Nursing Documentation and Evidence-Based Practice, Exams of Nursing

Download Nursing Documentation and Evidence-Based Practice and more Exams Nursing in PDF only on Docsity! Nur3330 Professionalism Exam 1 Review with complete solutions 2024/2025 A good NIS: - ANSWER-* Supports the way that nurses function and work by being able to view data collect information, provide patient care, and document a patient's condition and care provided * Supports and enhances nursing practice through improved access to information and clinical decision-making tools Altered self concept - ANSWER-Self care deficit, emotional & behavioral changes, anxiety & depression, and self destructive behavior Analysis Skills - ANSWER-Be open minded as you look at info about a pt. Do not make assumptions. Does data reveal a problem or trend that you believe is true. Anticipate and Prevent Complications - ANSWER-Identify risks to the patient Adapt interventions to the situation Evaluate the relative benefit of a treatment vs. the risk Initiate risk prevention measures Attributes of proper documentation - ANSWER-*Factual* • Descriptive objective information about what the nurse sees, hears, feels, smells and think • Vague terms like seem or apparently • Includes objective signs of problems • Subjective data is documented in client's exact words within quotation marks *Accurate* • Use of exact measurement establishes accuracy • e.g. Intake of 400ml of water then writing adequate amount of water *Complete* - be sure to include • Condition change • Patient's responses especially unusual, undesired or ineffective response. • Communication with patient family • Entries in all spaces on all relevant assessment form. Use N/A or other designation per policy for items that do apply to your patient. • Do not leave blank N/A *Timely* (date & time) • Document date & time of each recording • Record time in conventional manner (e.g. 9:00am to 6:00pm or according to the 24 hours clock) • Avoid recording in advance (this practice is illegal falsification of the records contributes to errors and confusion and threatens patient safety. • Client's name, the word can be omitted *Concise* • Recording need to be brief as well as complete to save time and communication *Legible* • Using black pen, clear enough to be read, readable particularly handwriting • Any mistakes occur while recording draw a line through it and write above or next to original entry with your initial or name. Benefits of NIS (Nursing Information System) - ANSWER-Better access to information Enhanced quality of documentation through prompts Reduced errors of omission Reduced hospital costs Increased nurse job satisfaction Compliance with requirements of accr. agencies Development of a common clinical database Enhanced ability to track records Benefits of Nursing Dx - ANSWER-1. Provides a precise definition of a patient's problem that provides a common language for understanding patients' needs 2. Allows nurses to communicate what they do among themselves and with other health care professionals and the public 3. Distinguishes the nurse's role from that of the physician or other health care provider 4. Foster development of nursing knowledge Evaluation research - ANSWER-Study that tests how well a program, practice, or policy is working Evaluation skills - ANSWER-Look at all situations objectively. Use citeria (expected outcomes, pain, characteristics) to determine results of nursing actions. Evidence-based practice - ANSWER-clinical decision making that integrates the best available research with clinical expertise and patient characteristics and preferences Evidence-Based Practice - ANSWER-EBP is the utilization of research and other evidence to make changes in clinical practice Here are some EBP Changes: Prevention of CAUTI Prevention of Ventilator Dependent Pneumonia (VDP) SIDs deaths Baby positioning Confirmation of placement of Lg. bore N/G tubes Oxygen Use in Pts. with COPD Examples of EBP - ANSWER-Listening to Bowel sounds Best practice for Tracheotomy dressing Early mobilization to prevent pneumonia Positioning to prevent pressure ulcer Examples of Nursing research - ANSWER-symptom clusters of patients with congestive heart failure quality of life outcome of pt of pre transplant and 5 years after transplant if the location of hospital impacts the follow up treatment of breast cancer patients Examples of Quality Improvement - ANSWER-Improving the discharge time of patients Improving documentation of critical lab values Improve patients satisfaction Decrease pressure sores with the use of pressure dressings Reduce time between provider writing an order (antibiotic) and when patient receives an order. Expected Outcomes - ANSWER-There is usually one expected outcome per nursing dx In clinical, you may have to write a short and long term expected outcome based on time The patient and/or family should be involved in development of the expected outcome These are focused on patient behavior and not nursing tasks Thus, they often start with, "The pt. will..." The expected outcome should be resolution of the nursing diagnosis These are NOT about resolution of each nursing intervention Experimental research - ANSWER-Study in which the investigator controls the study variable and randomly assigns subjects to different conditions to test the variable. Explanation skills - ANSWER-Support your findings and conclusions. Use knowledge and experience to choose strategies to use in the care of pts. Exploratory research - ANSWER-Initial study designed to develop or refine the dimensions of phenomena or to develop or refine a hypothesis about the relationships among phenomena Health Promotion activities for young adults - ANSWER-Monthly skin, breast, genitals self-examinations. Know partner's sexual history and practices. Use of safe sex practices. Health promotion for all ages - ANSWER-vaccinations, oral hygiene, self examining, nutrition counseling, physical activity, blood pressure screening. Historical research - ANSWER-Study designed to establish facts and relationship concerning past events How do we maintain privacy in EMR? - ANSWER-Have password, do not talk about pts, log out always. Identity stressors - ANSWER-cultural, social, personal factors (job loss, abuse or neglect, sexuality concerns, repeated failures, conflict with others) Indirect care interventions - ANSWER-Treatments performed away from the patient but on behalf of the patient or group of patients (documentation, managing pt's environment) Inference skills - ANSWER-Look at the meaning and significance of finding. Issues with Telehealth - ANSWER-Difficulties in complying with myriad state licensure and prescribing laws Lack of highly developed protocols and guidelines HIPAA privacy and security: Nursing - ANSWER-the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations Nursing Diagnosis - ANSWER-The most common standardized language used to label a diagnosis in acute care is NANDA-I These are not the same as medical diagnoses Not about nursing care, tasks, or problems These are pt. focused Almost all pts. have a knowledge deficit diagnosis, but it is seldom a high priority problem Objective information, no biases or blaming Avoid wording like; seems, appears, blood-like Accurate Complete Current/Timely Date and time all entries Organized Usually chronological order See agency specific policy re: making a late entry Do not leave empty lines on a page Draw a line through and then enter your name and credentials If an error is made, draw a line through the erroneous wording and write your initials (in small print) besides the line with the date If handwritten please write legibly Use only hospital-approved abbreviations Purpose of Documentation - ANSWER-To Communicate to other members of the healthcare team Legal purposes Your documentation or lack of, can help or harm you in a court case Reimbursement Auditing/monitoring For QI/research/EBP purposes Education Qualitative Research - ANSWER-To understand a phenomena or people's experiences Types Phenomenology/grounded theory (to dev. a theory) Ethnography (study of a culture) Obtain rich understanding of experiences/beliefs/ a phenomena Use of open ended questions Analyzing narrative data by themes Data collection methods: focus groups/interviews/surveys/ Storytelling/written stories Rigor Triangulation, peer debriefing, member checking, achieving saturation of data, thick, rich descriptions, audit trails, researcher positionality The researcher is part of the data collection The perspective of the research influences the findings Not worried about bias. Example: What is the experience of new mothers who lost a baby to SIDs? Quality improvement - ANSWER-the commitment and approach used to continuously improve every process in every part of an organization, with the intent of meeting and exceeding customer expectations and outcomes Quantitative research - ANSWER-Types Experimental/quasi-experimental/non-experimental (descriptive) Depending on the presence or absence of random selection to control or experimental groups Variables' influence on each other Independent and dependent variables Which one is varied in an experiment? Often you use a tool to gather data BP cuff, survey, pain scale Use of numerical data to analyze Application of some type of statistical model based on the type of data-nominal, ordinal, interval, or ratio Rigor = Validity/reliability Most rigorous Randomized control study/trials-highly experimental, Example: Does hand massage lower BP? Role performance stressors - ANSWER-Role conflict, Role ambiguity, Role strain, Role overload ( inability to balance career and family, physical emotional and cognitive deficits, loss of satisfying role) Secondary prevention - ANSWER-Focus is on people who have health issues or are ill and at risk for complications Hospitalized people/care to treat problems Used after the disease has occurred in a person but before the person notices anything is wrong EX: checking a mole that has grown Early Diagnosis and Prompt Tx Self-regulation skills - ANSWER-Reflect on your experiences. Be responsible for connecting your actions with outcomes.Identify the ways to improve performance. smart - ANSWER-Specific, Measurable, Attainable, Realistic, Timely Steps in EBP - ANSWER-Step 0: Cultivate a spirit of inquiry Step 1: Ask clinical questions in PICOT (PICO) format Step 2: Search for the best evidence Step 3: Critically appraise the evidence Step 4: Integrate the evidence with clinical expertise and patient preferences and values Step 5: Evaluate the outcomes of the practice decisions or changes based on evidence Step 6: Disseminate EBP results Tertiary prevention - ANSWER-Minimizing the effects of long term disease or disability, e.g. pts in rehab post-stroke Targets the person who already has symptoms of disease aims to slow down disease, prevent damage to the person, and tx the signs and symptoms of the disease Restoration and Rehabilitation The skills needed for critical thinking: Interpretation - ANSWER-Be orderly in collecting data about pts. Apply reasoning while looking for patterns to emerge.Categorize the data. Gather additional data or clarify the data about which uncertain