RNSG 1137 Final Study Guide

RNSG 1137 Final Study Guide 1. Clinical Judgment #1,2,3 Clinical Judgment Tanner’s Clinical Model Knowledge Safe and Effective Car e Environment: Management of Care Nursing Process Tanner A class of nursing students is ...

RNSG 1137 Final Study Guide 1. Clinical Judgment #1,2,3 Clinical Judgment Tanner’s Clinical Model Knowledge Safe and Effective Car e Environment: Management of Care Nursing Process Tanner A class of nursing students is in their first semester of nursing school. The instructor explains that one of the changes they will undergo while in nursing school is learning to “think like a nurse.” What is the most current model of this thinking process? A) Critical-thinking Model B) Nursing Process Model C) Clinical Judgment Model D) Active Practice Model Ans: C Feedback: To depict the process of “thinking like a nurse,” Tanner (2006) developed a model known as the clinical judgment model. The nursing student uses evidence-based practice findings in the development of a care plan. This is an example of which type of nursing skill? A) Cognitive skill B) Technical skill C) Interpersonal skill D) Ethical/legal skill Ans: A Feedback: The student is demonstrating the use of cognitive skills, which is characterized by identifying scientific rationales for the client’s plan of care, selecting nursing interventions that are most likely to yield the desired outcomes, and using critical thinking to solve problems. Technical skills focus on manipulating equipment skillfully to produce a desired outcome. Interpersonal skills are used to establish and maintain a caring relationship. Ethically and legally skilled nurses conduct themselves in a manner consistent with their personal moral code and professional role responsibilities. A nurse has come on day shift and is assessing the client’s intravenous setup. The nurse notes that there is a mini-bag of the client’s antibiotic hanging as a piggyback, but that the bag is still full. The nurse examines the patient’s medication administration record (MAR) and concludes that the night nurse likely hung the antibiotic but failed to start the infusion. As a result, the antibiotic is three hours late and the nurse has consequently filled out an incident report. In doing so, the nurse has exhibited which of the following? A) Ethical/legal skills B) Technical skills C) Interpersonal skills D) Cognitive skills Ans: A Feedback: Reporting problems and unacceptable practices is an aspect of ethical/legal skills. Technical skills enable the safe performance of kinesthetic tasks while interpersonal skills are the manifestations of caring. Cognitive skills encompass knowledge and critical thinking. What is a systematic way to form and shape one’s thinking? A) Critical thinking B) Intuitive thinking C) Trial-and-error D) Interpersonal values Ans: A Feedback: Critical thinking is defined as “a systematic way to form and shape one’s thinking. It functions purposefully and exactingly. It is thought that is disciplined, comprehensive, based on intellectual standards, and, as a result, well-reasoned” (Paul, 1993, p. 20). What step in the nursing process is most closely associated with cognitively skilled nurses? A) Assessing B) Planning C) Implementing D) Evaluating Ans: B Feedback: Cognitively skilled nurses are critical thinkers and are able to select those nursing interventions that are most likely to yield the desired outcomes. Members of the staff on a hospital unit are critical of a client’s family, who has different cultural beliefs about health and illness. A student assigned to the patient does not agree, based on her care of the client and family. What critical thinking attitude is the student demonstrating? A) Being curious and persevering B) Being creative C) Demonstrating confidence D) Thinking independently Ans: D Feedback: Although all the attitudes listed are components of critical thinking, the student is thinking independently. Nurses who are independent thinkers are careful not to let the status quo or a persuasive individual control their thinking. Clinical Judgment/ Tanner’s Clinical Model First test was Noticing -recognizing a potential issue, perceptually grasping situation Tanners clinical judgment model Remembering Remembering = Reflecting: attending to patient’s responses to nursing action while in the process of acting Reflection on action and clinical learning, breakdown in clinical judgement which is critical in developing clinical knowledge and improvement of clinical reasoning (incorporation of skills and clinical knowledge in patient situations) “Thinking Like A Nurse” (2006) Clinical Judgment Model 208 Excerpts from Tanner: Research on nursing work in acute care environments has shown how contextual factors profoundly influence nursing judgment. Ebright et al. (2003) found that nursing judgments made during actual work are driven by more than textbook knowledge; they are influenced by knowledge of the unit and routine workflow, as well as by specific patient details that help nurses prioritize tasks. Benner, Tanner, and Chesla (1997) described the social embeddedness of nursing knowledge, derived from observations of nursing practice and interpretation of narrative accounts, drawn from multiple units and hospitals. Benner’s and Ebright’s work provides evidence for the significance of the social groups style, habits and culture in shaping what situations require nursing judgment, what knowledge is valued, and what perceptual skills are taught. A number of studies clearly demonstrate the effects of the political and social context on nursing judgment. Interdisciplinary relationships, notably status inequities and power differentials between nurses and physicians, contribute to nursing judgments in the degree to which the nurse both pursues understanding a problem and is able to intervene effectively (Benner et al., 1996; Bucknall & Thomas, 1997). The literature on pain management confirms the enormous influence of these factors in adequate pain control (Abu-Saad & Hamers, 1997). Studies have indicated that decisions to test and treat are associated with patient factors, such as socioeconomic status (Scott, Schiell, & King, 1996). However, others have suggested that social judgment or moral evaluation of patients is socially embedded, independent of patient characteristics, and as much a function of the pervasive norms and attitudes of particular nursing units (Grieff & Elliot, 1994; Johnson & Webb, 1995; Lauri et al., 2001; McCarthy, 2003a; McDonald et al., 2003). In this model, noticing is not a necessary outgrowth of the first step of the nursing process: assessment. Instead, it is a function of nurses’ expectations of the situation, whether or not they are made explicit. These expectations stem from nurses’ knowledge of the particular patient and his or her patterns of responses; their clinical or practical knowledge of similar patients, drawn from experience; and their textbook knowledge. For example, a nurse caring for a postoperative patient whom she has cared for over time will know the patient’s typical pain levels and responses. Nurses experienced in postoperative care will also know the typical pain response for this population of patients and will understand the physiological and pathophysiological mechanisms for pain in surgeries like this. These understandings will collectively shape the nurse’s expectations for this patient and his pain levels, setting up the possibility of noticing whether those expectations are met. Other factors will also influence nurses’ noticing of a change in the clinical situation that demands attention, including nurses’ vision of excellent practice, their values related to the particular patient situation, the culture on the unit and typical patterns of care on that unit, and the complexity of the work environment. The factors that shape nurses’ noticing, and, hence, initial grasp, are shown on the left side of the Figure. *Deciding on a course of action deemed appropriate for the situation, which may include “no immediate action,” termed “responding.” *Attending to patients’ responses to the nursing action while in the process of acting, termed “reflecting.” *Reviewing the outcomes of the action, focusing on the appropriateness of all of the preceding aspects (i.e., what was noticed, how it was interpreted, and how the nurse responded).Conclusions Thinking like a nurse, as described by this model, is a form of engaged moral reasoning. Expert nurses enter the care of particular patients with a fundamental sense of what is good and right and a vision for what makes exquisite care. Educational practices must, therefore, help students engage with patients and act on a responsible vision for excellent care of those patients and with a deep concern for the patients’ and families’ well-being. Clinical reasoning must arise from this engaged, concerned stance, always in relation to a particular patient and situation and informed by generalized knowledge and rational processes, but never as an objective, detached exercise with the patient’s concerns as a sidebar. If we, as nurse educators, help our students understand and develop as moral agents, advance their clinical knowledge through expert guidance and coaching, and become habitual in reflection on-practice, they will have learned to think like a nurse. Blueprint note: Research based on Tanners clinical judgement Noticing -recognizing a potential issue, perceptually grasping situation Interpreting: reasoning pattern, analytic, intuitive, narrative, developing a sufficient understanding of the situation Observation and interpretation are hallmarks of trained nursing practice Responding: deciding on the court of action deemed appropriate for the situation, which may include, no immediate action Reflecting: attending to patient’s responses to nursing action while in the process of acting Blueprint note: Know what clinical judgement model is? Which model is relevant? • Clinical judgement model Supports the idea that nurses engage in a complex process of clinical reasoning when caring for patients. Nurses draw on personal knowledge and experience from various situations and consider the contextual background of the clinical culture. Blueprint note: Effective use of clinical judgement, center of the process • Critical Thinking is the center of the process for clinical judgement This article reviews the growing body of research on clinical judgment in nursing and presents an alternative model of clinical judgment based on these studies. Based on a review of nearly 200 studies, five conclusions can be drawn: (1) Clinical judgments are more influenced by what nurses bring to the situation than the objective data about the situation at hand; (2) Sound clinical judgment rests to some degree on knowing the patient and his or her typical pattern of responses, as well as an engagement with the patient and his or her concerns; (3) Clinical judgments are influenced by the context in which the situation occurs and the culture of the nursing care unit; (4) Nurses use a variety of reasoning patterns alone or in combination; and (5) Reflection on practice is often triggered by a breakdown in clinical judgment and is critical for the development of clinical knowledge and improvement in clinical reasoning. A model based on these general conclusions emphasizes the role of nurses’ background, the context of the situation, and nurses’ relationship with their patients as central to what nurses notice and how they interpret findings, respond, and reflect on their response. Reflection-in-action and reflection-on-action together comprise a significant component of the model. Reflection in-action refers to nurses’ ability to “read” the patient—how he or she is responding to the nursing intervention—and adjust the interventions based on that assessment. Much of this reflection-in-action is tacit and not obvious, unless there is a breakdown in which the expected outcomes of nurses’ responses are not achieved. Reflection-on-action and subsequent clinical learning completes the cycle; showing what nurses gain from their experience contributes to their ongoing clinical knowledge development and their capacity for clinical judgment in future situations. As in any situation of uncertainty requiring judgment, there will be judgment calls that are insightful and astute and those that result in horrendous errors. Each situation is an opportunity for clinical learning, given a supportive context and nurses who have developed the habit and skill of reflection-on-practice. To engage in reflection requires a sense of responsibility, connecting one’s actions with outcomes. Reflection also requires knowledge outcomes: knowing what occurred as a result of nursing actions. 2. Clinical Judgement #1,2,3,4 Clinical Judgment Components of Critical Thinking Application Psychosocial Integrity Nursing Process Brunner ****A care conference has been organized for a patient with complex medical and psychosocial needs. When applying the principles of critical thinking to this patient's care planning, the nurse should most exemplify what characteristic? A) Willingness to observe behaviors B) A desire to utilize the nursing scope of practice fully C) An ability to base decisions on what has happened in the past D) Openness to various viewpoints Ans: D Feedback: Willingness and openness to various viewpoints are inherent in critical thinking; these allow the nurse to reflect on the current situation. An emphasis on the past, willingness to observe behaviors, and a desire to utilize the nursing scope of practice fully are not central characteristics of critical thinkers. ***Achieving adequate pain management for a postoperative patient will require sophisticated critical thinking skills by the nurse. What are the potential benefits of critical thinking in nursing? Select all that apply. A) Enhancing the nurse's clinical decision making B) Identifying the patient's individual preferences C) Planning the best nursing actions to assist the patient D) Increasing the accuracy of the nurse's judgments E) Helping identify the patient's priority needs Ans: A, C, D, E Feedback: Independent judgments and decisions evolve from a sound knowledge base and the ability to synthesize information within the context in which it is presented. Critical thinking enhances clinical decision making, helping to identify patient needs and the best nursing actions that will assist patients in meeting those needs. Critical thinking does not normally focus on identify patient desires; these would be identified by asking the patient. The nursing instructor cites a list of skills that support critical thinking in clinical situations. The nurse should describe skills in which of the following domains? Select all that apply. A) Self-esteem B) Self-regulation C) Inference D) Autonomy E) Interpretation Ans: B, C, E Feedback: Skills needed in critical thinking include interpretation, analysis, evaluation, inference, explanation, and self-regulation. Self-esteem and autonomy would not be on the list because they are not skills. Blueprint note: A nurse sees a patient with a diagnosis of anorexia and orders a diet/nutrition consult what clinical reasoning skill is used? Clinical Judgment ***The nurse is providing care for a patient with chronic obstructive pulmonary disease (COPD). The nurse's most recent assessment reveals an SaO2 of 89%. The nurse is aware that part of critical thinking is determining the significance of data that have been gathered. What characteristic of critical thinking is used in determining the best response to this assessment finding? A) Extrapolation B) Inference C) Characterization D) Interpretation Ans: D Feedback: Nurses use interpretation to determine the significance of data that are gathered. This specific process is not described as extrapolation, inference, or characterization. ***A nurse uses critical thinking every day when going through the nursing process. Which of the following is an outcome of critical thinking in nursing practice? A) A comprehensive plan of care with a high potential for success B) Identification of the nurse's preferred goals for the patient C) A collaborative basis for assigning care D) Increased cost efficiency in health care - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - -- - -- Ans: A Feedback: Correlational quantitative research is used to examine relationships between two or more variables. In this case, the variables are perceptions of partner support and length of Stage 2 labor. There is no manipulation of the variables as there would be in an experimental or quasi-experimental study. The focus on the relationship between the two variables goes beyond simple description of events. Concept: EBP, Quantitative Research Process Page/Book: Taylor 32 Quantitative Research? It involves the concepts of basic and applied research. is a method of research conducted to gain insight by discovering meanings? At its core is the idea that reality is based on perceptions, which differ for each person and change over time.  Variable: Something that varies and has different values that can be measured  Dependent variable: The variable being studied, determined as a result of a study  Independent variable: Causes or conditions that are manipulated or identified to determine the effects on the dependent variable  Hypothesis: Statement of relationships between the independent and dependent variables that the researcher expects to find  Data: Information the researcher collects from subjects in the study (expressed in numbers)  Instruments: Devices used to collect and record the data, such as rating scales, pencil-and-paper tests, and biologic measurements. Instruments should be both reliable (produce the same results [data] on repeated use) and valid (test what they are supposed to test). 48.Safety 4 Safety/Hand off communication/ ISBARQ Previous Content Knowledge Safe and Effective Care Environment: Management of Care Communication/Documentation Brunner The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which of the following techniques would be most appropriate for the nurse to use when communicating with the health care provider? A) ISBAR B) EMAR C) SOAP D) CBE Ans: A Feedback: The nurse should use ISBAR to communicate verbally to the health care provider. Identify/Introduction, Situation, Background, Assessment, and Recommendation (ISBAR) is the communication tool to provide critical client information to the health care provider. EMAR is Electronic Medication Administration Record, which documents medication administration. SOAP is Subjective, Objective, Assessment, and Plan, which is a progress note that relates to only one health problem. CBE is Charting by Exception and permits the nurse to document only those findings that fall outside the standard of care and norms that have been developed by the institution. The nurse should utilize ISBARR communication (Introduction, Situation, Background, Assessment, Recommendation, Read Back) during which of the following clinical situations? A) When communicating a client’s change in condition to the client’s physician B) When providing a change-of-shift report to a colleague C) When documenting the care that was provided to a client whose condition recently deteriorated D) When reporting to a client’s family member or significant other Ans: A Feedback: ISBARR communication is an increasingly common tool for interdisciplinary communication. It is not typically used during change-of-shift report nor when communicating with family members. ISBARR is considered a framework for communication rather than a format for documentation. Concept: Safety/ Hand off communication/ISBARQ Page/Book: Taylor 169 I-Introduction: People involved in the handoff identify themselves, their roles, and their jobs S-Situation: Complaint, diagnosis, treatment plan, patient’s wants and needs B-Background: Vital signs, mental health and codes status, list of medications, and lab results A-Assessment: Current provider’s assessment of the situation R-Recommendation: Identify pending lab results and what needs to be done over the next few hours and other recommendations for care Q-Questions and answer: An opportunity for questions and answers 49.Safety 2 Safety/Population with Special Care Coordination Previous Content Application Health Promotion and Maintenance: Health Promotion and Maintenance Nursing Process: Analysis Taylor Concept: Safety/ Population with Special Care Coordination Page/Book: Taylor 173 & 185 Mental Age of a 12 y/o: Greatest Nursing Concern -During pre-entry phase of home visit, the nurse can determine whether the patient’s caregiver can answer questions related to patient’s family needs and can also learn about the patient’s cognitive abilities, orientation, and caregiver status. 50.Safety 5 Safety/Factors to consider during discharge planning Previous Content Comprehension Safe and Effective Care Environment Management of Care Nursing Process: Analysis Taylor A man 75 years of age is being discharged to his home following a fall in his kitchen that resulted in a fractured pelvis. The home health nurse makes a home assessment that will be used to design interventions to meet which priority need? A) Sleep and rest B) Support from family members C) Protection from potential harm D) Feeling a sense of accomplishment Ans: C Feedback: Physical safety and security means being protected from potential or actual harm. Assessing potential risks for harm in the home environment is necessary to meet physical safety needs. For this situation, protecting the patient from potential harm has a higher priority than interventions that focus on sleep and rest, support from family members, and feeling a sense of accomplishment. The nurse recognizes that the goals established for a client’s discharge are more likely to be accomplished when … A) the client assists in developing the goals. B) the physician develops the goals. C) the nurse develops the goals. D) the multidisciplinary team develops the goals. Ans: A Feedback: If the client is involved in establishing the goals, it is more likely that the expected outcomes of the discharge plan will be met. The client may fail to follow the plan if the goals are not mutually agreed on or are not based on a complete assessment of the client’s needs. At what point during hospital-based care does planning for discharge begin? A) Upon admission to the hospital B) After the patient is settled in a room C) Immediately before discharge D) After leaving the hospital Ans: A Feedback: Planning for discharge begins on admission to the hospital, when admission information about the client is collected and documented. A nurse, preparing for a client’s discharge after surgery, is teaching the client’s wife to change the dressing. How can the nurse be certain the wife knows the procedure? A) Tell the wife exactly how to do it. B) Give the wife information about supplies. C) Have the wife demonstrate the procedure. D) Ask another nurse to reinforce teaching. Ans: C Feedback: All steps of a procedure should be demonstrated, practiced, and provided in writing. The client or caregiver should then perform the procedure in the presence of the nurse to demonstrate understanding. Simply stating the information, providing information about supplies, or asking another nurse to reinforce teaching does not mean the caregiver knows the information. A client is diagnosed with mild dementia while in the hospital. In preparing for discharge, what should the nurse should discuss with the family? A) Possible need for home care B) Legal responsibility for the future C) Need for transfer to a long-term care facility D) Lack of free resources of care Ans: A Feedback: The needs of the client should be considered when making discharge plans. Common risk factors associated with the need for home care include limited social, mental, or physical functioning. Legal issues, long-term care, and free resources are not indicated in this situation. The nurse is planning the discharge of a client who had surgery for a left hip replacement. The client is being discharged from the hospital to the home and requires a walker and high-rise toilet seat. Which type of home health care service does the client require? A) Custodial services B) Home medical services C) High-technology pharmacology services D) Hospice services Ans: B Feedback: Home medical services provide durable medical equipment, such as walkers, canes, crutches, wheelchairs, high-rise toilet seats, commodes, beds, and oxygen. Custodial services include homemaking and housekeeping services, as well as companionship and live-in services. Hospice services provide pain management, physician services, spiritual support, respite care, and bereavement counseling. High-technology pharmacology services provide intravenous therapy, home uterine monitoring, ventilator management, and chemotherapy. The home health nurse receives a referral from the hospital for a client who needs a home visit. After reading the referral, what would be the first action the nurse should take? A) Identify community services initially for the client B) Obtain client information from the discharge planner C) Call the client to obtain permission to visit D) Schedule a home health aide to visit the client Ans: B Feedback: After receiving a referral, the first step is to call the physician or discharge planner to collect as much information as possible about the client. After the nurse reviews the information, he or she can call the client to obtain permission and schedule the visit. The nurse may identify community services or the need for a home health aide after she assesses the client and the home environment during the first visit with the client. A client being prepared for discharge to his home will require several interventions in the home environment. The nurse informs the discharge planning team, consisting of a home health care nurse, physical therapist, and speech therapist, of the client’s discharge needs. This interaction is an example of which professional nursing relationship? A) Nurse-health care team B) Nurse-patient C) Nurse-patient-family D) Nurse-nurse Ans: A Feedback: A nurse-health care team professional relationship occurs when the nurse coordinates the input of the multidisciplinary team into a comprehensive plan of care. The nurse may also serve as a liaison between the client and family and the health care team, as necessary. Concept: Safety/ Factors to consider during discharge planning Page/Book: Taylor 179 Concept: Safety/ Factors to consider during discharge planning Page/Book: Taylor 179 What is a factor to consider during discharge planning? Language Preference Other Factors to consider: -Age or Gender -Medical Dx -Functional Limitations (Impaired Sight or hearing, amputation, use of wheelchair) -Emotional Support -Caregiver’s age and relationship to patient as well as feelings and living status -Home Environment -Financial Resources What is a factor to consider during discharge planning? Language Preference Other Factors to consider: -Age or Gender -Medical Dx -Functional Limitations (Impaired Sight or hearing, amputation, use of wheelchair) -Emotional Support -Caregiver’s age and relationship to patient as well as feelings and living status -Home Environment -Financial Resources ........................................CONTINUED...........................................