Nursing 4400A/B Study Guide - Fall 2018, Comprehensive Midterm Notes - Nursing, Heart Failure, Anxiety
12 Oct 2018
School
Department
Course
Professor
Nursing 4400A/B
MIDTERM EXAM
STUDY GUIDE
Fall 2018
1
Week 1
Course Introductions & Documentation
Outline
• Introductions
• Groups
• Course Syllabus
• SBN, CJM, SOAP, SBAR,
• Assignment today: PEP module
Strength-Based Nursing (SBN)
• What can you remember about strengths-based
nursing?
o Promoting empowerment, self-efficacy, and
hope
o 8 values:
▪ Health and healing
▪ uniqueness
▪ Holism/ embodiment
▪ Person- environment
▪ Subjective reality
▪ Self determination
▪ Learning, timing, readiness
▪ Collaborative partnership
Clinical Judgement Model (CJM)
• What can you remember about the clinical judgement model?
• Ex. Giving a patient metoprolol
• Noticing
o Vitals – BP and HR
o Check how patient presents at the time – lethargic, alert
• Interpreting
o Vitals falling within expected range → looking at patient baseline
• Responding
o Giving medication if necessary
o Hold medication if necessary
• Reflecting (in and on action)
o In: being mindful of the medication
o On: check in on patient vitals- around 30 minutes after
Guidelines for Documentation
• Why is it important?
o Essential to look back on patient history and information
• What does good documentation look like? Lets see…
find more resources at oneclass.com
find more resources at oneclass.com
2
Documentation for SOAP
• A way to organize information
• Date and time
o S: Subjective
o O: Objective
o A: Nursing
diagnosis
o P: Plan
• How would you
document the case
study?
o S: Anything the
patient says
o O: Vitals, O x 3,
pallor
o A: Hypotensive
and bradycardia
(do not include
diagnosis)
o P: monitor, alert
team of issues
• Chart Q 12 hours
SOAP – Assessment
• Assessment – what does this mean?
o Analysis and interpreting data – a statement writing what is happen to the
patient at the time
• This is your Nursing Diagnosis
o Be sure you dont provide a medical diagnosis here
SOAP – Plan
• What does PLAN include?
• What the nurse will do
• Interventions....Responding!
• Monitor patient
• Alert team of issues
SBAR for Communication
• S: situation
o Hypotensive and bradycardic
o Had a beta blocker (metoprolol)
• B: background
o Why he came in
o What his baseline is
find more resources at oneclass.com
find more resources at oneclass.com
Document Summary
Introductions: groups, course syllabus, sbn, cjm, soap, sbar, assignment today: pep module. Strength-based nursing (sbn: what can you remember about strengths-based nursing, promoting empowerment, self-efficacy, and hope, 8 values, health and healing, uniqueness, holism/ embodiment, person- environment, subjective reality, self determination, learning, timing, readiness, collaborative partnership. Clinical judgement model (cjm: what can you remember about the clinical judgement model, ex. Giving a patient metoprolol: noticing, vitals bp and hr, check how patient presents at the time lethargic, alert. Soap plan: what does plan include, what the nurse will do, monitor patient, alert team of issues. Sbar for communication: s: situation, hypotensive and bradycardic, had a beta blocker (metoprolol, b: background, why he came in, what his baseline is. Sbar cornell (2014: when will you use it, when transferring patient to another unit, transfer to a different hospital, between nurses, talking to doctors, fosters dialogue, focused and consistent, enabled novice nurses to present like experienced ones.
