practical nursing clinical (online help)

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Infection Prevention and Control (IPAC)

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Norwalk Virus

Overview: Norwalk virus causes acute gastrointestinal illness sporadically or in outbreaks.

Mode of transmission: direct and indirect contact. Can be aerosolized from emesis.

Incubation period and period of infectivity: Symptoms usually develop 12 to 48 hours after being exposed, and recovery typically occurs within 1 to 3 days. Can be transmitted from infection to 3 days after illness.

Treatment: no specific treatment, supportive management only.

Preventative measures and vaccinations: prevention involves proper hand washing and disinfection of contaminated surfaces. Alcohol-based sanitizers are not effective against the Norwalk virus. Vaccine under development.

Vancomycin-Resistant Enterococcus (VRE)

Overview: type of bacteria present in the gastrointestinal tract and the female genital tract that develop resistance to many antibiotics, especially vancomycin.

Mode of transmission – direct and indirect contact.

Incubation period and period of infectivity: The incubation period is variable and indefinite. Occurs commonly around 4 – 10 days after exposure. Enterococcus can live on hands for as long as 60 minutes after contact and as long as four months on inanimate surfaces. Can be transmitted until the person is cured.

Treatment: Most VRE infections can be treated with antibiotics other than vancomycin. Doxycycline, chloramphenicol, and rifampin in various combinations have been used to treat VRE infections, but the newer antibiotic choices are also now available. No vaccine.

Preventative measures and vaccinations: prevention involves proper hand washing and disinfection of contaminated surfaces. No current vaccine.

Extended Spectrum Beta-Lactamase (ESBL)

Overview: ESBL is an enzyme found in some strains of bacteria that make them resistant to antibiotics. These bacteria include Escherichia coli (E. coli) and Klebsiella pneumoniae. ESBL infections are serious and can be life-threatening.

Mode of transmission – direct and indirect contact.

Incubation period and period of infectivity: The incubation period is variable. It occurs commonly around 4–10 days. A person can spread ESBL as long as they are colonized.

Treatment: antibiotics the bacteria is not resistant to such as Carbapenems. Supportive treatment for the infection.

Preventative measures and vaccinations: prevention involves proper hand washing and disinfection of contaminated surfaces. No current vaccine.

Measles

Overview: Measles is an acute viral respiratory illness. It is characterized by a prodrome of fever (as high as 105°F) and malaise, cough, coryza, and conjunctivitis -the three “C”s -, a pathognomonic enanthema (Koplik spots) followed by a maculopapular rash.

Mode of transmission: Airbourne.

Incubation period and period of infectivity: Incubation is 7-21 days from the onset of the fever. It is contagious from 4 days before, until 4 days after, the rash appears.

Treatment: No specific treatment, supportive treatment only.

Preventative measures and vaccinations: MMR vaccine.

Communication in Clinical Practice

Patient and Family Centred Care

It is important to acknowledge that patient- and family-centred care focuses on the whole person as a unique individual and not just on their illness or disease.

In viewing the individual through this lens, health-care providers come to know and understand the person’s life story, experience of health, the role of family in the person’s life, and the role they may play in supporting the person to achieve health.

Potter & Perry, 2019

Data Collection

First step in nursing process is assessment

Nurses collect pertinent data about the client’s health or situation.

This includes information from the nursing health history and physical assessment

Potter & Perry, 2019

Sources of Data

Primary

Secondary

Tertiary

Potter & Perry, 2019

Nursing Interview – Purpose

Obtain a nursing health history, identify health problems and risk factors

Reason for seeking care

Patient’s perception of the illness

Provides subjective data

Why is this important?

Potter & Perry, 2019

Phases of an Interview

Orientation – introduction and purpose of interview

Working – gather information, observe verbal and non-verbal behaviour

Termination – end interview

Potter & Perry, 2019

Questioning Techniques – Open-ended Questions

Explore broader issues

Invite longer answers

Encourage patients to discuss and elaborate

Identify patient’s priorities

Potter & Perry, 2019

Questioning Techniques – Closed-ended Questions

Can be answered with a yes or no

Do not invite discussion

No additional information is required

Potter & Perry, 2019

Nursing and Cultural Diversity

What are the challenges in cross cultural communication?

What strategies can we use to overcome them?

Potter & Perry, 2019

Nurse-Client Interviews with Patients with Special Needs

Our duty to elicit the information

Must adapt communication so that the patient can understand it and we can understand the answers

Think of some examples and how we can ensure the message is received and understood, and we receive and understand the answer

Potter & Perry, 2019

Components of a Health History Interview

Nursing Health History – subjective data

Family History

Documentation of findings

Physical Examination – objective data

Potter & Perry, 2019

How to Observe during the Interview

Use your senses

Notice general appearance

Observe body language

Notice interaction patterns

Think holistically (physical, psychosocial, emotional, spiritual, etc.)

Be present, be fully there!

Potter & Perry, 2019

Professional Communication among Health Care Workers

Communication problems among healthcare personnel have been implicated as a cause of most client errors

Poor communication between nurses and physicians was the most importance factor causing dissatisfaction with working relationships

Ontario’s Bill 168, OHSA prevents disruptive behaviours in workplaces, supported by CAN and CFNU

Potter & Perry, 2019

Disruptive Behaviour

Includes, incivility, lateral violence & bullying

Let’s discuss some clinical examples

Potter & Perry, 2019

Assertive Communication

What does it mean?

Why is it important for nurses?

What would be an example of non-assertive communication?

Potter & Perry, 2019

Professional Communication Styles among Health Care Workers

Nurses tend to be descriptive

Physicians tend to be brief, to the point and problem-focused

SBAR communication helps facilitate

Potter & Perry, 2019

SBAR

S – situation – introduction and brief reason for call

B – background – history of illness, all relevant past data

A – assessment – current assessment of situation

R – recommendations – what next?

Potter & Perry, 2019

SBAR Report

Let’s look at some SBAR reports

Potter & Perry, 2019

Rounds

Nursing perspective for the multidisciplinary team

Short and concise outlining reason for admission, progress to date and barriers to discharge

Potter & Perry, 2019

Telephone and Verbal Orders

Know who can give and accept telephone orders

Ask prescriber to spell out unfamiliar medications

Read back the order to the prescriber

Use words and not abbreviations

Write on the physician order sheet, record date and time, indicate it was a telephone order, sign name with credentials

Transcribe the order if necessary

Potter & Perry, 2019

Professional Communication – Nursing Reports

When should nurses report to each other?

What are the important elements of a patient report?

Potter & Perry, 2019

Change-of-Shift Reports

Can be done in person at the nursing station

At the bedside – consider confidentiality

Can be recorded

Can be written

Potter & Perry, 2019

Transfer Reports

Usually telephone reports

May be given in person

Concise, may include the following:

past history,

diagnoses etc.,

summary of progress to date

goals for discharge

social supports

Potter & Perry, 2019

Electronic Communication

We will cover this next week

Welcome to PNC 121

Practical Nursing – Clinical Preparation

Overview of PNC 121 and Addendum

Blackboard

Course Description

Academic Integrity

Discrimination/Harassment

Academic Accommodations

Late Assignments/Assignment Extension

Request for Deferred Evaluation Privilege

Modes of Evaluation

Evaluation	Explanation	Percentage of Final Grade
Class Assignments	4 assignments on content worth 5% or 10% each	25%
2-Part Nursing Care Plan Assignment	Part 1 = 5% Part 2 = 10%	15%
Infection Prevention and Control (IPAC) Group PowerPoint and Presentation	In class group presentation = 6% Group power point = 4%	10%
Midterm Exam	Multiple Choice and/or Alternate Format Questions on weeks 1-6	24%
Final Exam	Comprehensive multiple Choice and/or Alternate Format Questions	26%

The Online Community

In order to get to know each other please post an introduction to yourself in the Discussion Forum by next class. This should include a short description of yourself and why you want to be a nurse.

Definitions of Nurses

What is your definition of a Nurse?

Common Themes in Nursing

Patient focus – patient centred care

Information focus – how information is used

Quality improvement – many aspects to improve care

Staff focus – healthier working environments improve patient outcome

Leadership – critical in shaping care

Potter & Perry, 2019

Issues and Trends in Practical Nursing

Educational preparation and entry to practice competencies

Registration

Continuing education

The role of the practical nurse

Workplace issues

Workforce trends

Potter & Perry, 2019

Who are the Recipients of Care

Individuals

Groups

Organizations

Communities

Potter & Perry, 2019

What are the different Practice Settings?

Institutional Sector

Community Sector

Potter & Perry, 2019

Categories of Nurses

RPN

Nurse Practitioner

https://www.cna-aiic.ca/en/nursing-practice/the-practice-of-nursing/health-human-resources/nursing-statistics

Potter & Perry, 2019

Who provides care?

RN and RPN Practice: The Client, the Nurse and the Environment

http://www.cno.org/en/learn-about-standards-guidelines/educational-tools/webcasts/rn-and-rpn-practice-the-nurse-the-client-and-the-environment-webcast/

CNO, 2013

What roles and functions are nurse involved in?

Roles Functions

Potter & Perry, 2019

Occupation versus Profession

What is the difference between an occupation and profession?

Potter & Perry, 2019

The Professional Standards Practice Standard

https://www.cno.org/globalassets/docs/prac/41006_profstds.pdf

Let’s look at the each of the Professional Standards and how a nurse may demonstrate them.

CNO, 2002

Accountability

Each nurse is accountable to the public and responsible for ensuring that her/his practice and conduct meets legislative requirements and the standards of the profession.

CNO, 2002

Continuing Competence

Each nurse maintains and continually improves her/his competence by participating in the College of Nurses of Ontario’s Quality Assurance (QA) Program

CNO, 2002

Ethics

Each nurse understands, upholds and promotes the values and beliefs described in CNO’s Ethics practice standard.

CNO, 2002

Knowledge

Each nurse possesses, through basic education and continuing learning, knowledge relevant to her/ his professional practice.

CNO, 2002

Knowledge Application

Each nurse continually improves the application of professional knowledge

CNO, 2002

Leadership

Each nurse demonstrates her/his leadership by providing, facilitating and promoting the best possible care/service to the public

CNO, 2002

Relationships

Each nurse establishes and maintains respectful, collaborative, therapeutic and professional relationships

Relationships include therapeutic nurse-client relationships and professional relationships with colleagues, health care team members and employers

CNO, 2002

Therapeutic Nurse-Client Relationships

The client’s needs are the focus of the relationship, which is based on trust, respect, intimacy and the appropriate use of power.

CNO, 2002

Professional Relationships

Professional relationships are based on trust and respect, and result in improved client care

CNO, 2002

Fitness to Practice

What does fitness to practice mean for nursing?

CNO

Duty to Provide Care

What is Duty to Care?

CNO

Nursing Practice Concepts

There are 5 nursing practice concepts in your clinical courses:

Competency

Connectedness

Health & Healing

Critical Thinking

Professionalism

Let’s look at these and discuss how you can meet them

PNC 220

Competency

The student will be able to demonstrate knowledge and skill in providing safe and organized care for one stable client with multiple health needs.

The student will be able to report and document client care in a clear, accurate, and timely manner, in a variety of formats

PNC 220

Connectedness

The student will be able to demonstrate knowledge, development and evaluation of the therapeutic nurse-client relationships, when providing care, while respecting confidentiality, privacy and client’s rights.

The student will be able to consult and collaborate with peers, clinical supervisor and members of the health care team to provide client care

PNC 220

Health & Healing

The student will be able to articulate and utilize nursing and health sciences knowledge and research when assessing, planning, implementing and evaluating client care.

The student will be able to, in collaboration with the client, client’s family or designate, develop an appropriate nursing plan of care respecting client independence.

PNC 220

Critical Thinking

The student will be able to reflect on their practice, and that of others, to uncover new meaning and insights.

The student will be able to make clinical decisions supported by research to ensure safe client care.

PNC 220

Professionalism

The student will be able to practice in a professional manner, complying with the college expectations, standards of the nursing regulatory body and practice-setting’s policies and procedures.

PNC 220

Client Safety & Safe Working Environments

Potter & Perry, 2019)

Client Safety

The aim of the Canadian health care system is to provide quality care and access for all. This includes the following:

Cultural Competence, Safety and Humility

Evidence-Informed Practice (EIP)

Quality and Patient Safety

Quality Workplaces

Improved Patient Outcome Metrics

Potter & Perry, 2019)

Quality Care

How is quality care delivered?

How do nurses achieve quality in nursing practice?

Potter & Perry, 2019)

Quality Improvement and Risk Management

Risk management is a system of ensuring appropriate care by identifying potential hazards and preventing harm from occurring.

One tool used in risk management is the “incident report” or “adverse occurrence report”

By tracking incidents areas for improvement can be identified

Potter & Perry, 2019)

Patient Safety Incidents (or Adverse Events)

An event or circumstance that could have resulted, or did result in unnecessary harm to a patient

Harmful incident – resulted in patient harm

Near miss- did not reach the patient

No-harm incident – reached the patient but did no harm

Potter & Perry, 2019)

Factors Affecting Patient Safety

Patient and Provider Factors

Task Factors

Technology Factors

Environmental Factors

Organizational Factors

Potter & Perry, 2019)

Risk Factors at Developmental Stages

Infant/toddlers – poisoning

Toddlers/preschoolers – not restrained properly in vehicles, drowning

Adolescents – risk taking behavior, substance use

Adults – accidents due to alcohol or drugs

Older people – age related changes

Potter & Perry, 2019)

Risk Factors in the Home Environment

Physiological

Environmental

Potter & Perry, 2019)

Fire Safety in the Home Environment

Smoke detectors on every floor of the house

Have a fire extinguisher at home

What other fire risks are there in the home environment?

Potter & Perry, 2019)

Risk Factors in the Health Care Environment

What can the nurse do to improve safety for patients in hospital?

Potter & Perry, 2019)

Prevention of Falls

Screen individuals – history of previous falls, balance, gait or mobility issues, use of clinical judgement

Use a validated fall assessment tool for those at risk – e.g., Hendrick II Fall Risk Model

Use falls prevention interventions

Assess after a fall

Potter & Perry, 2019)

Medication Errors

A medication error is any event that could lead to a patient either receiving inappropriate medication therapy or failing to receive appropriate medication therapy.

Causes of medication errors include nurse fatigue, burn out, distractions and interruptions.

Potter & Perry, 2019)

Fire Safety in the Clinical Setting – Code Red

If a fire is suspected call a code RED

R – Remove those in immediate danger

E – Ensure fire is contained, close doors

A – Activate the nearest fire alarm

C – Call fire department

T – Try to extinguish the fire if able to do so safely

Potter & Perry, 2019)

Fire Extinguishers

Fire extinguishers are designated according to the cause of the fire.

Class A fires – ordinary combustibles such as paper, wood, cloth

Class B – fires involving flammable or combustible liquids

Class C – fires involving live electricity or power

Class D – combustible metals such as magnesium, uranium spills (not very common)

Class K – fires involving cooking materials such as cooking oils and grease

P – Pull the pin

A – Aim

S – Squeeze

S – Sweep

Potter & Perry, 2019)

Code Green – Evacuation

Evacuation will be ordered if:

The fire cannot be controlled, or patients, visitors and employees are in immediate danger

There will be a DESIGNATED CODE CAPTAIN whose role is to communicate the fire fighters

Two types of evacuation:

Horizontal- Evacuation through smoke/fire barrier doors to a safe area on the same floor

Vertical – Evacuation of all occupants on a floor to another safe floor

Potter & Perry, 2019)

Staff Safety

Environmental Risk

Infection Prevention and Control

Violence

Potter & Perry, 2019)

Global Harmonized System

The global harmonized system includes criteria for the classification of health, physical and environmental hazards, as well as specifying what information should be included on labels of hazardous chemicals as well as safety data sheets.

The goal is that the same set of rules classifying hazards, and the same format and content for labels and safety data sheets will be adopted and used around the world (ccohs.ca, retrieved 2020)

Potter & Perry, 2019)

WHMIS

This sets a standard for the control of hazardous substances in workplaces across Canada (Health Canada, 2015)

WHMIS consists of 3 main elements – worker education programs, cautionary labelling of products and the provision of Material Safety Data Sheets (MSDS)

Potter & Perry, 2019)

WHIMS Symbols

Potter & Perry, 2019)

Infection Prevention and Control

Employers have a responsibility to protect employees from risk from infectious diseases

They must have policies and procedures in place for staff to follow

Must provide ongoing education

Must ensure sufficient, appropriate PPE is available

Potter & Perry, 2019)

Code White- Violent patient

Safety of patients and staff is critical when dealing with violent patients. Steps to reduce risk of injury include:

Prevention – know history, potential for violence, look for signs and symptoms

De-escalate – use strategies to prevent further escalation and ensure safety of self and others

Potter & Perry, 2019)

Restraints

“Restraints are physical, chemical or environmental measures used to control the physical or behavioural activity of a person or a portion of his/her body”. (CNO. 2017b).

Restraints have been linked to significant patient harm such as pressure injuries, decreased mobility, increased agitation, increased falls and even death

Potter & Perry, 2019)

Alternatives to Restraints

In June 2001, the province of Ontario in Canada enacted the Patient Restraints Minimization Act, 2001 (Bill 85).

Most facilities now have a least restraint policy.

Potter & Perry, 2019)

Other Important Codes

Code Blue- Cardiac Arrest

Code Pink- Cardiac Arrest (18 yrs & under)

Code Yellow – Missing person

Code Amber- Missing child

Code Black-Bomb threat

Code Brown-Hazardous spill

Potter & Perry, 2019)

Code Orange – External Disaster

An emergency may be described as a present or imminent event that requires a rapid and skilled response to protect the health, safety and wellness of individuals and limit damage to property or the environment (Public Safety Canada, 2015a)

A disaster is the outcome of a natural hazard or event (e.g. hurricane, flood, earthquake) or as a result of human action or error whether malicious (e.g., terrorist attacks, use of biological warfare) or unintentional (e.g., accidental chemical spill), that seriously disrupts the functioning of a community or society (Public Safety Canada, 1015a)

Potter & Perry, 2019)

Approaches to Disaster Planning

Two common approaches:

1. Agent-specific approach – planning efforts are directed those likely to be affected in a specific geographical region

2. All-hazards approach – comprehensive strategy for potential possibilities, used across all jurisdictions.

Potter & Perry, 2019)

Steps in Emergency/Disaster Management

Mitigation

Preparedness

Response

Recovery

Potter & Perry, 2019)

CNO Practice Guideline – RN and RPN Practice: The Client, the Nurse and the Environment

Designed to ensure patient safety by looking at 3 areas that impact patient care.

The Client

The Nurse

The Environment

Potter & Perry, 2019)

Regulated Vs Unregulated Staff

An Unregulated Care Provider (“UCP”) refers to someone who is not regulated under the Regulated Health Professions Act but who may provide health or other care to patients.

Regulated Health Professions – In Ontario, regulated health professions are governed under the Regulated Health Professions Act, 1991 (RHPA) and health profession Acts (i.e., Medicine Act, 1991).

Potter & Perry, 2019)

CNO Practice Guideline – Working with UCPs

A nurse cannot assume that a UCP is competent to perform any procedure regardless of how straight forward the procedure appears

Nurses must ensure there is ongoing assessment of the patient’s health care needs, develop a plan of care, evaluate the patient’s condition and judge the ongoing effectiveness of the interventions

Potter & Perry, 2019)

Documentation

What is Documentation?

It is a nursing action that produces a written account of pertinent patient data, nursing clinical decisions and interventions and patient responses in a health record (Potter & Perry, 2019).
It reflects the nursing care that is provided (CNO 2008).

Purpose of Nursing Documentation

Reflects a client’s perspective.
Communicates to all health care providers
Integral component of interprofessional documentation
Demonstrates the nurse’s commitment to safe, effective and ethical care
Meets the professional standard regulations

(CNO, 2008)

What Activities do Nurses Document?

What is a Medical Record? (Client Record or Chart)

A formal, legal document that provides evidence of a client’s care and can be written or computer based.
Although health care organizations use different systems and forms for documentation, all client records contain similar information.

Potter & Perry, 2019

Purpose of Medical Records (Client’s Records or Charts)

Facilitate interdisciplinary communication and care planning
Provide a legal record of care provided
Facilitate funding and resource management
Allow for auditing monitoring and evaluation of care provided
Serve as sources of research data and as learning resources for nursing and health care education

Potter & Perry, 2019

Access to Client’s Charts and Documentation

Where are client’s charts kept in community settings, hospitals, doctor’s offices, and long term care facilities?

Who has access to them?

Potter & Perry, 2019

Ethical and Legal Considerations of Documentation

Accurate documentation is one of the best defenses against a legal claim
. Documentation must be clear, concise, accurate, relevant, and completed in a timely manner.
Subjective opinions must be avoided and objective language should be used when documenting or reporting client care.

Potter & Perry, 2019

Legal Guidelines for Documentation

What legal guidelines should the nurse follow for documentation?

Potter & Perry, 2019

8 Common Charting Mistakes that can Result in Malpractice

Failing to record pertinent health or drug information
Failing to record nursing actions
Failing to record that medications have been given
Recording on the wrong chart

Potter & Perry, 2019

8 Common Charting Mistakes that can Result in Malpractice (cont’d)

Failing to document a discontinued medication
Failing to record drug reactions or changes in the patient’s condition
Transcribing orders improperly or transcribing improper orders
Writing illegible or incomplete records

Potter & Perry, 2019

CNO Documentation Standard

How does the nurse meet the CNO standards below?

Communication

Accountability

Security

CNO, 2088

Electronic Documentation

What do you think are advantages of electronic documentation?

What about disadvantages?

Potter & Perry, 2019

Security for Computerized Records

What can we do as students and nurses to prevent breaches of security for computerized records?

Potter & Perry, 2019

PHIPA ACT (2004)

PHIPA specifies that health information custodians should ensure that clients’ personal health information is kept confidential and secure.
PHIPA also ensures that clients have a right to access their health information records and sets out a process for access and corrections, should they be needed.

Potter & Perry, 2019

Confidentiality

Nurses must follow principles to maintain patient confidentiality
Only members of a health care team that are directly involved in a patient’s care have legitimate access to the patients record.

Potter & Perry, 2019

Content of Patient Record or Chart

Patient identification and demographic data
Informed consent
Advance Directives
Admission nursing history
Nursing problem/diagnosis and care plan
Record of nursing care treatment and evaluation
Medical history
Medical diagnosis
Therapeutic orders
Progress notes for various health care providers
Reports of physical exams and consults
Reports of diagnostic studies
Record of patient and family education
Summary of Operations and procedures
Discharge plans and summary

Potter & Perry, 2019

Guidelines for Quality Documentation

Factual

Accurate

Complete

Current

Organized

Compliant with Standards

Potter & Perry, 2019

Methods of Documentation

Narrative

Problem Orientated Medical Record (POMR)

Source Records

Charting by exception

Case management and Use of Critical Pathways

Potter & Perry, 2019

Narrative Charting

Narrative: The use of a story-like format to document information. This method can be time consuming and repetitious.

Potter & Perry, 2019

Problem-Oriented Medical Records

Consists of database, problem list, care plan and progress notes
Progress notes follow POMR format of SOAP, SOAPIE, PIE or DAR

Potter & Perry, 2019

SOAP & SOAPIE

S – Subjective
O – Objective
A – Assessment
P – Plan
I – Intervention
E – Evaluation

Potter & Perry, 2019

PIE

P- Problem
I – Intervention
E – Evaluation

Potter & Perry, 2019

DAR Note

D – Data
A – Action
R – Response

Potter & Perry, 2019

Source Records

Organized so each discipline makes notations in a separate section

Disadvantage is that information about a particular problem is distributed throughout the record

Potter & Perry, 2019

Charting by Exception

The philosophy behind charting by exception (CBE) is that a patient meets all standards unless otherwise documented
The predefined statements used to document nursing assessment of body systems are called within defined limits (WDL) or within normal limits (WNL) definitions. They consist of written criteria for a “normal” assessment for each body system.

Potter & Perry, 2019

Case Management Model

Emphasizes quality, cost effective care delivered within an established length of stay.

Uses a multidisciplinary approach to planning and documenting client care by using critical pathways.

Potter & Perry, 2019

Critical Pathways

Critical pathways (also known as clinical pathways, practice guidelines, or CareMap tools) are interprofessional care plans that identify patient problems, key interventions, and expected outcomes within an established time frame.

Potter & Perry, 2019

Common Record Keeping Forms

Admission Nursing History Form
Flow Sheets and Graphic Records
Patient Care Summary or Kardex
Standardized Care Plans
Discharge Summary Forms
MAR

Potter & Perry, 2019

Guidelines for Home Health Care Documentation

Potter & Perry, 2019

Patients/family members complete documentation, nurse often teaching and helping client and family members achieve greater independence.
Documentation needs to provide the entire health care team with information to work effectively together.

Potter & Perry, 2019

Documentation in the Long-Term Health care Setting

Daily documentation often occurs on flow sheets with progress notes only for changes in condition, specific incidents or weekly assessments
May have paper charts and electronic documentation

Potter & Perry, 2019

Documentation using the Nursing Process

Assessment data: Initial assessment forms, flow sheets, progress notes (nurses’ notes)

Nursing diagnoses: Care plans, critical pathways, progress notes, problem lists

Planning: Nursing care plans, critical pathways, Kardex

Implementation: Progress notes, flow sheets

Evaluation: Progress notes

Potter & Perry, 2019

Telephone, Verbal and Written Orders

TO: Health care provider gives orders over the phone
VO: Health care provider gives orders to a registered nurse while they are standing near each other.
Written orders: may be transcribed by nurses or pharmacist. Need to clarify all orders if unsure.

Potter & Perry, 2019

Incident or Occurrence Reports

An incident or occurrence is any event that is not consistent with the routine, expected care of a patient or the standard procedures in place on a health unit
An incident report is completed whenever an incident or occurrence occurs

Potter & Perry, 2019

Preparing for Client Care

Nursing Research

Critical Thing & Reasoning

Development of Research in Nursing

Started with Florence Nightingale

First nursing research journal published in Canada was in 1969 called Nursing Papers

Research

Some research tests nursing theories; other research generates theory from findings

Nurse’s examine factors relevant to nursing in the context of the larger health care picture

The scientific knowledge needed for nursing is discovered, tested and enhanced through research

Clinical Research Expectations

Clinical research is dynamic

Needs to be reviewed and updated regularly so that the information is current/relevant

Research Literacy

An essential competency for evidence-informed practice; It is the ability to locate, understand and critically evaluate empirical literature for application in practice

When critiquing evidence first evaluate the scientific merit and clinical applicability of each studies findings

Do the articles together offer evidence to explain or answer your question?

Do the articles show that the evidence is true and reliable?

Can you use the evidence in practice?

Evidence-Based Nursing

The evidence-based nurse knows what needs to be done, how it should be done, and the evidence that supports his or her practice.

“Armed with evidence!”

Evidence-Informed Practice (EIP)

Basing health care decisions upon evidence is essential for quality care in all domains of nursing practice

Evidence-informed clinical decision making is affected by:

Evidence from research and theories

Evidence from patient assessment and health care resources

Clinical expertise

Patient preferences and actions

Steps of the Evidence-Informed Practice Process

RNAO Best Practice Guidelines (BPG)

The Registered Nurses Association of Ontario (RNAO) has developed many Best Practice Guidelines for the use in nursing.

RNAO

Other Credible Resources for Nursing Research

Research articles:

Seneca library: databases for Proquest, CINAHL, Cochrane database, DARE, MEDLINE, EBSCO or Embase

Library tutorial on how to conduct research – see link on your BB site

Research in the Clinical Setting

In clinical, researching information on your patients is synonymous with investigating and looking up information, in order to establish facts.

You need to research all pertinent information about your client’s care in order to provide care.

What information do you think you need to research about your patient prior to providing care?

What resources would be used to conduct this research?

Diagnosis Research Template

Let’s take a look at the template you will use in clinical and each of the components

Medical Diagnosis

“A medical diagnosis is the identification of a disease condition on the basis of a specific evaluation of physical signs and symptoms , the client’s medical history, and the results of diagnostic tests and procedures.” (Potter & Perry, 2019, p. 196)

Example of a medical diagnosis

Clinical Manifestations

Relates to signs and symptoms

Signs evident upon examination

Symptoms identified through client history and interview

Examples?

Associated Lab Values and Diagnostic Tests including Normal Values

What types of tests might be used to support a medical diagnosis?

Medical/Surgical Interventions Prescribed by the Physician

Interventions ordered based on medical diagnosis , e.g. medications, catheterization, wound care, g-tube insertion

Can change several times throughout a shift depending on patient acuity

All interventions ordered must be completed and documented.

Nursing Assessments Needed (physical, psychological, social, spiritual, economic)

Can include:

Head to toe assessment

Vital signs information

ADLs

Family concerns

Financial worries, etc…

Common Nursing Diagnoses/Problems

Nursing diagnoses or problems can include an actual problem or an at-risk problem that affects the patient

Includes a diagnostic label of the problem e.g., impaired physical mobility

Plus related factors associated to that diagnosis or problem, e.g., related to pain

Also includes an “as evidenced by” portion relating the problem to the signs and symptoms

Nursing Interventions/Implications

These are the actual things we do for the patient, including the outcome.

It is any treatment based on clinical judgement and knowledge, to enhance client outcomes

Choosing Nursing Interventions

Interventions should alter the signs and symptoms related to the diagnostic label

Interventions should have an expected outcome

Interventions should be evidence-based, research evidence in support of a nursing intervention

Feasibility of successfully implementing the intervention –consider cost and time

Acceptability to the client – must match the client’s goals

Capability of the nurse – current knowledge of the intervention, be prepared to carry it out, know the scientific rationale for the intervention

Independent Nursing Interventions

The things nurses initiate based on their scope of practice, such as bathing, ongoing assessments, making referrals to other health care professionals, initiating wound care, raising an edematous leg etc.

Dependent Nursing Interventions

Interventions prescribed by a doctor or NP order

E.g. medication administration, specific diet, test and treatments

The nurse is still responsible for explaining, assessing the need for, administering and evaluating the medical order.

Assignment 3

This assignment involves completion of the Diagnosis Research Form.

One medical diagnosis is to be researched and completed on the “Diagnosis Research” template that is included in the PNC 121 course outline.

Worth 5% of your grade

The rubric is in the course outline

Maintain APA format when citing resources

Clinical Research Sample

A sample Research Form has been prepared for the medical diagnosis “COPD”

Note the content found under each heading

Note the use of in-text and reference page citations

Note integration of medical-surgical text research and professional nursing journal resources

Critical Thinking

Critical thinking is a complex phenomenon defined as a process acquired through learning and experience.

Requires purposeful and reflective reasoning.

(Potter& Perry, 2019, p. 174-175)

Critical Thinking Model for Nursing Judgement

Involves 3 levels – basic, complex and commitment.

Includes 5 components – specific knowledge base, experience, critical thinking competencies, attitudes and standards

Critical Thinking Model for Nursing Judgement

General Critical Thinking Competencies

The scientific method

Problem solving

Decision making

The Scientific Method

Involves 5 steps

1. Identification of the problem

2. Collection of data

3. Formulation of a research question or hypothesis

4. Testing of the question or hypothesis

5. Evaluation of the results of the test or study

Problem Solving Process

Involves working through a process of recognizing, clearly defining and then solving a problem

The nurse obtains information that clarifies the nature of the problem and evaluates possible solutions, then possibly in collaboration with other health care professionals, chooses the best one to implement, and continues to monitor outcomes to determine the effectiveness of the solution

Problem solving for one situation contributes to the nurse’s body of knowledge that can be used for problem solving in other similar situations

Decision Making

The product of critical thinking that focuses on problem resolution

Decision making process involves: identifying the problem, assessing all options, weighing each option against a set of criteria, considering the consequences and then making a final decision

Specific Critical Thinking Competencies

These include:

Diagnostic reasoning

Clinical inference

Clinical decision making

Diagnostic Reasoning and Clinical Inference

Diagnostic reasoning – the process of determining a patient’s health status after making behavioural and physical observations and after assigning meaning to the behaviours, signs and symptoms exhibited by the patient

Clinical Inference – this is part of diagnostic reasoning and refers to the process of drawing conclusions from related pieces of evidence.

Clinical Reasoning

A cognitive process of thinking about patient issues, making inferences and deciding on the actions to be implemented in a particular clinical situation.

It is the process by which nurses collect cues, process the information, come to an understanding of a problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process.

Clinical Decision Making

Focuses on defining patient problems and selecting appropriate interventions

Distinguishes professional nurses from technical personnel

It is a judgement that includes critical and reflective thinking and action and the application of scientific and practical knowledge

Clinical Judgement

Clinical Judgement – involves “recognizing the most important aspects of a clinical situation, interpreting their meanings, and responding appropriately.” (Potter & Perry, 2019, p. 180)

How does critical thinking influence clinical judgement and clinical decision making?

Clinical Judgement – involves “recognizing the most important aspects of a clinical situation, interpreting their meanings, and responding appropriately.” (Potter & Perry, 2019, p. 180)

Clinical decision making – “focuses on defining patient problems and selecting appropriate interventions.” (Potter & Perry, 2019, p. 180)

Critical thinking is central to both these processes.

It helps to help choose the best action to meet a desired goal

The importance of Critical Thinking in Nursing

“Critical thinking is central to nursing practice because it allows you to test and refine nursing approached, learn from successes and failures, apply nursing research findings, and ensure holistic patient-centred care.” (Potter& Perry, 2019, p. 174)

“Nurses recognize that an issue exists, analyzes information about the issue, evaluates information and draws conclusions.” (Potter& Perry, 2019, p. 174)

How do nurses apply critical thinking to nursing?

In consultation with the patients, nurses consider what is important in a situation, explore alternative solutions, consider ethical principles, and then make informed decisions about how to proceed. (Potter & Perry, 2019, p.174)

Nurses apply the nursing process as a critical thinking competency by assessing , diagnosing, planning, implementing and evaluating patient care

Critical Thinking and Application

A 77-y-old male has been admitted with a COPD exacerbation.

He is currently on 2L nasal prongs with an order to titrate to maintain his oxygen saturations between 88-92%.

Assessment findings: RR = 32 and SaO2 = 86%.

Through critical thinking you realize that this is not appropriate for this patient.

What should you do first?

Critical Thinking and Application (cont’d)

Unfortunately repositioning, coughing and deep breathing do not help, so you make the decision to increase his oxygen to 4L, and monitor for a couple of minutes.

Evaluation: initially SaO2 = 90%, but drops back down to 86%.

What should the nurse do next?

Critical Thinking and Application (cont’d)

Findings: coarse crackles in his right mid and lower lobes.

Blood work from this am: WBC has increased from 12 to 18

You are now questioning if the patient has pneumonia.

The nurse identified what was important in this situation, explored alternative solutions, and then made informed decisions about how to proceed.

This is critical thinking in action!

Reflective Practice and Critical Thinking

What is reflective practice?

Why is it important for nurses?

How does reflective practice use critical thinking skills?

Concept Mapping

Technique that uses a graphic depiction of linear and nonlinear relationships to represent critical thinking

Used to develop analytical skills

Allows one to organize (and reorganize) and connect information, making meaning of the concepts

Effective method to facilitate creative, reflective, and critical thinking

3 Steps to Concept Mapping

The process of concept mapping involves three major steps:

List key concepts/terms related to the topic

Build up concepts to elaborate key concepts

Identify links between concepts

Examples of Concept Maps

The Nursing Process & Care Plan Development

Potter & Perry (2019)

What is the nursing process?

Intellectual process of reasoning

Aims to identify, diagnose, and treat actual and potential health issues and challenges of clients from a holistic perspective

Guides clinical judgement, decision making, and reflective practice

Encourages critical thinking

Potter & Perry (2019)

5 Phases of the Nursing Process

Potter & Perry (2019)

Phase one : Assessment

Systematic collection of data to determine the client’s current and past health and functional status.

Nurse collects a variety of different types of data in order to fully understand the client priority needs(can you think of types of data that may be collected by the nurse?)

Holistic and comprehensive assessment

Potter & Perry (2019)

Phase Two: Diagnosis

Nurse analyzes the assessment data in order to determine the key issues and make clinical judgements in the form of a nursing diagnosis

This step directs the plan of care for the client

Identify outcomes for the client that are individualized to the client and the client’s situation

Potter & Perry (2019)

Phase Three: Planning

Creation of a formal plan

Prescribes strategies and alternatives to attain the expected outcome

Potter & Perry (2019)

Phase Four: Implementation

Carrying out the plan

May occur by coordinating care delivery, providing health teaching and health promotion activities, , consulting with other health care professionals, or providing medications or other therapies (can you think of any other examples?)

Potter & Perry (2019)

Phase Five: Evaluation

Evaluating the client’s response to the selected interventions

Determine whether the interventions were effective

Potter & Perry (2019)

Let’s look at each phase in more detail

Potter & Perry (2019)

Phase One – Assessment

Critical thinking is foundational to a comprehensive and accurate nursing assessment

Enables the nurse to have a broader perspective from which to form conclusions and make decision concerning client’s health condition

Includes collection and verification of data from a variety of sources.

Potter & Perry (2019)

Assessment – Primary Sources of Data

Primary Sources of data – the client.

This is the best source of data if the patient is able to provide it

Potter & Perry (2019)

Assessment – Secondary Sources of Data

Secondary sources of data: this includes the family and significant others.

Health Care Team – Every member of the health care team is a source of information for identifying and verifying information about the client

Medical Records

Potter & Perry (2019)

Assessment – Tertiary Sources of Data

Literature

Nurse’s Experience

Potter & Perry (2019)

Assessment (Cont’d)

While gathering data during the assessment phase of the nursing process the nurse:

Synthesizes relevant knowledge

Recalls prior clinical experiences

Applies critical thinking standards and available evidence

Uses standards of practice directing assessment in a meaningful and purposeful way

Potter & Perry (2019)

Types of Data: Subjective Data

Subjective data are obtained through the health history and the nurse’s questions

It is the client’s verbal descriptions of their health concerns

ONLY client’s provide subjective data

Data can reflect physiological changes which nurses further explore through objective data collection. For example the client may state she has chest pain the nurse will then collect further data to support this symptom.

Potter & Perry (2019)

Types of Data: Objective Data

Objective data are observations or measurements of a client’s health status, based on an accepted standard(Celsius, kilograms, milliliters, known characteristics of behavior such as anxiety or paranoia)

Objective may be considered a normal or abnormal finding

Potter & Perry (2019)

Methods of Data Collection:
Nursing Health History

Family History

Physical Exam including observation of client behavior

Diagnostic and laboratory data

Potter & Perry (2019)

Interpreting Assessment Data

When nurses critically think about interpreting assessment information, they determine the presence of abnormal findings

Nurses who critically think about interpreting assessment findings know what further observations are needed to clarify information and the client’s health problems

Validation of assessment data is necessary to avoid making incorrect inferences

Potter & Perry (2019)

Phase Two – Diagnosis

Diagnostic language is shared by nurses

A clinical judgement about individual, family, or community responses to actual and potential health problems or life processes that is within the domain of nursing

A judgement that is based on a comprehensive nursing assessment

Potter & Perry (2019)

Components of a Nursing Diagnosis/Problem

Diagnostic Label: describes the essence of the client’s response to health conditions in as few words as possible

Related Factors: A condition or etiology identified from the client’s assessment data. Associated with the clients actual or potential response to the health problem and can be altered through the use of nursing interventions

Also an “as evidenced by” portion that connects the diagnosis to the signs and symptoms

Potter & Perry (2019)

Components of a Nursing Diagnosis/Problem (cont’d)

Definition: Nanda approved definitions for diagnoses, not necessarily used now. Can use nursing problems instead.

Risk Factors: Environments, physiological, phycological, genetic, or chemical elements that increased the vulnerability of an individual, family, or community to an unhealthful event

Support of the nursing diagnostic statement: Nursing assessment data must support the nursing diagnostic label and the related factors must be included in these data

Potter & Perry (2019)

Phase Three – Planning: Establishing Priorities

Set client centered goals, expected outcomes, plan and prioritize nursing interventions

Multiple nursing diagnoses are possible

Rank the nursing diagnoses or client problems using principles such as urgency to establish an order for nursing actions attending to client’s most important needs first

High priority nursing diagnoses examples: Decreased cardiac output, risk for violence, impaired gas exchange

Potter & Perry (2019)

Planning – Establishing Goals and Expected Outcomes

Goals and outcomes are specific, measurable client behavior or physiological responses that nurses set to achieve through a nursing diagnosis.

They provide a focus for the type of intervention required to care for the client

A Client-centered goal is a specific and measurable behavioral response that reflects a client’s highest possible level of wellness and independence in function

Potter & Perry (2019)

Planning – Establishing Goals and Expected Outcomes (cont’d)

Short-term goal: objective behavior or response that the client is expected to achieve in a short time, usually less than 1 week or in acute care may be in just a few hours

Long-term goal: objective behavior or response that a client is expected to achieve over a longer period, several days, weeks, or months

Mutual goal setting includes client’s and client’s families

Ensure SMART goals

Potter & Perry (2019)

Phase Four – Implementation

Selection of nursing interventions involves complex decision making and is based on critical thinking to ensure that an intervention is correct and appropriate for the clinical situation

Refer to the standards and practice guidelines of each agency

Standards of practice are guidelines are standards of practice and sanction principles to provide safe and competent care

Potter & Perry (2019)

Types of Nursing Interventions

Independent nursing interventions: do not require direction or orders from other health providers e.g. elevating an edematous leg

Dependent nursing interventions: require an order or direction from a physician or NP and are directed towards managing a medical diagnosis, e.g., administering a medication

Potter & Perry (2019)

Phase Five: Evaluation

This is the final step

It involves two components:

An examination of a condition or situation

A judgement as to whether change has occurred

Potter & Perry (2019)

Evaluation Process

Identifying evaluative criteria and standards

Collecting evaluative data

Interpreting and summarizing findings

Documenting findings

Revising, discontinuing, modifying a care plan

Potter & Perry (2019)

Schematic of Care Plan Development

Potter & Perry (2019)

Concept Map of Care Plan Development

Potter & Perry (2019)

Communication Overview

What is communication?

A means of persuasion to influence other so that the desired effect is achieved

A process by which two or more people exchange ideas, facts, feelings, or impression in ways that each gains a common understanding of the meaning, intent and use of a message

A lifelong process for the nurse. Nurses must communicate effectively with patient, colleagues, family members and interprofessional teams(where some times team members have different priorities)

Potter & Perry, 2019

Therapeutic Communication

Used by health care workers

Focuses on advancing the physical and emotional well-being of a patient

Uses specific techniques to encourage the expression of feelings and ideas and coveys acceptance and respect

Potter & Perry, 2019

Interprofessional and Intraprofessional Communication

Interprofessional – communication between members of different health care teams

Intraprofessional – communication occurring between members of the same health care team

Potter & Perry, 2019

Intrapersonal Communication

Known as ‘Self-talk” or “inner thought”

Occurs within an individual

Helps develop self-awareness and positive self-concept

Can facilitate self-expression

May improve health and self-esteem

Potter & Perry, 2019

Interpersonal Communication

Face to face interaction between the nurse and the client

The most common type of communication used in the health care setting

Nurses take into consideration client’s values, belief systems, opinions and experiences prior to and during the communication process

Potter & Perry, 2019

Elements of Communication

Potter & Perry, 2019

Forms of Communication

Verbal – The use of spoken or written words

What do we need to consider when using verbal forms of communication?

Potter & Perry, 2019

Forms of Communication

Non Verbal – Transmission of message that do not involve spoken or written words.

Using our senses to communicate

How do non-verbal communication techniques affect communication?

Potter & Perry, 2019

Zones of Personal Space

Can you think of a practice setting where this will be especially important to consider?

Potter & Perry, 2019

Zones of Touch

Is it appropriate to touch patients during communication?

Potter & Perry, 2019

Forms of Communication

Electronic Communication – Documentation

We will be looking at this in more detail on week 4

Potter & Perry, 2019

The Nurse-Patient Helping Relationship

4 goal-directed phases

Preinteraction

Orientation

Working

Termination

Potter & Perry, 2019

Elements of Professional Communication

Courtesy

Use of names

Trustworthiness

Autonomy and Responsibility

Assertiveness

Potter & Perry, 2019

Factors Influencing Communication

What patient factors can you think of that may influence the communication process?

Potter & Perry, 2019

Creating a Therapeutic Environment

Depends on the nurse’s ability to communicate.

Can provide comfort, and help patient meet their needs.

Therapeutic interaction can increase feeling of personal control by helping patients feel secure, facilitates emotional comfort and promotes recovery.

Potter & Perry, 2019

Therapeutic Communication Techniques

Let’s discuss some of the therapeutic techniques we can use as nurses

Potter & Perry, 2019

Barriers to Communication

Asking personal questions

Giving opinions

Changing subject

Automatic responses

False reassurance

Sympathy

Requesting explanations

Approval/disapproval

Defensive

Passive or aggressive responses

Arguing

Potter & Perry, 2019

Communicating with Patients with Special Needs

Nurses frequently have adapt their method of communication for a variety of reasons

Potter & Perry, 2019

Components of the CNO Therapeutic Nurse-Client Relationship (2006)

Trust

Respect

Professional Intimacy

Empathy

Power

https://www.cno.org/globalassets/docs/prac/41033_therapeutic.pdf

Potter & Perry, 2019

CNO Therapeutic Communication Techniques

What therapeutic communication techniques are identified in the CNO Therapeutic Nurse-Client Relationship Practice Standard?

Potter & Perry, 2019

Client-Centred Care

How does the nurse ensure client centred care in the therapeutic nurse-client relationship?

Potter & Perry, 2019

Maintaining Boundaries/Accepting Gifts

What strategies can the nurse use to maintain boundaries with a client?

Is accepting gifts ever acceptable?

Potter & Perry, 2019

Warning Signs of Crossing Boundaries

It is important to identify any boundary drifts and address them before they become a boundary violation

Potter & Perry, 2019

Protecting the client from Abuse

Let’s explore ways nurses can protect clients from abuse

Potter & Perry, 2019

Giving and Receiving Feedback

Let’s look at how to give and receive feedback

Potter & Perry, 2019

Clinical Peer Feedback Form

Potter & Perry, 2019

MIDTERM REVIEW

PNC 121

What are some of the common themes in nursing?

What issues and trends are affecting RPNs?

Understand the different Canadian Health Care practice settings

Can you think of other consumers of long-term care outside of whom you might expect?

Understand the types of nurses in Ontario, their education and roles

Review the 7 Professional Standards from the CNO and how to meet them

What is:

Fitness to practice?

Duty to provide care?

What are the Seneca College Practice Concepts?

How does the student nurse meet them?

COMMUNICATION

Includes:

Levels of communication

The communication process

Forms of Communication

Understand cultural norms in communication

Phases of the Helping Relationship

Factors affecting communication

Therapeutic communication techniques

Barriers to communication

The CNO Therapeutic Nurse-Client Relationship

Know the 5 components

Understand the 4 standard statements and how they apply to nursing

Understand giving and receiving feedback in nursing

COMMUNICATION

Understand sources of data

Describe the 3 stages of the interview

Types of questions for interviewing

Interviewing clients with special needs

Communication amongst professionals – assertive communication, SBAR

What are the important nursing considerations for the following?

Telephone and verbal orders

Change of shift reports

Transfer reports

Documentation

What is the purpose of documentation?

What is the purpose of a medical chart?

Remember the ethical and legal considerations for documentation and how they connect to the CNO Documentation Standard

Electronic Documentation

How do we maintain security for electronic records.

How does PHIPA affect computerized documentation?

Guidelines for Quality Documentation

Factual

Accurate

Complete

Current

Organized

Compliant with standards

Methods of Documentation

Narrative

SOAP, PIE & DAR

Charting by exception

Critical pathways

Written orders

Incident or occurrence reports

Research

Identify where the best sources of research may be found for the practice of nursing and what type of research this may be.

Understand the process of Evidence-Informed practice

Nursing Research for Clinical Practice

Medical and nursing diagnoses

Clinical manifestations

Types of nursing interventions

Critical Thinking

What is critical thinking and why is it important in nursing?

Understand general and specific critical thinking competencies

How do concept maps assist in critical thinking?

Reflective Practice

What is reflective practice and why is it important in nursing?

Concept maps

How do concept maps use critical thinking skills and how do they assist us when caring for patients?

practical nursing clinical (online help)

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