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51 Cards in this Set

  • Front
  • Back
Describe the components of a critical thinking model for clinical decision making
According to this model, there are five components of critical thinking: knowledge base, experience, critical thinking competencies (with emphasis on the nursing process), attitudes, and standards. The elements of the model combine to explain how nurses make clinical judgments that are necessary for safe, effective nursing care.
Discuss critical thinking skills used in nursing practice
Critical thinking is an active, organized, cognitive process used to carefully examine one’s thinking and the thinking of others. It involves recognizing that an issue (e.g., client problem) exists, analyzing information about the issue (e.g., clinical data about a client), evaluating information (reviewing assumptions and evidence) and making conclusions. A critical thinker considers what is important in a situation, imagines and explores alternatives, considers ethical principles, and then makes informed decisions.
Explain how professional standards influence a nurse’s clinical decisions
Professional standards for critical thinking refer to ethical criteria for nursing judgments, evidence-based criteria used for evaluation, and criteria for professional responsibility.

The standards of professional responsibility that a nurse tries to achieve are those standards cited in Nurse Practice Acts, institutional practice guidelines, and professional organizations’ standards of practice. The American Nurses Association Standards of Professional Performance is an example. These standards “raise the bar” for the responsibilities and accountabilities that a nurse assumes in guaranteeing quality health care to the public.
Differentiate between subjective and objective data.
Subjective data are your clients’ verbal descrip-tions of their health problems. Only clients provide subjective data. For example, Ms. Divine’s report of back pain and her ex-pression of dread over having to have surgery are subjective fi nd-ings. Subjective data usually include feelings, perceptions, and self-report of symptoms.

Objective data are observations or measurements of a client’s health status. Inspection of the condition of a wound, a descrip-tion of an observed behavior, and the measurement of blood pres-sure are examples of objective data. The measurement of objective data is based on an accepted standard, such as the Fahrenheit or Celsius measure on a thermometer, centimeters on a measuring tape, or known characteristics of behaviors (e.g., anxiety or fear).
Discuss the critical thinking attitudes used in clinical decision making
There are 11 attitudes that are central features of a critical thinker. These attitudes define how a successful critical thinker approaches a problem. For example, when a client complains of anxiety before having a diagnostic procedure, the curious nurse will explore possible reasons for the client’s concerns. The nurse will also show discipline in collecting a thorough assessment to find the source of the client’s anxiety. Attitudes of inquiry involve an ability to recognize that problems exist and that there is a need for evidence to support what you suppose is true. Critical thinking attitudes are guidelines for how to approach a problem or decision-making situation. An important part of critical thinking is interpreting, evaluating, and making judgments about the adequacy of various arguments and available data. Knowing when you need more information, knowing when information is misleading, and recognizing your own knowledge limits are examples of how critical thinking attitudes guide decision making.

These 11 components are confidence, thinking independently, fairness, responsibility and authority, risk taking, discipline, perseverance, creativity, curiosity, integrity, humility
Discuss how the use of interview techniques helps clients to tell their health stories
Interviews allow you to learn more about a client’s situation and to focus on specifi c problem areas. An interview helps clients relate their own interpretation and understanding of their condition. Therefore you and the client become partners during the interview rather than your controlling the interview. An interview consists of three phases, similar to that of a therapeutic relationship: orientation, working, and termination.

How you conduct the interview is just as important as the questions you ask. Pay attention to the environment, client comfort, and use good communication techniques. During the interview you are responsible for directing the flow of the discussion so that you get enough information and your client has the opportunity to contribute freely. Ideally you want clients to tell their stories about their health problems so that you are able to get as much detailed information as possible.
Describe the components of a nursing history
Biographical information is factual demographic data about the client. The client’s age, address, occupation and working status, marital status, source of health care, and types of insurance are included.

Reason for seeking health care: what brings them to the clinic, office, hospital, etc.

Patient expectations; is not the same as the reason for seeking medical care, although they are often related.

Health History; provides data on the client’s health care experiences and current health habits. Included is history of hospitalizations, injuries, surgeries, allergies, current medications, eating, sleeping, and lifestyle habits

Family history; The purpose is to obtain data about immediate and blood relatives. The objectives are to determine whether the client is at risk for illnesses of a genetic or familial nature and to identify areas of health promotion and illness prevention; also provides information about family structure, interaction, and function that is often useful in planning care

Environmental History; provides data about a client’s home and working environments with a focus on determining the client’s safety.

Psychosocial History. client’s support system, which often includes spouse, children, other family members, and close friends; includes information about ways that the client and family typically cope with stress

Spiritual Health, Review of Systems, and documentation of health history are also components.
Describe the relationship between data collection and data analysis
Collection and verification of data from a primary source (the client) and secondary sources (e.g., family, health profession-als, and medical record)

The analysis of all data as a basis for developing nursing diagnoses, identifying collaborative problems, and developing a plan of individualized care
Differentiate between nursing diagnosis, medical diagnosis, and collaborative problem
A nursing diagnosis is a clinical judgment about individual, family, or community re-sponses to actual and potential health problems or life processes

A medical diagnosis is the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client’s medical history, and the results of diagnostic tests and procedures.

A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a client’s status
Discuss the relationship of critical thinking to the nursing diagnostic process
Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which you, as a nurse, are accountable. A nursing diagnosis focuses on a client’s actual or potential response to a health problem rather than on the physiological event, complication, or disease.

Diagnostic reasoning is a process of using the assessment data you gather about a client to logically explain a clinical judgment, in this case a nursing diagnosis. The diagnostic process flows from the assessment process and includes decision-making steps. These steps include data clustering, identifying client needs, and formulating the diagnosis or problem.Clusters and patterns of data often contain defining characteristics, the clinical criteria or assessment findings that support an actual nursing diagnosis. Clinical criteria are objective or subjective signs and symptoms, clusters of signs and symptoms, or risk factors that lead to a diagnostic conclusion.

As a nurse, you will learn to recognize patterns of defining characteristics and then readily select the corresponding diagnosis.
Describe the steps of the nursing diagnostic process.
Assessment - data gathering

Validation - comparison with laboratory and diagnostic test values, professional standards, and normal anatomical or physiological limits

Analysis/interpretation of data; research / look for defining characteristics

Formulation of diagnosis based on information provided
Explain the relationship of planning to assessment and nursing diagnosis
Nursing diagnosis is a mechanism for identifying the domain of nursing. Diagnoses provide direction for the planning process and the selection of nursing interventions to achieve desired outcomes for clients

Planning is to set priorities for a client. Remember, a single client often has multiple diagnoses and collab-orative problems. Priority setting is the ordering of nursing diagnoses or client problems using notions of urgency and/or importance to establish a preferential order for nursing actions
Explain how defining characteristics and the etiological process individualize a nursing diagnosis.
Identify a treatable etiology rather than a clinical sign or chronic problem. You will select interventions directed toward correcting the etiology of the problem. A diagnostic test or a chronic dysfunction is not an etiology or a condition that a nursing intervention is able to treat. A client with pneumonia sometimes presents with restlessness, hypoxia, abnormal blood gas levels, and dyspnea. Impaired gas exchange related to altered blood gases is an incorrect diagnostic statement. Impaired gas exchange related to alveolar capillary membrane changes is a correct statement.
Explain the benefit of using NANDA International nursing diagnoses in practice
NANDA-I has developed a common language that allows all members of the health care team to understand a client’s needs
Discuss the criteria used in priority setting
In regard to importance, it helps to classify priorities as high, intermediate, or low. Nursing diagnoses that, if untreated, result in harm to the client or others have the highest priorities. For example, risk for other-directed violence, impaired gas exchange, and decreased cardiac output are typically high-priority nursing diagnoses that drive the priorities of safety, adequate oxygenation, and adequate circulation. However, it is always important to consider each client’s unique situation. High priorities are sometimes both physiological and psychological and may address other basic human needs. Avoid classifying only physiological nursing diagnoses as high priority.

Intermediate priority nursing diagnoses involve the nonemergent, non–life-threatening needs of the client.

Low-priority nursing diagnoses are not always directly related to a specific illness or prognosis but affect the client’s future well-being. Many low-priority diagnoses focus on the client’s long-term health care needs.
Describe goal setting
Goals and expected outcomes are specific statements of client behavior or physiological responses that you set to achieve nursing diagnosis or collaborative problem resolution. Goals and outcomes provide a clear focus for the type of interventions necessary to care for your client. A goal is an aim, intent, or end.
Discuss the difference between a goal and an expected outcome
Expected outcomes are measurable criteria to evaluate goal achievement..

A goal is a broad statement that describes the desired change in a client’s condition or behavior.
List the seven guidelines for writing an outcome statement
The guidelines are: client-centered, singular, observable, measurable, time-limited, mutual, and realistic
Discuss the differences between nurse-initiated, physician-initiated, and collaborative interventions
Nurse-initiated interventions are autonomous actions based on scientific rationale. Examples include elevating an edematous extremity, instructing clients in side effects of medications, or directing a client to splint an incision during coughing.

Physician-initiated interventions are dependent nursing interventions, or actions that require an order from a physician or another health care professional. The interventions are based on the physician’s or health care provider’s response to treat or manage a medical diagnosis.

Collaborative interventions, or interdependent nursing interventions, are therapies that require the combined knowledge, skill, and expertise of multiple health care professionals. Typically, when you plan care for a client, you will review the necessary in-terventions and determine if the collaboration of other health care disciplines is necessary. A client care conference with an interdisciplinary health care team results in selection of interdependent nursing interventions.
Discuss the process of selecting nursing interventions.
When choosing interventions, consider six important factors: (1) characteristics of the nursing diagnosis, (2) goals and expected outcomes, (3) evidence base (e.g., research or proven practice guidelines) for the interventions, (4) feasibility of the intervention, (5) acceptability to the client, and (6) your own competency
Describe the association between critical thinking and selecting nursing interventions
The selection of nursing interventions is a complex decision-making process that involves critical thinking. The context in which you deliver care to each client and the many interventions required result in decision-making approaches for each clinical situation. Critical thinking is necessary to consider the complexity of interventions, including the number of alternative approaches and the amount of time available to act. Before implementing any intervention, use critical thinking to determine whether an intervention is correct and appropriate for a clinical situation. Even though you have planned a set of interventions for a client, you have to exercise good judgment and decision making before actually delivering each intervention. Always think before you act. .
Identify preparatory activities to use before implementation
* Review the set of all possible nursing interventions for the client’s problem
* Review all possible consequences associated with each possible nursing action
* Determine the probability of all possible consequences
* Make a judgment of the value of that consequence to the client
Discuss steps used to revise a plan of care before performing implementation
Modifi cation of the existing written care plan includes four steps:
1. Revise data in the assessment column to reflect the client’s current status. Date any new data to inform other members of the health care team of the time that the change occurred.
2. Revise the nursing diagnoses. Delete nursing diagnoses that are no longer relevant, and add and date any new diagnoses. It is necessary to revise related factors, as well as the client’s goals, outcomes, and priorities. Date any revisions.
3. Revise specific interventions that correspond to the new nursing diagnoses and goals. This revision should reflect the client’s present status.
4. Determine the method of evaluation for determining if you achieved outcomes.
Describe and compare direct and indirect nursing interventions
Direct care interventions are treatments performed through interactions with clients. For example, a client receives direct intervention in the form of medication administration, insertion of an intravenous infusion, or counseling during a time of grief.

Indirect care interventions are treatments performed away from the client but on behalf of the client or group of clients. For example, indirect care measures include actions for managing the client’s environment (e.g., safety and infection control), documentation, and interdisciplinary collaboration.
Explain the legal concepts of standard of care and informed consent
Standards of care are the legal guidelines for nursing practice and provide the minimum acceptable nursing care. Standards reflect values and priorities of the profession.

The American Nurses Association (ANA) has developed standards for nursing practice, policy statements, and similar resolutions. The standards outline the scope, function, and role of the nurse in practice. Nursing standards of care are set out in every state’s Nurse Practice Act, by the federal and state laws regulating hospitals and other health care institutions, by professional and specialty nursing organizations, and by the policies and procedures established by the health care facility where nurses work.

Informed consent is a person’s agreement to allow something to happen, such as surgery or an invasive diagnostic procedure, based on a full disclosure of risks, benefits, alternatives, and consequences of refusal
Describe the legal responsibilities and obligations of nurses regarding the following federal statutes: Americans with Disabilities Act (ADA), Emergency Medical Treatment and Active Labor Act (EMTALA), Health Insurance Portability and Accountability Act of 1996 (HIPAA), and Patient Self-Determination Act (PSDA).
ADA - protects health care workers in the workplace with disabilities, such as HIV infection. Likewise, health care workers may not discriminate against HIV-positive clients

EMTALA - when a client comes to the emer-gency department or the hospital, an appropriate medical screen-ing occurs within the hospital’s capacity. If an emergency condi-tion exists, the hospital is not to discharge or transfer the client until the condition stabilizes.

HIPAA - Privacy is the right of clients to keep information about themselves from being disclosed. Confidentiality is how health care providers treat client private information once it has been disclosed to others. Client confidentiality is a sacred trust. Nurses help organizations protect clients’ rights to confi dentiality. Although HIPAA does not require such measures as soundproof rooms in hospitals, it does mean that nurses and all health care providers need to avoid discussing clients in public hallways and provide reasonable levels of privacy in communicating with and about clients in any manner.

PSDA - requires health care institutions to provide written information to clients concerning the clients’ rights under state law to make decisions, including the right to refuse treatment and formulate advance directives. Under the act, the client’s record must contain documentation whether the client has signed an advance directive. In order for living wills or durable powers of attorney for health care to be enforceable, the client must be legally incompetent or lack decisional capacity to make decisions regarding health care treatment.
List sources for standards of care for nurses
Nursing standards of care are set out in every state’s Nurse Practice Act, by the federal and state laws regulating hospitals and other health care institutions, by professional and specialty nursing organizations, and by the policies and procedures established by the health care facility where nurses work
List the elements needed to prove negligence
The nurse owed a duty to the client.
The nurse did not carry out the duty or breached the duty (failure to use that degree of skill and learning ordinarily used under the same or similar circumstances by members of his or her profession).
The client was injured: (e.g. Medical bills, lost wages, Pain and suffering, Perinatal damages, Wrongful death damages)
The client’s injury was caused by the nurse’s failure to carry out that duty (“but for” the breach of duty the client would not have been injured).
Describe the nursing implications associated with legal issues that occur in nursing practice
Legal issues occuring in nursing practice can include short staffing, floating, questionable physician orders. Legal problems can occur when there are not enough nurses to provide adequate care or are floated to an area outside of their scope of knowledge. Nurses must inform the supervisor and document potential shortages or knowledge deficits in these cases. In the event of questionable physician's orders, nurses must seek to clarify or have corrected orders that are unclear and or incorrect. The nursing supervisor has an obligation to ensure adequate and safe practice is taking place not only for the patient but for the nurse as well. A nurse must not "walk off" or leave the job as this is considered patient abandonment and can result in potential loss of license.
Identify purposes of a health care record
A record is a valuable source of data for all members of the health care team. Its purposes include communication, legal documentation, financial billing, education, research, and auditing-monitoring.
Discuss legal guidelines for documentation
-Do not erase, apply correction fluid, or scratch out errors made while recording.
-Do not write retaliatory or critical comments about client or care by other health care professionals. Do not write personal opinions.
-Correct all errors promptly.
-Record all facts.
-Do not leave blank spaces in nurses’ notes.
-Record all entries legibly and in black ink. Do not use felt tip pens or erasable ink.
-If order is questioned, record that clarifi cation was sought.
-Chart only for yourself.
-Avoid using generalized, empty phrases such as “status unchanged” or “had good day.”
-Begin each entry with date and time, and end with your signature and title.
-For computer documentation keep your password to yourself.
Identify ways to maintain confidentiality of records and reports
-Pt education on privacy protections
-Ensure patient access to their medical records
-Receive consent before anything is released
-Providing recourse when privacy protections are violated (holding accountable)
Describe five quality guidelines for documentation and reporting
Must be factual, must be accurate, must be complete, must be current, and must be organized.
Discuss the relationship between documentation and health care financial reimbursement
Accreditation agencies such as The Joint Commission (TJC) specify guidelines for documentation. Under the prospective payment system, Medicare reimburses hospitals a set dollar amount for each diagnosis-related group (DRG). Everything that is done for a client must be documented in the medical record for the health care institution to recover its costs.

If it isn't documented, it didn't happen and the hospital will not get reimbursed for it. If documentation is shady, inaccurate, incomplete or vague it can and will affect reimbursement received by Medicare and other insurance companies.
Accurately assess pulse rate, respirations, oxygen saturation, and blood pressure
Skill performed in lab and clinicals. Normal ranges are as follows:

Pulse rate: 60 - 100 bpm
Respirations: 12 - 20 bpm
BP: <120/80
O2 Sat: 95% - 100%
Temp: Oral - 98.6 F (37 C); Rectal - 99.5 F (37.5 C); Axillary - 97.7 F (36.5 C)
Describe cultural and ethnic variations with blood pressure assessment
The incidence of hypertension (high blood pressure) is higher in African Americans than in European Americans. African Americans tend to develop more severe hypertension at an earlier age and have twice the risk for complications such as stroke and heart attack. Genetic and environmental factors are often contributing factors. Hypertension-related deaths are also higher among African Americans.
Identify ranges of acceptable vital sign values for an infant, a child, and an adult
BP:
Adult <120/80
Child 14 - 17 <120/75
Child 10 - 13 <110/65
Child 6 <105/65
Child 1 95/65
Infant 1 mo 85/54
Newborn 40 (mean)

Pulse:
Infant 120-160
Toddler 90-140
Preschooler 80-110
School-age child 75-100
Adolescent 60-90
Adult 60-100

Resp:
Newborn 30-60
Infant (6 months) 30-50
Toddler (2 years) 25-32
Child 20-30
Adolescent 16-19
Adult 12-20

Temp (adults)
Average oral/tympanic: 37 C (98.6 F)
Average rectal: 37.5 C (99.5 F)
Average axillary: 36.5 C (97.7 F)
Newborns: 35.5 - 37.5 C (95.9 - 99.5 F)
Identify when to take vital signs
• On admission to a health care facility
• When assessing the client during home care visits
• In a hospital on a routine schedule according to the health care provider’s order or the hospital’s standards of practice
• Before and after a surgical procedure or invasive diagnostic procedure
• Before, during, and after a transfusion of blood products
• Before, during, and after the administration of medication or therapies that affect cardiovascular, respiratory, or temperature-control functions
• When the client’s general physical condition changes (e.g., loss of consciousness or increased intensity of pain)
• Before and after nursing interventions influencing a vital sign (e.g., before a client previously on bed rest ambulates or before a client performs range-of-motion exercises)
• When the client reports nonspecific symptoms of physical distress (e.g., feeling “funny” or “different”)
Accurately record and report vital sign measurements
Special graphic flow sheets exist for recording vital signs. Identify the institution’s procedure for documenting on the graphic or vital sign flow sheet. In addition to the actual vital sign values, record in the nurses’ notes any accompanying or precipitating symptoms such as chest pain and dizziness with abnormal blood pressure, shortness of breath with abnormal respirations, cyanosis with hypoxemia, or flushing and diaphoresis with elevated temperature. Document any interventions initiated as a result of vital sign measurement, such as administration of oxygen therapy or an antihypertensive medication.
Appropriately delegate vital sign measurement
Delegation of the measurement of VS can only be done in stable patients and must be interpreted/analyzed by the nurse.
List techniques used to prepare a client physically and psychologically before and during an examination
Physically:
provide clean, quiet, well equiped, private setting
ensure client is comfortable, dressed appropriately, positioned appropriately,and does not need to use the restroom
ensure room temperature is appropriate - not too cold and not too hot

Psychologically -
Keep explanations simple and in understandable terms
Keep open, relaxed and approachable demeanor to create atmosphere where pt feels free to ask questions or seek clarification
Observe pt responses and in event of anxiety or stress remain calm and explain each step clearly
For opposite gender exams, provide a third person of pts gender for the exam
Make environmental preparations before an examination
Room should be private and well equipped
Eliminate extraneous sources of noise if possible
Place HOB at 30 degree angle and provide pt with pillow
Ensure room and equipment has been cleansed
Make sure equipment is available, arranged and in proper working order
Identify data to collect from the nursing history before an examination
Complete health history including concerns, current medications, allergies, family medical history, expectations from visit or care provided
Discuss normal physical findings in a young adult, middle-age adult, and older adult
Acceptable range of VS
Warm, dry, intact skin free from rashes, irregular shaped moles, or spots
Unlabored breathing with no use of accessory muscles
Elastic skin turgor; pink moist mucous membranes
No clubbing, and cap refill <3 sec
PERRLA
Oriented appropriately
No JVD or bruits
Presence of bowel sounds
Lung sounds clear with no wheezing, crackles or rhonci
Normal Heart sounds
Examine the nurse’s role and responsibilities in medication administration
The nurse is responsible for evaluating the effects of medication on the client's health status, teaching clients about their medications and their side effects, ensuring adherence with medication regimen and evaluating the client's ability to self administer medication. In acute and restorative care setting nurse spend a great deal of time administering medications to clients and ensure that clients or their families are adequately prepared to self administer when discharged.

The nurse is responsible for following legal provisions when administering medications. The nurse is responsible for safe and responsible adminstration of all medications.
Implement nursing actions to prevent medication errors
Implement six rights of med admin
Be sure to read labels at least 3x comparing with MAR
Use at least two pt identifiers
Do not allow interruptions when collecting/admin meds
Double check all calculations
Do NOT interpret illegible orders; clarify with doc
Questions doses out of normal ranges
Document as soon as given
Be accountable when error is made and learn from mistake
Evaluate context of which error was made; is additional resource/education needed?
Analyze factors for repeated errors; process error?
Attend inservices often that focus on Med Error preventtion
Apply the six (eight) rights of medication administration in clinical settings
Right medication
Right dose
Right patient
Right route
Right time
Right documentation
Correctly prepare and administer subcutaneous, intramuscular, and intradermal injections; oral preparations; eye, ear, and nose drops
Special notes: easiest and most desireable way is via enteral (oral) route

Nasal drops: for access to ethmoid or sphenoid sinus tilt head straight back; for access to maxillary or frontal sinus tilt head back and to side

Eyes: drop 1 - 2 drops in conjunctival sac without touching eye; for ointments - apply on lower lid starting from inner to outer canthus

Ears - down and back for kids; up and back for adults. Do not place drop inside ear but hover above the ear. Advise pt to remain with head turned in same position for 2 - 3 min

Subq - in skin at 45 degree angle while pinching skin to ensure in fatty part of the body

IM - in deltoid, vastus lateralis or ventrogluteal primarily

Intradermal - just under the skin; one blip or bubble; generally for TB testing or such. do not aspirate
Properly assess a wound
In emergency settings:
Inspect for bleeding
Inspect wounds for foreign bodies or contaminated material
Assess size of wound and clean and cover as needed

In stable settings:
Physician is always 1st to remove dressing post surgery. Only remove in emergency situations
After this; observe wound edges for approximations and closing
Note character of drainage and drain sites
Observe wound closures (sutures, staples, wound closures)
Observe swelling or separation of edges, lightly press edges noting areas of tenderness or redness
Describe the differences of wounds healing by primary and secondary intention
primary intention: skin edges are approximated (closed) and risk of infection is low; healing occurs quickly, with minimal scar formation as long as infection and secondary breakdown is prevented.

secondary formation: occurs with wounds involving loss of tissue such as a burn or pressure ulcer or severe lacerations. high potential for scarring, infection and takes longer to heal. In severe cases can lose functioning of some tissue
List appropriate nursing interventions for a client with impaired skin integrity
Reposition q 90 min ensuring not to place on site of impaired skin
Do not elevate HOB >30 degree
Keep skin clean and dry; do not rub area
Use a moisture barrier ointment at least 3 times day and provide moisture to open tissue
Change dressing regularly
Increase protein and calorie intake to encourage wound healing