable. Each clinical criterion is an objective or subjective sign, symptom or risk factor that when analyzed with other criteria, leads to a diagnostic conclusion.

question

What does nursing diagnosis mean?

answer

A clinical judgement about individual, family or community responses to actual or potential health processes/life processes, It is the basis for selection of nursing interventions

question

Differentiate a medical diagnosis from a nursing diagnosis

answer

Medical Dx is the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the patient's medical history and results of diagnostic tests and procedures. Medical Dx is of disease. Nursing Dx is of the human response. Nursing diagnosis involves the patient in dx process, medical does not.

question

Components of a nursing diagnosis

answer

1. Diagnostic label 2. Related factors (etiology)

question

PES

answer

1. P-Problem--NANDA label 2. E-Etiology or related factor 3. S-Symptoms or defining characteristics

question

What are the parts of an actual nursing diagnostic statement? (PES)

answer

NANDA-I label, the related factor, the defining characteristics Example: Impaired physical mobility r/t incisional pain, AEB restricted turning and positioning.

question

Discuss the rationale for having consistent terminology (NANDA) for nursing diagnoses

answer

Before using a classification system of diagnoses, nurses/HC providers would use a variety of terms to describe/document the same condition or symptoms. A classification system prevents conditions from going undiagnosed. Before 1972 (when the first conference of nursing diagnoses was held) nurses lacked the terms to described problems (outside of medical diagnoses) and also lacked the assessment questions to uncover such problems.

question

Collaborative problem

answer

An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's status. When collaborative problems develop, nurses intervene in collaboration with personnel from other health care disciplines.

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Defining characteristics

answer

The clinical criteria that are observable and verifiable. Supports the diagnostic judgement.

question

Related factor

answer

A condition, historical factor, or etiology that gives a context for the defining characteristics and shows a type of relationship the the nursing diagnostics and shows a type of relationship with the nursing diagnosis.

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Actual nursing diagnosis

answer

Describes human responses to health conditions or life processes that exist in an individual, family, or community

question

Risk nursing diagnosis

answer

Describes human responses to health conditions or life processes that may develop in a vulnerable individual, family or community. These diagnoses do not have related factors or defining characteristics because they have not occurred yet.

question

Etiology

answer

or related factor of a nursing diagnosis is always within the domain of nursing practice and a condition that responds to nursing interventions.

question

How does judgement impact the diagnostic statement?

answer

We need to make professional rather than prejudicial judgements. By adding in personal beliefs/values and not focusing on the objective/subjective data you could make errors in Dx.

question

How can 'nursing judgment' potentially 'interfere' with an accurate nursing diagnosis?

answer

When there is an error in nsg Dx the interventions you plan according to the incorrect Dx will not help solve/relieve what ever the true issues are and the pt will not get better etc.

question

What are defining characteristics in Carpenito.

answer

signs and symptoms, when seen together represent a diagnosis. The major characteristic are evident in this diagnosis with a frequency score of 80-100%. Minor characteristics provide evidence but may not be present. signs (ob) & symptoms (sub) - defining characteristics must be present.

question

What is a primary nursing diagnosis?

answer

Are those nursing diagnoses or collaborative problems when not managed right away will deter progress to achieve outcomes or will negatively affect functional status.

question

What is a secondary nursing diagnosis?

answer

Are those diagnoses or collaborative problems for which treatment can be delayed without compromising present functional status.

question

When patients have multiple nursing diagnoses, how do we decide which is the most essential or primary?

answer

With multiple diagnoses, the nurse needs to establish a priority set of diagnoses to be able to direct resources toward goal achievement. Priority diagnoses are those which affect functional status if not managed immediately.

question

Priority setting

answer

The ordering of nursing diagnoses or patient problems using determinations of urgency and/or importance to establish a preferential order for nursing actions.

question

How is an outcome different/similar to a goal?

answer

A goal is a broad statement that describes a desired change in a patient's condition or behavior. An expected outcome is a measurable criterion to evaluate goal achievement.

question

What is an outcome?

answer

Condition of a patient at the end of treatment, including the degree of wellness and the need for continuing care, medication, support, counseling or education.

question

What needs to be considered when writing an outcome?

answer

1. Patient Centered--Write a goal or outcome to reflect a patient's specific behavior, not to reflect your goals or interventions. 2. Singular Goal or Outcome--Each goal and outcome should address only one behavior or response. 3. Observable--Observable changes occur in physiological findings and in the patient's knowledge, perceptions and behavior. 4. Measurable--You learn to write goals and expected outcomes that set standards against which to measure the patients response to nursing care. Terms describing quality, quantity, frequency, length or weight allow you to evaluate outcomes precisely. 5. Time-Limited--when you expect the response to occur. It is very important to collaborate with patients to set realistic and reasonable time frames. 6. Mutual Factors--Mutually set goals and expected outcomes ensure that the patient and nurse agree on the direction and time limits of care. Mutual goal setting increases the patient's motivation and cooperation. 7. Realistic--Set goals and expected outcomes that a patient is able to reach based on your assessment.

question

Patient-centered goal

answer

Reflects a patient's highest possible level of wellness and independence in function. It is realistic and based on patient needs and resources.

question

Short-term goal

answer

An objective behavior or response that you expect a patient to achieve in a short time, usually less than a week. In an acute care setting you often set goals for over a course of just a few hours.

question

Long-term goal

answer

Is an objective behavior or response that you expect a patient to achieve over a longer period, usually over several days, weeks, or months.

question

Expected outcome

answer

A specific measurable change in a patient's status that you expect to occur in response to nursing care.

question

Nursing-sensitive patient outcome

answer

A measurable patient, family or community state, behavior, or perception largely influenced by and sensitive to nursing interventions.

question

Think about how you would incorporate the client's ethnicity, culture, and diversity into the plan of care.

answer

Take the following into consideration and plan accordingly: 1. Identified cultural affiliation 2. Health beliefs and values 3. Customary health practices 4. Spiritual beliefs and practices 5. Culturally specific social structures related to health care.

question

Identify examples how/when the patient is included in determining outcomes.

answer

For example a patient may have a goal of losing 20 pounds. You think the patient can do this in 6 months, but you ask the patient what they think they can do and then you can adjust the timed goal.

question

What are the three domains of planning care?

answer

1. Cognitive 2. Affective 3. Psychomotor

question

What is the focus for the affective domain?

answer

-attitudes -feelings -values

question

What is the focus for the cognitive domain?

answer

-acquires knowledge -intellectual skills

question

What is the focus for the psychomotor domain?

answer

-motor skills

question

Write an example of the affective domain

answer

patient will "express"

question

Write an example of the cognitive domain

answer

patient will "demonstrate"

question

Write an example of the psychomotor domain

answer

patient will "ambulate"

question

How would the "domain" impact our approach to selecting interventions?

answer

The intervention must match the domain. If the outcome states "patient will have a soft formed stool within 3 days", a psychomotor domain then the intervention must address the same domain. "cathartic will be administered daily for 3 days".

question

What does this statement mean? "Outcomes are driven by the nursing diagnosis and trigger planned interventions"

answer

The nursing diagnosis and the planned interventions will directly affect the success of a pt. outcome. After the nsg Dx is made you will decide which is the best way to approach/address and resolve by choosing the best intervention to achieve the outcome.

question

How do the outcomes suggest planned interventions?

answer

Once you have an outcome set you need to use critical thinking to chose the intervention that will have the greatest likelihood of success. Planned interventions are based off outcomes.

question

What are some of the factors present when deciding which interventions are needed/appropriate?

answer

1. Characteristics of the nursing diagnoses 2. Goals and expected outcomes 3. Evidence base (e.g. research or proven practice guidelines) for the interventions 4. Feasibility of the intervention 5. Acceptability to the patient 6. Your own competency As you select interventions, review your patient's needs, priorities, and previous experiences to select the interventions that have the best potential for achieving the expected outcomes.

question

What is a nursing order?

answer

Nursing orders or interventions comes directly from the nurse, are independent and do not require input from another health care professional. They are based on scientific evidence and usually relate to ADL's, health education and promotion, and counseling and are outlined in the legal scope of nursing in each state under the Nurse Practice Acts.

question

How does this relate to a medical order?

answer

Medical orders must be provided by a physician or other health care professional. The interventions are to treat or manage medical diagnosis. Nurses can carry out these orders, but cannot write them (unless the nurse is an advance practice nurse)

question

How do nursing orders relate to scope of practice?

answer

-Under the Nurses Practice Acts, a nurse cannot practice outside of their scope of practice, meaning the nurse must follow the statutes enacted by the legislature of the state and only perform tasks for which they are trained in. -Nursing orders must follow under the same guidelines in that a nurse cannot follow an order that is not in their field or prescribe/mandate an order to be done for which they are not trained in. -The nurse can coordinate the care but cannot prescribe care outside of their scope of practice (Carp, p.43) -Nursing orders contain Date, direct verb, what, when, how often, how long, where, and a signature (Carp, p.40)

question

Independent nursing interventions

answer

Actions that a nurse initiates. These do not require an order from another health care provider.

question

Dependent nursing interventions

answer

Actions that require an order from a physician or another health care professional. The interventions are based on the physician's or health care provider's response to treat or manage a medical diagnosis.

question

Collaborative interventions

answer

or interdependent interventions, are therapies that require the combined knowledge, skill and expertise of multiple health care professionals.

question

NIC

answer

Nursing Intervention Classification

question

NOC

answer

Nursing Outcome Classification

question

Nursing Outcome Classifications (NOC)

answer

A comprehensive, standardized classification of patient/client outcomes developed to evaluate the effects of interventions provided by nurses or other health care professionals.

question

Nursing Intervention Classifications (NIC)

answer

A set of nursing interventions that provides a level of standardization to enhance communication of nursing care across all health care settings and to compare outcomes.

question

How do NIC and NOC relate to outcomes?

answer

Comprehensive, research-based, standardized classifications of nursing diagnoses, nursing interventions and nursing-sensitive patient outcomes. These classifications provide a set of terms to describe nursing judgments, treatments and nursing-sensitive patient outcomes.

question

Characteristics of the nursing diagnosis

answer

1. Interventions should alter the etiological (related to) factor or signs and symptoms associated with the diagnostic label. Ex. Acute pain related to incisional trauma: choose interventions that relieve swelling and strain on incision site (position and turning measures) and lower pain reception (analgesic). 2. When an etiological factor cannot change, direct the interventions toward treating the signs and symptoms (e.g., defining characteristics for a diagnosis) Ex. Deficient knowledge regarding surgical recovery related to inexperience--choose interventions directed toward providing information that answer patient's questions about recovery procedures and relieve anxiety. 3. For potential or high-risk diagnoses, direct interventions at altering or eliminating risk factors for diagnosis.

question

Choosing expected outcomes

answer

1. State outcomes in terms used to evaluate the effect of an intervention. This language assists in selecting the intervention. Ex. For the outcome "patient will preform urinary catheter care by discharge." the nurse will evaluate skills instruction by observing the patient perform catheter care. 2. Nursing Interventions Classification (NIC) is designed to show the link to Nursing Outcomes Classification (NOC). Use these reference in developing care plans.

question

Nursing care plan

answer

Includes 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.

question

Interdisciplinary care plans

answer

Include contributions from all disciplines involved in patient care.

question

Direct care interventions

answer

Treatments performed through interaction with patients. For example a patient receives counseling during a time of grief.

question

Indirect care interventions

answer

Treatments performed away from the patient but on behalf of the patient or group of patients. Ex. Actions for managing the patients environment, documentation, and interdisciplinary collaboration.

question

IADL

answer

Instrumental activities of daily living

question

Instrumental Activities of Daily Living (IADL's)

answer

Include skills such as shopping, preparing meals, house cleaning, writing checks, and taking medications.

question

How are the following terms related: Intervention, implementation, nursing care, and nursing order.

answer

Intervention: is an treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. Implementation: is the fourth step of the nursing process, beginning after the nurse develops a plan of care. Interventions are part of the implementation process. Nursing Care: how nursing interventions are delivered. Nursing Orders: are the specific interventions that the nurse has written.

question

Who determines who will implement the plan of care?

answer

The nurse and the patient. Plan of care is a collaborative process.

question

Nursing-sensitive outcome

answer

A measurable patient or family state, behavior, or perception largely influenced by and sensitive to nursing interventions. The interventions must be within the scope of nursing practice and integral to the processes of nursing care.

question

Evaluative measures

answer

Assessment skills and techniques (e.g., observations, physiological measurements, patient interview) In fact, evaluation measures are the same as assessment measures, but you perform them at the point of care when you make decisions about the patients status and progress.

question

To objectively evaluate the degree of success in achieving outcomes of care, perform the following steps:

answer

1. Examine the outcome criteria to identify the exact desired patient behavior or response. 2. Evaluate the patient's actual behavior or response. 3. Compare the established outcome criteria with the actual behavior or response. 4. Judge the degree of agreement between outcome criteria and the actual behavior or response. 5. If there is no agreement (or only partial agreement) between the outcome criteria and the actual behavior or response, what is/are the barrier(s)? Why did they not agree?

question

standard of care

answer

The minimum level of care accepted to ensure high quality of care to patients.

question

What can be delegated?

answer

Tasks that need to be done but not the pt in entirety. e.g. asking fellow staff to obtain a sample while you attend to a pt pain medication-accomplishes two tasks for pt, more efficient.* promotes job enrichment and teamwork, improved quality of pt care, increased productivity.

question

How is this determined?

answer

Care is delegated based on assessment findings and priority setting. Must know which skills you are able to delegate (Nurse Practice Act)

question

Who is responsible for delegation?

answer

The RN is in most situations but it is not uncommon for a LPN to delegate in LTC settings.

question

How does delegation fit in with scope of practice?

answer

You can not delegate outside scope of practice. You need to know what tasks can be delegated to you and what tasks you,as a nurse, can delegate to CNAs and other nurses.

question

Discuss how implementation is impacted by "available resources"... patient and/or agency?

answer

Before implementing an intervention, it must be determined what resources are needed and if they are available. Resources can include equipment, personnel, and environment. -If equipment is required, determine if it's safe and working properly. Place supplies in convenient location and always keep extras on stock and only open if you need them (to control HC costs). -Personnel: Identify which care delivery model is being used (e.g, primary nurse or team nurse). As a nurse you are responsible for deciding whether to perform an intervention or to delegate it to another member of the nursing team. - Environment: Must be safe and conducive to implementing therapies. Pt safety is first concern. Prevent injuries by adapting environment to patient's sensory deficits, physical disabilities and altered level of consciousness. Practice using privacy to help patient relax, reduce distractions, provide adequate lighting. - Ensure patient is physically and psychologically comfortable to help patient cooperate and more fully participate in the implementation of the intervention. Consider the patient's level of endurance, plan only what can be tolerated comfortably. Be aware of the patient's psychosocial needs to help create a favorable emotional climate.

question

The five rights of delegation

answer

1. Right task-the right task is one that you delegate for a specific patient such as tasks that are repetitive, require little supervision, are relatively noninvasive, have results that are predictable, and have potential minimal risk. 2. Right Circumstances-Consider the appropriate patient setting, available resources and other relevant factors. In an cute care setting patients' conditions often change quickly. Use good clinical decision making to determine what to delegate. 3. Right Person-The right person is delegating the right tasks to the right person to be performed on the right person. 4. Right Direction/Communication-You give clear, concise description of the task, including its objective, limits and expectations. Communication needs to be ongoing between the registered nurse and the NAP during a shift of care. 5. Right Supervision/Evaluation--Provide appropriate monitoring, evaluation, intervention as needed, and feedback. NAP need to feel comfortable asking questions and seeking assistance.

NURS 141 Unit 4-Nursing Process – Flashcards

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