Instructor’s Resource Manual for LeMone & Burke’s MedicalSurgical Nursing: Clinical Reasoning in Patient Care
LeMone & Burke’s Medical-Surgical Nursing: Clinical Reasoning in Patient Care Seventh Edition
Gerene Bauldoff Paula Gubrud Margaret-Ann Carno
Chapter 1 Medical-Surgical Nursing in the 21st Century Learning Outcomes 1. Describe the core competencies for healthcare professionals: Patient-centered care, interprofessional teams, evidence-based practice, quality improvement, safety, and health information technology. 2. Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. 3. Explain the importance of nursing and interprofessional codes of ethics, standards of practice, and legal and ethical issues as guidelines for clinical nursing practice. 4. Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. Introduction A. Patient Protection and Affordable Care Act (ACA) 1. Healthcare access for more Americans B.
Medical-surgical nursing: Health promotion, healthcare, and illness care of adults
C.
Requirements of nurse: Knowledge of body systems and disorders Good communication skills Coordination of care and delegation of tasks Application of evidence-based practice, clinical reasoning skills, nursing care standards Awareness of patients’ family and community situations Ability to prioritize activities and care needs
1. 2. 3. 4. 5. 6.
I. Core Competencies for Safe and Effective Healthcare A. Healthcare system challenges 1. Aging population 2. More chronic illness 3. Changing consumer desires and expectations 4. Rapidly expanding information and technologies 5. Focus on improving quality and safety of care B. IHI Critical objectives 1. Improve the patient care experience (including quality and satisfaction). 2. Improve the health of populations. 3. Reduce the per capita costs of healthcare. . Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition
C. Quality and Safety Education for Nurses (QSEN) initiative, core competencies for nurses 1. Patient-centered care 2. Teamwork and collaboration 3. Evidence-based practice (EPB) 4. Quality improvement 5. Safety 6. Use informatics II. Clinical Reasoning in the Nursing Process A. Clinical reasoning and judgment 1. Clinical reasoning: Cognition, metacognition, discipline-specific knowledge to gather and analyze information 2. Clinical judgment a) Outcome of clinical reasoning process b) Conclusion about a patient’s needs, concerns, problems c) Decision on whether to take action or not 3. Thinking strategies a) Heuristics: Informal thinking strategies or cognitive shortcuts b) Reflecting-on-action: Analysis in retrospect 4. Clinical Reasoning: a) Knowledge gained through classroom studies, textbooks, and current resources and by interacting with experienced nurses. b) Experience gained by working with patients experiencing similar problems or disorders. c) Understanding the patient as an individual, who presents with both current and previous illness experiences. d) Personal values and beliefs, including recognition of prejudices that may influence thinking. e) An ability to identify other possible options, evaluate the alternatives, and reach a conclusion. B. The Nursing Process 1. Phases used cyclically 2. Assessment a) Data are collected, validated, organized, clustered into patterns, communicated (1) Objective and subjective data b) Initial (baseline) and ongoing assessments performed c) Focused assessment of identified or potential problem (1) Identify response to disease or treatment d) Wide variety of knowledge and skill needed e) Attitude of inquiry when gathering data 3. Diagnosis . Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition
a) Describe actual or potential health problems that can be legally diagnosed by a nurse, for which nurse can prescribe primary interventions b) Conclusion from analysis of data organized within frameworks (1) Basic human needs, body systems, human response patterns, functional health problems (a) Functional health problems: Include physical and psychological c) Diagnostic reasoning (1) Level I: Recognize significant cue (2) Level II: Cluster cues and identify data gaps (3) Level III: Draw conclusions about the present health status (4) Level IV: Determine etiologies and categorize problems d) Categories of nursing diagnoses (1) Nursing problem/actual nursing diagnoses (2) Potential (or risk) nursing problem/diagnoses (3) Collaborative problems: Involve medical interventions as well as nursing interventions e) NANDA system (1) Official system of nursing diagnosis, list of nursing diagnoses 4. Planning a) Identification of desired outcomes, nursing interventions to achieve outcomes (1) Established by patient and nurse b) Documentation of the plan of care c) Outcomes: (1) Patient-centered, time specific, measurable (2) Classifications: Cognitive, affective, psychomotor d) Interventions: Specific and individualized (1) Evidence-based practice guidelines used to evaluate appropriateness e) Moving evidence into action (1) Impact of Integrated Electronic Health Records on Quality of Nursing Care and EBP f) Care bundles (1) 3–5 interventions with strong clinician agreements (2) Each bundle is relatively independent (3) Used with defined patient population in one location (4) Developed by multidisciplinary team 5. Implementation a) Nurse carries out planned interventions or assigns and supervises assistive personnel b) Ongoing assessment essential c) Changes in plan if appropriate d) Principles of implementation (1) Set daily priorities . Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition
(2) Be aware of interrelated nature of interventions (3) Determine the most appropriate interventions for each patient (4) Use resources wisely e) Documentation essential 6. Evaluation a) Determine if plan is effective b) Decide to continue, revise, or terminate plan c) Outcome criteria established in planning step are basis III. Guidelines for Nursing Practice A. Codes for nurses 1. Codes of ethics: Principles of conduct a) ICN Code (2012) b) ANA Code (2001) B. Standards of nursing practice 1. ANA Standards of Practice (2016) 2. Standards of Professional Performance 3. Health information privacy rules a) Ethical code and federal rules b) Health Insurance Portability and Accountability Act and the Standards for Privacy of Individually Identifiable Health Information (HIPAA) (1) Protect health information (2) Allowing for information sharing as needed for care, even without patient’s explicit consent c) Some laws override patient’s right to privacy. (1) For example, must report evidence of abuse 4. Professional boundaries a) Must maintain appropriate level of involvement C. Legal and Ethical Issues in Nursing 1) Issues involved in dilemmas a) Confidentiality (1) Patient’s right to confidentiality may interfere with nurse’s right to personal safety b) Patient rights (1) Right to refuse treatment may interfere with ethical principle of beneficence c) Issues of dying and death (1) Conflicts regarding quality of life and death with dignity versus technologic methods of preserving life IV. Roles of the Nurse in Medical-Surgical Nursing Practice . Bauldoff/Gubrud/Carno, Instructor's Resource Manual for LeMone & Burke's Medical-Surgical Nursing: Clinical Reasoning in Patient Care, 7th Edition