Please don't remove anything, just make a comment if it’s wrong or add more from textbook.
Do your reading :)
I made the questions that I can’t find the answer in red→ ask the instructor in class time to
find the answer
D(dose) divided by H(have) times Q(quantity)
Week 1
1.
2. Nursing process and 11 needs assessment guide. Posted on e-centennial
Human needs are ranked on an ascending scale according to Maslow
● Physiological needs- water, shelter, food, oxygen
● Safety and security needs
● Love and belonging needs
● Self-esteem needs
● Self-actualization
3. Clinical reasoning: A thought process used to assess a client’s evolving situation and health care
concerns, gather data, and make decisions to solve problems within a particular clinical context to
achieve better client outcomes.
4. Distinguish clinical reasoning from clinical judgment and critical thinking
Critical thinking: a systematic process that facilitates the nurse and client to make a more informed
decision. The skill needs to use relevant information, knowledge, and communication technologies to
support evidence-informed nursing practice.
● Recognize key words
● Recognize who is the client: what is client’s condition
● Ask yourself what is happening
● Critical: see what option you have available
,● Eliminate the options
Clinical reasoning: similar process, involves many of the same strategies to address patients and client
issue, but it also focuses on the alternative generated. Complex process using cognition and discipline
specific knowledge to analyze patient info and evaluate what is important
Clinical judgement: a process of evaluating alternatives and concluding about best approach- the
outcome of thinking
5. Role of critical thinking and clinical reasoning in nursing process
-clinical judgement is the evaluation. Critical thinking is the assessment phase. Clinical
reasoning is priority setting (kozier 4th ed p. 369).
6. The purposes and legal and ethical considerations of documentation in health care. (kozier, 462)
● Communication: Clear, concise, relevant, and accurate documentation provides continuity of care
and increases the probability of quality health care.
● Planning client care: use by each health care provider to plan care
● Accountability: Their documentation must be accurate, relevant, timely, and complete
● Auditing for quality assurance
● Education and research
● Legal documentation
Limitation
● Time consuming “
● Remove human connection
● High cost
7. What is documentation? CNO
Documentation — whether paper, electronic, audio or visual — is used to monitor a client’s progress and
communicate with other care providers. It also reflects the nursing care that is provided to a client. It
is aIterative (changes each time but repetitive)
8. Purpose of charting or documentation, indicate main one
9. Make a list of “roles/guideline” (do and don’t) to follow for charting. What must be included in
your charting entries?
Do Do not
first name, last name and role Miss a line after you are done
Document (communication, accountability,
and security)
Example:
Date: 2019/Jan/21
Note: Patient vomited blood. Nurse manager aware, MD informed and new orders made, patient will
continue to monitor---------------------------------------------------------Niousha Tavakoli, PRN
Know abbreviations commonly used for documentation and reporting (lab).
9. Type of documentation method
A. Sources-oriented: Each person or department makes notations in a separate section or sections of
the client’s chart. Source-oriented records are convenient because health care providers from each
, discipline can easily locate the forms on which to record data, and it is easy to trace the information
to a specific discipline. The disadvantage is that information about a particular client problem is
scattered throughout the chart, so it is difficult to find chronological information on a client’s problem
and progress.
a. Narrative charting: It consists of written notes that include routine care, normal findings, and client
problems. The information has no right or wrong order, although a chronological order is
recommended and frequently used. Narrative documentation is being replaced by other systems,
such as charting by exception and focus charting.
B. problem-oriented medical record (POMR) or (POR): data are arranged according to the problem
the client has rather than according to the source of the information. The advantages of POR are (a) it
encourages collaboration; and (b) the problem list is in the front of the chart, which alerts health care
providers to the client’s needs and makes it easier to track the status of each problem. The
disadvantages are (a) health care providers differ in their ability to use the required charting format;
(b) it takes constant vigilance to maintain an up-to-date problem list; and (c) repetitive because
assessments and interventions that apply to more than one problem must be repeated. POR has fur
components; database, problem list, plan of care, progress notes (SOAP)
C. The assessment, problem, intervention, evaluation (ADPI) model: This system consists of a client
care assessment flowsheet and progress notes.
D. Focus charting (DAR- data action response): it is intended to make the client’s concerns and
strengths the focus of care. Three columns for documenting are usually used: (a) date and time, (b)
focus, and (c) progress notes (see the example at the end of this section).
E. Computerized documentation: use to manage huge volume of information required in
contemporary health care
F. Charting by exception: a documentation system in which only significant findings or exceptions to
norms are recorded by using flowsheets as much as possible
G. Soap (subjective, objective, assessment, planning)
H. The key elements of a change-of-shift (SBAR) report. (Murray, 80) The SBAR is a communication
tool commonly used during change-of-shift reports to promote and maintain effective
communication between the health care team when discussing a client’s condition and progress.
1. Situation: include your name, place you work at, a person's first name and last name, describe the
problem and concern
2. Background: state briefly the patient medical history/any recent changes/emergent issue and
treatment date and its effectiveness
3. Assessment of any issue/symptoms: onset, provoking/palliating, quality region/radial, severity,
treatment, understanding/impact on resident and values (OPQRSTUV) (murray p. 81 & 65)
4. Recommendation: state what you would like to see done, and in what time frame.
10. Discuss the purpose of incident reporting and the nurse's responsibility in promoting a culture of
safety for quality client care. (promotion of quality, not punishment)
Documentation (Kozier, 471)
A. Long-term care: The nurse usually completes a nursing care summary at least once a week for
clients requiring skilled care and every 2 to 4 weeks for those requiring intermediate care.
1Summaries should address the following:
● Specific problems expressed by clients and/or familie
● Mental health status
, ● Activities of daily living (ADLs)
● Hydration and nutrition status
● Elimination status
● Safety measures needed
● Medications
● Treatments
● Preventive measures
Vital signs are taking once a month
The Minimum Data Set (MDS) for assessment and care screening must be performed
within 4 days of a client's admission to a long-term care facility and reviewed every 3
months
B. Acute care
C. Home care: Health care providers often document in client-held records that remain at the
residence. Health care providers may access critical information through the use of voicemail,
wireless devices, and laptops, which enhances their ability to care for their clients and maintain
accurate and current records.
Week 2
1. Describe the differences and similarities between a group and a team.
● A group is a number of individuals assembled together or having some unifying relationship. Groups
could be all the parents in an elementary school, all the members of a specific church, or all the
students in the school of nursing because the members of these various groups are related in some
way to one another by definition of their involvement in a certain endeavour.
● A team, on the other hand, is a number of individuals who work closely together toward a common
purpose, are accountable to one another and sharing responsibility. Not every group is a team, and
not every team is effective. Teams have defined objectives, ongoing relationships, and a supportive
environment and are focused on accomplishing specific goals. Teams are essential in providing cost-
effective, high-quality care. As resources are expended more prudently, teams must develop clearly
defined goals, use creative problem solving, and demonstrate mutual respect and support.
● A group of people does not constitute a team. A team is a group of interdependent individuals who
seek out opportunities to combine their expertise to achieve common goals: Collaboration
2. Compare and contrast types of teams. exercise in Yoder-Wise book p 354
● Manager-led team: The manager is the team leader and controls the agenda, decisions, direction,
and outputs of the team.
● Self-managing team: The manager sets the overall direction and defines the goal and outcome for
the team. The members of the team determine the direction, strategies, and focus of the team to
achieve the goal.
● Self-directed team: The manager identifies the outcome, and the team members determine the
direction, strategies, methods, and focus to achieve the outcome. Often, these teams function in
quality improvement initiatives to address quality challenges and opportunities.
Do your reading :)
I made the questions that I can’t find the answer in red→ ask the instructor in class time to
find the answer
D(dose) divided by H(have) times Q(quantity)
Week 1
1.
2. Nursing process and 11 needs assessment guide. Posted on e-centennial
Human needs are ranked on an ascending scale according to Maslow
● Physiological needs- water, shelter, food, oxygen
● Safety and security needs
● Love and belonging needs
● Self-esteem needs
● Self-actualization
3. Clinical reasoning: A thought process used to assess a client’s evolving situation and health care
concerns, gather data, and make decisions to solve problems within a particular clinical context to
achieve better client outcomes.
4. Distinguish clinical reasoning from clinical judgment and critical thinking
Critical thinking: a systematic process that facilitates the nurse and client to make a more informed
decision. The skill needs to use relevant information, knowledge, and communication technologies to
support evidence-informed nursing practice.
● Recognize key words
● Recognize who is the client: what is client’s condition
● Ask yourself what is happening
● Critical: see what option you have available
,● Eliminate the options
Clinical reasoning: similar process, involves many of the same strategies to address patients and client
issue, but it also focuses on the alternative generated. Complex process using cognition and discipline
specific knowledge to analyze patient info and evaluate what is important
Clinical judgement: a process of evaluating alternatives and concluding about best approach- the
outcome of thinking
5. Role of critical thinking and clinical reasoning in nursing process
-clinical judgement is the evaluation. Critical thinking is the assessment phase. Clinical
reasoning is priority setting (kozier 4th ed p. 369).
6. The purposes and legal and ethical considerations of documentation in health care. (kozier, 462)
● Communication: Clear, concise, relevant, and accurate documentation provides continuity of care
and increases the probability of quality health care.
● Planning client care: use by each health care provider to plan care
● Accountability: Their documentation must be accurate, relevant, timely, and complete
● Auditing for quality assurance
● Education and research
● Legal documentation
Limitation
● Time consuming “
● Remove human connection
● High cost
7. What is documentation? CNO
Documentation — whether paper, electronic, audio or visual — is used to monitor a client’s progress and
communicate with other care providers. It also reflects the nursing care that is provided to a client. It
is aIterative (changes each time but repetitive)
8. Purpose of charting or documentation, indicate main one
9. Make a list of “roles/guideline” (do and don’t) to follow for charting. What must be included in
your charting entries?
Do Do not
first name, last name and role Miss a line after you are done
Document (communication, accountability,
and security)
Example:
Date: 2019/Jan/21
Note: Patient vomited blood. Nurse manager aware, MD informed and new orders made, patient will
continue to monitor---------------------------------------------------------Niousha Tavakoli, PRN
Know abbreviations commonly used for documentation and reporting (lab).
9. Type of documentation method
A. Sources-oriented: Each person or department makes notations in a separate section or sections of
the client’s chart. Source-oriented records are convenient because health care providers from each
, discipline can easily locate the forms on which to record data, and it is easy to trace the information
to a specific discipline. The disadvantage is that information about a particular client problem is
scattered throughout the chart, so it is difficult to find chronological information on a client’s problem
and progress.
a. Narrative charting: It consists of written notes that include routine care, normal findings, and client
problems. The information has no right or wrong order, although a chronological order is
recommended and frequently used. Narrative documentation is being replaced by other systems,
such as charting by exception and focus charting.
B. problem-oriented medical record (POMR) or (POR): data are arranged according to the problem
the client has rather than according to the source of the information. The advantages of POR are (a) it
encourages collaboration; and (b) the problem list is in the front of the chart, which alerts health care
providers to the client’s needs and makes it easier to track the status of each problem. The
disadvantages are (a) health care providers differ in their ability to use the required charting format;
(b) it takes constant vigilance to maintain an up-to-date problem list; and (c) repetitive because
assessments and interventions that apply to more than one problem must be repeated. POR has fur
components; database, problem list, plan of care, progress notes (SOAP)
C. The assessment, problem, intervention, evaluation (ADPI) model: This system consists of a client
care assessment flowsheet and progress notes.
D. Focus charting (DAR- data action response): it is intended to make the client’s concerns and
strengths the focus of care. Three columns for documenting are usually used: (a) date and time, (b)
focus, and (c) progress notes (see the example at the end of this section).
E. Computerized documentation: use to manage huge volume of information required in
contemporary health care
F. Charting by exception: a documentation system in which only significant findings or exceptions to
norms are recorded by using flowsheets as much as possible
G. Soap (subjective, objective, assessment, planning)
H. The key elements of a change-of-shift (SBAR) report. (Murray, 80) The SBAR is a communication
tool commonly used during change-of-shift reports to promote and maintain effective
communication between the health care team when discussing a client’s condition and progress.
1. Situation: include your name, place you work at, a person's first name and last name, describe the
problem and concern
2. Background: state briefly the patient medical history/any recent changes/emergent issue and
treatment date and its effectiveness
3. Assessment of any issue/symptoms: onset, provoking/palliating, quality region/radial, severity,
treatment, understanding/impact on resident and values (OPQRSTUV) (murray p. 81 & 65)
4. Recommendation: state what you would like to see done, and in what time frame.
10. Discuss the purpose of incident reporting and the nurse's responsibility in promoting a culture of
safety for quality client care. (promotion of quality, not punishment)
Documentation (Kozier, 471)
A. Long-term care: The nurse usually completes a nursing care summary at least once a week for
clients requiring skilled care and every 2 to 4 weeks for those requiring intermediate care.
1Summaries should address the following:
● Specific problems expressed by clients and/or familie
● Mental health status
, ● Activities of daily living (ADLs)
● Hydration and nutrition status
● Elimination status
● Safety measures needed
● Medications
● Treatments
● Preventive measures
Vital signs are taking once a month
The Minimum Data Set (MDS) for assessment and care screening must be performed
within 4 days of a client's admission to a long-term care facility and reviewed every 3
months
B. Acute care
C. Home care: Health care providers often document in client-held records that remain at the
residence. Health care providers may access critical information through the use of voicemail,
wireless devices, and laptops, which enhances their ability to care for their clients and maintain
accurate and current records.
Week 2
1. Describe the differences and similarities between a group and a team.
● A group is a number of individuals assembled together or having some unifying relationship. Groups
could be all the parents in an elementary school, all the members of a specific church, or all the
students in the school of nursing because the members of these various groups are related in some
way to one another by definition of their involvement in a certain endeavour.
● A team, on the other hand, is a number of individuals who work closely together toward a common
purpose, are accountable to one another and sharing responsibility. Not every group is a team, and
not every team is effective. Teams have defined objectives, ongoing relationships, and a supportive
environment and are focused on accomplishing specific goals. Teams are essential in providing cost-
effective, high-quality care. As resources are expended more prudently, teams must develop clearly
defined goals, use creative problem solving, and demonstrate mutual respect and support.
● A group of people does not constitute a team. A team is a group of interdependent individuals who
seek out opportunities to combine their expertise to achieve common goals: Collaboration
2. Compare and contrast types of teams. exercise in Yoder-Wise book p 354
● Manager-led team: The manager is the team leader and controls the agenda, decisions, direction,
and outputs of the team.
● Self-managing team: The manager sets the overall direction and defines the goal and outcome for
the team. The members of the team determine the direction, strategies, and focus of the team to
achieve the goal.
● Self-directed team: The manager identifies the outcome, and the team members determine the
direction, strategies, methods, and focus to achieve the outcome. Often, these teams function in
quality improvement initiatives to address quality challenges and opportunities.
