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105 Cards in this Set
- Front
- Back
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Clinical Judgment
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depends on a deep and meaningful understanding of the professional identity of the nurse, incorporating health and illness concepts along with the norms and values that characterize the nurse as a designer, manager, and coordinator of care and as a member of a profession
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2 types of Reflection in Nursing
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Reflection-in-Action and Reflection-on-Action
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5 types of Nursing Dx
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Actual Nursing Diagnosis, Health Promotion Nursing Diagnoses, Risk Nursing Diagnosis, Syndrome Nursing Diagnosis, Collaborative Nursing Diagnosis
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ABC
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airway, breathing, and circulation - always top priority!
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Actual Nursing Diagnosis
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“Describes human responses to health conditions/life processes that exist in an individual family or group, or community”. Nurse can tx independantly.
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ADPIE
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Assessment, (Nursing) Diagnosis, Planning, Implementing, Evaluation
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Assessment
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data on all dimensions of the “patient’s story,” including biophysical, psychological, sociocultural, spiritual, and environmental characteristics, are embedded in the assessment. It involves performing a thorough holistic nursing assessment of the client;
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Care Coordination
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a set of activities purposefully organized by a team of personnel that includes the patient, to facilitate the appropriate delivery of the necessary services and information to support optimal health and care across settings and over time
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Care Plan
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outlines the nursing care to be provided to an individual/family/community. It is a set of actions the nurse will implement to resolve/support nursing diagnoses identified by nursing assessment.
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Clinical Reasoning
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the thinking process by which a nurse reaches a clinical judgment. (Clinical Reasoning is also part of the Diagnosis step in the Nursing Process)
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Collaboration
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the development of partnerships to achieve best possible outcomes that reflect the particular needs of the patient, family, or community, requiring an understanding of what others have to offer. Collaboration also involves a joint responsibility for patient outcomes.
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Collaboration
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the development of partnerships to achieve best possible outcomes that reflect the particular needs of the patient, family, or community, requiring an understanding of what others have to offer. Collaboration also involves a joint responsibility for patient outcomes
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Collaborative Interventions
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actions that the nurse performs in collaboration with other health care professionals, and that may require a physician’s order and may be in response to both medical and nursing diagnoses
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Communication
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fundamental to the nursing discipline and as such constitutes a substantial part of what actually happens in moment-to-moment nursing practice
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EBP
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Evidence-Based Practice
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etiology
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"Related to” (r/t) phrase or etiology: related cause or contributor to the problem.
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Evaluation
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done throughout the entire nursing process; (re)asses the client: where the client was before the intervention (baseline) and where the client is following the intervention; measuring the effectiveness of nursing care plan and the quality of care.
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Evidence-Based Practice
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a systematic process that uses current evidence in determining interventions that have a scientific rationale supported by nursing research or research from other disciplines
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Experienced nurses are assoiated with this type of reasoning
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analytic, intuitive, and narrative
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External Care & Safety Standards
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standards of care are established by regulatory agencies (The Joint Commission) or professional organizations (American Nurses Association)
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Health Promotion Nursing Diagnoses
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“A clinical judgment about a person’s, family’s, group’s, or community’s motivation and desire to increase well-being and actualize human health potential as expressed in the readiness to enhance specific health behaviors, and which can be used in any health state”. Nurse can tx independantly.
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Implementation
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the “carrying out” of the specific, individualized, jointly agreed-on interventions in the plan of care; the point at which you actually give nursing care; the nurse continues to assess the client to determine whether the interventions are effective and the desired outcomes are met
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Independent Interventions
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autonomous actions that are initiated by the nurse in response to a nursing diagnosis
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Informatics
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nurse’s ability to “use information and technology to communicate, manage knowledge, mitigate error, and support decision making
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Internal Care & Safety Standards
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standards of care are policies and procedures established by health care institutions
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Interpreting/Diagnosing
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the process of assembling information to make sense of it; reasoning; reasoning patterns tend to vary with the experience of the nurse
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Interventions
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all treatments, based on clinical judgment and knowledge that a nurse performs to enhance client outcomes
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Leadership and Ethics
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govern the nurse's social contract with patients and families in his or her care, affirming that advocacy for the patient and family is a primary consideration for all decisions made within the health care environment
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medical diagnosis
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not something the nurse can treat independently, without “physicians orders.”
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Models of Care Coordination
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Social Models Medically Oriented Models Integrated Models
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NIC Interventions
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a comprehensive, standardized classification of treatments that nurses perform. The classification includes both physiological and psychosocial interventions and covers all nursing specialties
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NOC
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Nursing Outcomes Classification
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Noticing/Assessment
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noticing things about a patient in the context of the nurse’s background & experience, context of environment, and knowing the patient; looking for patterns that are consistent with previous experiences and uses that information to guide care.
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Novice nurses are assoiated with this type of reasoning
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analytic reasoning
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Nursing
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an integral part of the health care system that encompasses the promotion of health, prevention of illness, and care of physically ill, mentally ill, and disabled people of all ages, in all health care and other community settings.
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Nursing Diagnosis
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() a clustering of the information/symptoms within the "client story " to formulates an evaluative judgment about a client’s health status through the use of clinical reasoning; prioritized first by immediate needs based on ABC & Maslow
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Nursing Diagnosis - Three-Part System
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consists of the nursing diagnosis, the “related to” (r/t) statement, and the defining characteristics, which are “observable cues/inferences that cluster as manifestations of an actual or wellness nursing diagnosis”
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Nursing Diagnosis - Two-Part System
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often used when the defining characteristics, or signs and symptoms identified in the assessment, may be obvious to those caring for the client.
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Nursing Diagnosis - One-Part System
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defined by Wellness, Readiness for Enhanced
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Nursing-Sensitive Outcome
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measured along a continuum in response to nursing interventions; stated as concepts that reflect a client, caregiver, family, or community's state, perception of behavior rather than as expected goals
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objective information
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obtained by performing a physical assessment, taking vital signs, and noting diagnostic test results
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Patient-Centered Care
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recognizing the pt or designee as The Source of control & full partner; assoc with better care and safety
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PES system (3 part Dx)
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problem, etiology, symptoms
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Planning
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Mutual goal setting along with symptom pattern recognition and triggers; helps prioritize interventions and determine which interventions are going to provide the greatest impact.
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Primary Nursing Model
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includes planning the patient's care, coordinating and communicating all aspects of care with other disciplines and those providing care in the nurse's absence. The focus is on continuity of care and interdisciplinary collaboration.
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problem
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The nursing diagnosis label: a concise term or phrase that represents a pattern of related cues. The nursing diagnosis is taken from the official NANDA-I list.
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Profession
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Referring to the Nursing profession as a profession that encourages improvements in health for all.
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Professional Identity
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is comprised of a compilation of the skills, values, and expertise common to a group of individuals who are part of the same profession. Professionalism is the comportment that creates professional identity in an individual. The professional identity of a nurse is multilayered and includes knowledge, simple and complex skills, expertise, and curiosity built upon beliefs, assumptions, and values that compose the nurse's identity as a person
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Professionalism
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The scope of professional identity in nursing includes autonomy, knowledge, competence, professionhood, accountability, advocacy, collaborative practice, and commitment. With knowledge and competence as the foundation of practice.
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QSEN
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Quality and Safety Education for Nurses
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Quality Improvement
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the use of data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems
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Reflecting/Evaluating
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the process of thinking and learning from experiences; is critical for development of knowledge and improvement in reasoning
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Reflection-in-Action
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happens in real time while care is occurring
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Reflection-on-Action
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happens after the patient care occurs
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Responding/Implementation of Interventions
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Responding is the implementation of actions and interventions, based on patient needs. Depending on the level of expertise, the nurse may or may not be able to judge the effectiveness of the intervention before initiating it.
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Risk Nursing Diagnosis
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“A clinical judgment about human experience/responses to health conditions/life processes that have a high probability of developing in a vulnerable individual, family group or community”. Nurse can tx independantly.
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Safety
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minimizing risk of harm to patients and providers through both system effectiveness and individual performance
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SMART Goals
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Outcomes
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Steps of Clinical Judgement
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Noticing/Assessment; Interpreting/Diagnosing; Responding/Implementation of Interventions; Reflecting/Evaluating
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subjective information
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Information that is obtained verbally from the client
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Symptom Management
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alleviating symptoms so that the client is able to function at their highest level.
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Symptom Pattern Recognition
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process of identifying symptoms the client has related to their illness, understanding which symptom patterns require intervention, and the associated timeframe to intervene effectively
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symptoms
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Defining characteristics phrase; 3rd part of the 3-part diagnostic system; it consists of the s/s from the the assessment phase. The phrase “as evidenced by” (aeb) may be used to connect the etiology (r/t) with the defining characteristics.
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Syndrome Nursing Diagnosis
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“A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions”. Nurse can tx independantly.
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Teamwork & Collaboration
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functioning effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care
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The Nursing Process
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a problem-solving approach to the identification and treatment of patient problems that is the foundation of nursing practice
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ANA Standards of Practice
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sets clear priorities in the ethical practice of nursing, such as compassion, respect, and primary commitment to the patient as well as advocacy for patient rights
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State Board of Nursing
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not-for-profit organizations through which boards of nursing act and counsel together on matters of common interest and concern affecting public health, safety and welfare, including the development of nursing licensure examinations. They provide education, service, and research through collaborative leadership to promote evidence-based regulatory excellence for patient safety and public protection.
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delegation
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transferring the authority or responsibility to perform a selected nursing task in a selected situation to a competent individual.
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Standards-Based Approach: Clinical Judgement
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systematic; analytic; rules-based; standards-based approach; locates the nurse & the individual needs of the pt outside the caregiving situation; selection from options of mutually exclusive possibilities, implying that there is one right decision.
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Interpretivist Perspective: Clinical Judgement
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intuitive; considers multiple factors in clinical reasoning; accounts for what the nurse personally contributes (including experience, values, and emotions); understood knowledge; often inductive in nature; engaged, practical reasoning
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Care Coordination Models
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a process connecting both services and resources and involving patients, providers, and families, with the goals of both optimal health care and optimal patient outcomes
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Care Coordination: Social Models
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support activities of daily living rather than skilled care. offer information, referral, screening and assessment, planning, authorization, and monitoring
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Care Coordination: Medically Oriented Models
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coordinate medical services and were traditionally designed to be diagnosis specific. (Case-management models, Disease management programs, Pharmacist-supported models)
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Care Coordination: Integrated Models
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Models committed to the integration of health care, social support, and community clinical and nonclinical services. (The PACE program is provider based and integrates both acute and long-term health care and social services)
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Problem identification, Nursing Diagnosis Label NANDA-I
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Nursing Diagnosis
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Set priorities, Care Plans- NOC/NIC
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Planning
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Nurse initiated, Physician initiated, Collaborative
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Implementation
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7 Ethical Principals
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Respect for Person/Autonomy; Veracity; Nonmaleficience; Beneficence; Justice; Utilitarianism
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Respect for Person/Autonomy
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human beings have an unconditional moral worth that requires us to treat each individual person with great value, dignity, and respect; patients must be treated in a way that respects their autonomy and their ability to express their wishes and make informed choices about their treatment.
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Veracity
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the principle of truthtelling. A patient is not able to make an informed choice about treatment unless the patient has received the truth about his or her condition and the proposed treatment, with the information presented in a manner that is understandable to the patient
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Nonmaleficience
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acting in ways that avoid harm to others, including even the risk of harm
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Beneficence
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an obligation to do good by acting in ways that promote the welfare and best interests of others. Beneficence can be accomplished by promoting good and preventing and removing harm
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Justice
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concerned with treating people equitably, fairly, and appropriately. justice is the underlying principle that prohibits a nurse from treating patients differently based on their social or economic status, their personal attributes (such as gender or ethnicity), or the nature of their health problems (such as obesity or self-inflicted harm)
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Fidelity
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requires us to act in ways that are loyal. Keeping your promises, doing what is expected of you, performing your duties, and being trustworthy
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Utilitarianism
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assumes that an action is right if it leads to the greatest possible balance of good consequences or to the least possible balance of bad consequences. Because the patient's pain medication was taken away, the consequences were all bad
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Societal Ethics
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ethics that serve the larger community (Embryonic stem cell, physician-assisted suicide, abortion); society provides a strong normative basis for ethical behavior through legal and regulatory systems; law is a minimum standard of behavior to which all members of society are held and which, generally, is believed to serve the interests of society as a whole
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Organizational Ethics
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involves a set of formal and informal principles and values that guide the behavior, decisions, and actions taken by members of an organization as well as the organizational structures, systems, practices, policies, and procedures developed to ensure ethical operation. (Catholic hospitals are guided by the Ethical and Religious Directives)
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Professional Ethics
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the ethical standards and expectations of a particular profession
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Code of Ethics for the ANA
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establishes clear priorities in the ethical practice of nursing, such as compassion, respect, and primary commitment to the patient as well as advocacy for patient rights
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Bioethics
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deals broadly with ethical questions surrounding the biological sciences and technology, especially as applied in health care
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Clinical Ethics
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involved primarily with decision making at the bedside and other patient-specific issues
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Research Ethics
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a specialized field within bioethics that examines the ethical conduct of research using human subjects and animals
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Personal Ethics
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an individual's own ethical foundations and practice
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Ethical Theories
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Ethics of Duty; Ethics of Consequence; Ethics of Character; Ethics of Relationship;
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Ethics of Duty / Deontological Ethics
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moral duties are seen as self-evident, needing no further justification. "ends do not justify the means"; moral action is then based on acting according to a specific duty simply because it is the right thing to do
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Ethics of Consequence/Teleology Ethics
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"results-orientated ethics"; moral actions are defined entirely on the basis of the outcomes or consequences of an action. Reaching a particular goal is what defines the ethical justification of an act regardless of your sense of duty or moral intent
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Ethics of Character/Virtue Ethics
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relies on the character of the individual as the primary source of moral action
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Moral Virtues
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include respect, honesty, sympathy, charity, kindness, loyalty, and fairness
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Practical Virtues
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intelligence, patience, prudence, and shrewdness
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Ethics of Relationship
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the nature and obligations inherent in human relationships and community
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Ethics of Relationship- justice
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a focus on justice, rights, and the development of universal rules to ensure fairness
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Ethics of Relationship- care
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focused on emotion and relationships; Primary attention is paid to preserving relationships, improving communication, enhancing cooperation, and minimizing harm to everyone involved while promoting an ideal of caring.
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Ethical Problem
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simply a problem with an ethical dimension. Patient needs assistance to go to the restroom.
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Ethical Dilemma
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involves a problem for which in order to do something right you have to do something wrong. Patient asks you to help him/her commit suicide.
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