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beginning nursing student or any nurse entering a situation with no previous experience

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novice

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some level of experience, may only be observational, nurse is able to identify meaningful aspects or principles of nursing care

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Advance beginner

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a nurse that has 2 to 3 years in the same clinical position, anticipates nursing care and establishes long range goals, experience with all types of psychomotor skills required by this specific group of pt

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competent

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more than 2-3 years of experiencing the same clinical position. this nurse perceives a pts clinical situation as a whole is able to assess an a entire situation and can readily transfer knowledge gained from managing care as opposed to managing and performing skills

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proficient

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a nurse with diverse experience who has an intuitive grasp of an existing or potential clinical problem. This nurse is able to zero in on the problem and focus on multiple dimensions of the situation. He or she is skilled at identifying both patient centered problems and problems related to the health care system or perhaps the needs of the novice nurse.

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Expert

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Assessment Diagnosis Outcomes identification & Planning Implementation Evaluation

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American Nursing Association Standards of Nursing Practice

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The Rn collects comprehensive data pertinent to the patients health and the situation

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Assessment

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the Rn analyzes the assessment data to determine the diagnosis or issues

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Diagnosis

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the RN developes a plan that prescribes strategies and alternatives to attain expected outcomes.

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Planning and outcome identification

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The Rn implements the identified plan.

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Implementation

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coordination of care health teaching and health promotion consultation prescriptive authority and treatment.

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Steps to implementation

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the Rn evaluates progress toward attainment of outcomes.

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Evaluation

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*A theoretical body of knowledge leading to defined skills, abilities, and norms *Has a code of ethics for practice *An extended education of its members, as well as a liberal arts foundation *Members have autonomy in decision-making and practice *Provides a specific service

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nursing as a profession posses what characteristics? 5

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Standards of Professional Performance (ANA, 2010)

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These standards describe a competent level of behavior in the professional role of nursing

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Quality of practice Education Professional Practice Evaluation Communication Collaboration Ethics Evidence Based Practice & Research Resources Leadership Environmental Health

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Standards of Professional Performance (ANA, 2010) characterists

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(notes) Standards of Care (ANA, 2010) or ANA standards of nursing practice (book)

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these standards describe a competent level of nursing care?

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most frequent route to becoming an RN is through completion of an associate degree or baccalaureate degree program

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Nursing Education

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2-3 years Hospital affiliated programs Very comfortable in the hospital setting Purpose: To increase the labor force No research, management, or community health courses

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diploma programs

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2 years at a junior college or university Technical skills focus No research, management, or community health courses

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Associate Degree programs

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ENTRY POINT FOR PROFESSIONAL NURSING PRACTICE 4 years at a college or university Includes liberal arts courses Critical thinking component Includes theory and practice Courses in Research, Community Health, Nrsg Mgmt Assumes leadership potential

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Baccalaureate degree

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MN, MSN Nurse Educator, Clinical Nurse Specialist, Nurse Administrator, Certified Nurse Midwife, Certified Registered Nurse Anesthetist, Nurse Researcher and Nurse Practitioner

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Graduate Degree

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DNP, PhD ( Research focused)

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Doctoral Preparation

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to remain current in nursing skills, knowledge, and theory Illinois Nurses Association

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Continuing and In-Service Education

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formal and must be approved by Illinois Nurses Association

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Continuing education 20 hours req per year for illinois

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regulates licensure and practice by state; Scopes are defined by state (most are similar) Most differences are r/t advanced practice roles (newer)

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Nurse Practice Act

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Definition of nursing Licensure requirements Revocation or suspension of license Reciprocity of license Members of the Board of Nursing State of Illinois | Department of Financial and Professional Regulation

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Components of the Nurse Practice Act

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Think QUALITY Requires written nursing policies and procedures must be available. Home - OSF Saint Francis Medical Center Intranet Portal lippencott procedures

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Joint Commission on Accreditation of Healthcare Organizations (Joint Commission)

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Autonomy and Accountability Responsibility Caregiver Advocate Teacher Communicator Manager of care

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Professional Responsibilities and Roles of a Nurse

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the ability to initiate decisions and critically think independently of medical orders.

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Autonomy

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the ability to answer for one's own actions. Ex) Teaching a client about insulin administration prior to discharge. Is this also a responsibility for the nurse? Yes!

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Accountability

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the characteristics of reliability and dependability Ex) Giving a patient a bath in bed Ex) Delegation of duties to a PCT or NA = transfer of responsibility

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Responsibility

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Created to deal with issues of concern to those practicing in the profession.

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Professional Nursing Organizations

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National League for Nursing (NLN) American Nurses Association (ANA) International Council of Nursing (ICN) Sigma Theta Tau International Specialty organizations

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Professional Nursing Organizations (Examples)

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which addresses the whole person in all dimensions, in health and illness, and in interaction with the family and community

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definition of holistic focus

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defining characteristics =

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Exceptional assessment data (S & O) =

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nursing diagnosis is the same as a

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Specific problem is the same as nursing diagnosis

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a clinical judgement about a person, family or community responses to actual and potential health problems or life processes

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What is a Nursing Diagnosis?

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nursing diagnosis is a clinical judgement, medical diagnosis is identification of the disease based on the s/s, medical Hx, and labs. Physicians are licenced to treat the disease or patholigical process described in the medical diagnosis.

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How is a nursing diagnosis different from a medical diagnosis?

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to offer a standardized language to promote understanding between nurse's to facilitate communication and care planning. distinguish nurses role from physicians role helps nurses focus on client care

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Why do we have nursing diagnoses?

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North American nursing Diagnosis association

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who is NANDA?

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"language of nursing problems/diagnosis" that are to develop, refine, and promote and used by professional nurses

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Nanda, what is it

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risk diagnoses, problem-focused diagnoses, and health promotion diagnoses.

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There are three types of nursing diagnoses:

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describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community.

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A risk nursing diagnosis

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a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community.

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A problem-focused diagnosis describes

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is a clinical judgment of a person's, family's, or community's motivation, desire, and readiness to increase well-being. Acute diagnoses and chronic diagnoses are not considered types of nursing diagnoses according to NANDA-I.

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A health promotion nursing diagnosis

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Potential response to a health problem

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On what should the nurse focus when formulating a nursing diagnosis?

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An accurate nursing diagnosis helps ensure effective and efficient nursing interventions. Selecting the correct nursing diagnosis is based on proper assessment of the patient and proper analysis of the health problem. It enhances the nursing care provided to the patient. nursing diagnosis is essential to evaluate the effectiveness of the activities performed.

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What is the benefit of an accurate nursing diagnosis? It does not decrease the side effects of the medicines or the cost of treatment. Further assessment after the

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Admitting a patient following open heart surgery to the cardiovascular intensive care unit

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Which nursing activity is found in a tertiary health care environment?

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Providing prenatal teaching on nutrition to a pregnant woman during the first trimester

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Which option below is an example of the nurse participating in primary care activities?

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Optimal patient care based on current research

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What is evidence-based practice?

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Data clustering, formulating the diagnosis, and identifying patient health problems are the decision-making steps in a diagnostic process.

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Which steps are essential for decision making in a diagnostic process? Select all that apply.

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The diagnostic process involves reviewing information collected about the patient, finding cues and patterns in the patient's data, and making conclusions related to health problems.

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The nurse is assessing patients on the unit. What activities would the nurse perform during the diagnostic phase of the nursing process? Select all that apply.

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The patient has acute pain due to inflammation of the pancreas. The related factor is inflammation of the pancreas. The acute pain diagnosis would change if there were a change in the status of the related factor. Fever, distention of the abdomen, and vomiting are not the reasons for the patient's pain.

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A patient diagnosed with pancreatitis complains of pain in the abdomen. The patient has vomited three times, and has a temperature of 101° F. Following an initial interview and assessment, the nurse prepares a nursing care plan. The nurse formulates a diagnosis of acute pain. What could be the related factor for this diagnostic label?

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The presence of abdominal pain, distention, and a change in bowel elimination pattern forms a cluster, suggesting an elimination problem.

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The nurse completed the following assessment: 63-year-old female patient has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2 to 3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37° C, pulse 82 and regular, blood pressure 128/72. Which data form a cluster, showing a relevant pattern? Select all that apply.

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Accurately interpreting and using reliable cues are ways to prevent errors in interpretation while making the nursing diagnosis. The nurse should also consider the influence of culture or developmental stage on the patient's health when formulating a nursing diagnosis.

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The nurse is preparing a nursing care plan. Which actions would most likely prevent errors in interpretation when making a nursing diagnosis? Select all that apply.

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The patient's needs should be met in the order of priority. The pain due to oral ulcers should be a priority because this pain could affect the patient's nutritional intake and affect all other related interventions. Once the pain is relieved, the nutritional intake can be increased. Correcting a nutritional imbalance should be the second priority because it may affect other body systems. However, this diagnosis can be only addressed once the oral pain is relieved. Deficient knowledge regarding the diet therapy is the third priority. This diagnosis can only be addressed once the patient is relieved of pain. Constipation is the last priority. It can be addressed once the pain is relieved. The risk can be prevented by increasing the dietary intake and advising the patient on diet changes.

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The nurse documents the following complaints following an initial assessment. Which would be a priority for meeting the patient's needs?

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The nurse should identify treatable etiology or risk factors, the problems caused by the treatment, and the patient's response in order to reduce errors in the diagnostic statement. Identifying a medical diagnosis does not reduce errors in the diagnostic statement. Similarly, identifying clinical signs and symptoms helps focus treatment but does not reduce diagnostic errors.

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A patient diagnosed with pancreatitis complains of pain in the abdomen. Following an initial interview and the assessment, the nurse prepares a nursing care plan. Which guidelines should the nurse follow to reduce errors in the diagnostic statement? Select all that apply.

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Accurately selecting the diagnoses Correct2 Identifying related factors pertinent to the diagnosis Correct3 Selecting interventions suited for treating the diagnosed condition Correct4 Identifying defining characteristics of the diagnosis

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What points should the nurse keep in mind when formulating the nursing diagnosis? Select all that apply.

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Related factors...Related factors are data that appear to show some type of patterned relationship with a nursing diagnosis

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Which term describes data that appear to show some type of patterned relationship with a nursing diagnosis?

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