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114 Cards in this Set
- Front
- Back
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Critical thinking
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intentional higher level reasoning process that is intellectually delineated by one's worldview, knowledge
-nurses use knowledge from other subjects -nurses deal with change in stressful environment - |
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Socratic thinking
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-Questions about the question/problem (is it clear? is it important?)
-Questions about assumptions -Questions about point of view? (can you ask this question another way?) -Questions about evidence and reasons (What evidence do you have?) -Questions about implications (What effect would that have?) |
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inductive reasoning vs. deductive reasoning
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-generalizations are formed from a set of facts or observations (all flames are hot)
-deductive reasoning (reasoning from general premise to specific conclusion) |
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Fact
Inference |
-can be verified through -investigation
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inference
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conclusion drawn from facts, going beyond facts to amke a statement about something not currently known
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judgments
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evaluation of facts that reflect values, an opinion
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opinions
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beliefs formed over time- even more subjective than a judgment
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nursing process
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a systematic, rational method of planning and providing individualizing nursing care
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clarity
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what is an example?
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when faced with several needs at once the nurse may....
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Priortize!
1-look at the advantages and disadvantages of each option 2- apply Maslow's hierarchy of needs 3-consider which tasks can be delegated to others 4-use another priority setting framework |
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accuracy
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how can i find out if that is true?
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precision
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can i be more specific?
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relevance
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how does that help me with this issue?
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depth
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what makes this a difficult problem?
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breadth
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do i need to consider another POV?
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logic
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does that follow from the evidence?
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significance
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which of these facts is most important?
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fairness
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Am I considering the thinking of others?
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Assessing
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Identify the purpose-why a decision is needed and what needs to be determined
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Diagnosing
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critical thinker often waits to diagnose, so its not premature
also assess culture/religious factors in diagnosis |
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Planning
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the critical thinker uses concepts about motivation, change theory, and multicultural nursing to understand the ct's behavior
Set the criteria: what is the desired outcome? what needs to be preserved? what needs to be avoided? Weigh the criteria: note what is most important priority Examine alternatives: why did you choose one strategy over another Project: applies creative thinking and skepticism to determine what might go wrong as a result of a decision and develops plans to overcome or minimize problems |
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Evaluating
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the nurse determines the effectiveness of the plan and whether or not the original purpose was achieved
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Integrity
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individuals apply the same rigorous standards of proof of their own knowledge and beliefs as they apply to the knowledge and beliefs of others
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Problem Solving
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the nurse obtains info that clarifies a problem suggests solutions
nurses places other options on reserve commonly used in problem solving: trial and error, intuition, research process |
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Mind map of critical thinking
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Trigger-you begin with a complex problem
Starting Point- caused by intuition, brain storming, aloud reflections Scaffolds- going off your knowledge bases, life experiences, expertise Processes- Reflection, nursing process, problem solving Outcomes- Problem Resolution, Clinical Judgment Reflective Practice |
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Nursing Process Template
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Remember ADOPIE!
Assess Diagnosis(Nursing) Plan Implement Evaluate |
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The Data You Use for Assessment
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Lab Data
Physical Exam Nursing Assessment History and Physical Physiological Parameters Psycho-socio cultural factors |
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What's In a health history?
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biographical info
client expectations present illness/health concerns health history family history environmental history psychosocial history spiritual health review of systems documentation of findings and diagnostic and lab data |
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Data collection
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signs-objective
symptoms-subjective primary-patient secondary- family,friends, nurse observations tertiary- medical records, other members of the healthcare team, lab and diagnostic tests |
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Assessing
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Collecting, organizing, validating, and documenting ct data
The purpose is to establish the health concern and manage their health needs What this entails is health history, physical assessment, review ct. records, review literature, consult support personnel, consult health professionals, organize and validate and document data. Communicate data to necessary personnel and to pt. Assessing is a continuous process carried out during all phases of the nursing process. For example in the evaluation phase, assessment is done ti determine the outcome as well go evaluate goal achievement. |
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Diagnosing
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Analyzing and synthesizing the data
The purpose is -id ct. strengths -id potential problems -id appropriate nursing interventions This involves comparing data against standards, clustering group data (by generating a tentative hypotheses_, identifying gaps and inconsistencies document on the care plan! |
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Planning
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Determining how to prevent, reduce or resolve the identified ct. problems how to sport client strengths, and how to carry out the care plan in an organized and practical way
This involves writing goals and outcomes, selecting nursing strategies/interventions, consulting other professionals, and communicating the plan to the appropriate people |
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Implementing
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Carrying out (or delegating) and documenting the planned interventions
Assisting the ct. to meet goals, promote wellness, prevent illness, restore health, facilitate coping This involves reassessment and documenting care and how it went. Involve and communicate with other health care pros when necessary |
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Evaluating
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Measuring the degree to which goals/outcomes have been achieved and identifying factors that help or are hurting the goal
Purpose is to determine whether to keep going, modify or end the care plan This involves collaborating with ct and collecting data related to the outcomes, judging how well the goal is being met, determining if you nned to modify or end the car plan, and you have to document all this too! |
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What must collecting data include
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-systematic
-continuous in order to prevent the omission of important things as well as reflecting the ct.'s changing status |
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Database
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This contains all the information about the client.
it includes - nursing health history -physical assessment -primary care provider's history and physical exam -results of lab and diagnostic tests - material contributed by other health personnel |
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Initial assessment
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Performed within specified time after admission to a healthcare agency
The purpose is to establish a complete database for problem identification, reference, and future comparison An example is a nursing admission assessment |
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Problem-focussed assessment
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Time-ongoing process associated with nursing nursing care
The purpose is to determine the status of a problem that was identified in an earlier assessment An example is I and O for an edematous pt. |
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Emergency assessment
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Time- during any physiological or psychological crisis of the ct.
The purpose is to identify life threatening problems or identify and new/overlooked problems An example is rapid assessment of ABC's during an arrest situation |
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Time-lasped assessment
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Takes place several months after an initial assessment
The purpose is to compare the ct.'s current status to baseline data previously obtained |
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Biographic data component of a nursing health history
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Name, date, time, address, age, sex, race, martial status, occupation, religious preference, health care financing, and usual source of medical care. source and reliability of the source
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Chief complaint
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Why are you here today?
Answer should be recorded in patient's own words Not a diagnosis INCLUDES DURATION |
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History of Present Illness component of history
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A clear chronological narrative account of the problem(s) for which the pt. is seeking care.
Has 8 dimensions L-Location: point to spot, radiation? O-Onset: setting in which symptom occurred, where? C-Characteristics: dull, sharp, burning, crampy, etc. S-Severity: graded on 0-10 scale T-Timing: duration, frequency, pattern A-Aggravating and Alleviating Factors: what makes it better? what makes it worse? A-Associated Symptoms-includes significant negatives!! M-Meaning: meaning to the pt. |
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Components of the Complete Health History
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1) Identifying Information/Patient Profile
2)Chief complaint (CC) 3) History of Present Illness (HPI) 4) Past Medical History (PMH) 5) Family History (FH) 6) Personal and Social History (SH) 7) Review of Systems (ROS) All of the health history is subjective because it is info given by the pt, family etc. |
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Past Medical History portion of the Health History
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-General health: as the pt perceives it
-Childhood illnesses -Adult illnesses -Psychiatric illnesses -Immunizations -Surgery -Serious injuries (and resulting disability) -Medications -Allergies (and reactions) to drugs, animals, insects, or other environment agents -Transfusions -Recent screening tests -OB/GYN history |
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Family History portion of the health history
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-At least a THREE generation analysis for diseases that have familial or genetic basis
-Record age/health or age/cause of death -Ask about heart disease, high blood pressure, cancer, stroke, sickle cell disease, diabetes, arthritis, TB, mental disorders alcoholism, obesity |
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Personal and Social History Component of the Health History
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Important things about the person
-EtOH, tobacco, coffee -Diet -Sleep patterns -Exercise -Self care/ Safety/ ADLs -Home conditions -Sexual History -Occupation -Environmental Hazards -Military Record -Religious and Cultural Preferences -Access to Care |
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Review of Systems component of the Health History
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-A specific review of each body system to id the presence or absence of health issue
-Ask about common symptoms in each system -Record negative and positive findings |
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What is most important in making a diagnosis?
Lab tests? Physical? History? |
HISTORY (next physical)
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Using the senses for obtaining ct. data
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Vision-the overall appearance, signs of distress or discomfort, facial and body gestures, skin color/lesions, abnormalities of movement, nonverbal demeanor (signs of anxiety, anger), religious or cultural artifacts
Smell-body or breath odors Hearing-lung and heart sounds, bowel sounds, ability to communicate, language spoken, ability to initiate conversations, ability to respond when spoken to, orientation to person place time, thought and feeling about self and health status Touch-skin temperature and moisture, muscle strength, pulse rate, rhythm, and volume, placatory lesions |
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The principal methods used to collect data
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-observing
-interview -examining |
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Observing
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gather data by using senses
involves -noticing the data -selecting, organizing, and interpreting the data |
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Phases of an Interview
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An interview involves a planned communication or a conversation with a purpose
1) Orientation Phase- most important part of the interview, includes an introduction. establishes rapport, includes explanation of purpose of interview The body- The Termination-nurse terminates when info is obtained but its possible for ct to terminate or other reasons for fatigue termination should ask if there any more questions, "well" statement, thanking the ct., express concern for the person's well being, plan for the next meeting, review the interview |
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directive vs. nondirective interview
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a highly structured interview that elicits specific info- it is controlled by the nurse, often time is limited and is mostly used in emergency type situations
nondirective interview- is a rapport building interview that lows the client to control the pace and subject matter |
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Culturally Responsive Care and Personal Space
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-varies by culture
-men of all cultures generally require more space than women do -anxiety increases the need for space ...so does direct eye contact -physical contact is only used as therapeutic-it can easily be misinterpreted, especially when of different genders |
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Planning an Interview
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Time-when the ct. is free of pn, when interruptions by family or other health providers is minimal, or when it is in their home the time should be chosen by the ct.
Place- in a well-lighted, well-ventilated room, free of distractions, and where others can not hear Seating Arrangement-when ct. is bed, nurse should sit at a 45 degree angle to the bed. don't want to create a formal setting (i.e. behind a desk) Distance-2 or 3 feet is usually good but varies from person to person |
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Collaborative problem
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an actual or potential complication that nurses monitor to detect a change in client status
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Wellness nursing diagnosis
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describe human responses to levels of wellness that have a readiness for enhancement
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Risk nursing diagnosis
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describes human responses to health conditions/life processes that may develop
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Actual nursing diagnosis
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describes human response to health conditions or life processes
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Components of a Nursing Diagnosis
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-diagnostic label
-related factors -etiology (explanation of cause) -definition -risk factors -support of the diagnostic statement |
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Sources of Error
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-data collection
-incorrect interpretation of data -not enough data to get a complete picture -wrong diagnostic label selected |
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Language and the Interviewing Process
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failure to communicate in a language the pt. can understand is a form of discrimination
medical terminology must be translated into common english Translators needed |
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SOAP narrative
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S-subjective
O-objective A-Assessment P-Plan |
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Getting nursing diagnosis right
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-Identify client response
-Have you identified a treatable etiology(cause) ? -note a problem caused by a tx or procedure -note the client response to equipment -don't mix up nursing problems with ct. problems- must be client focussed -stress the ct.'s problem rather than the goal -make a professional judgment -avoid legally inadvisable statements -id the problem and the etiology -id one one problem per nursing diagnosis statement |
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Planning
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-determine client centered outcomes
-NOC= nursing outcomes classification includes establishing priorities and selecting nursing interventions that match the outcomes you want NIC= nursing intervention classifications Rank priorities |
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Maslow's Hierarchy of Needs
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-Physiological needs (survival)
-Safety and security needs -Love and belonging needs -Self esteem needs -Self-actualization needs |
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Validating Assessment Data
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-Ensure assessment info is complete
-Be sure your data consists of cues not inferences -Double check data that is extremely abnormal -Determine the presence of factors may interfere with accuracy of the measurement (i.e. crying baby will have increased respirations) -Use references to explain phenomena |
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Setting Outcomes (goals)
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-must be time limited (by the end of shift? day? md followup?)
-clear statement of time frame -must be measurable, professive steps toward a larger, longer term goal -link outcome to nursing diagnosis -must be ct. centered -address only 1 behavior per response -shared by both ct. and nurse -must be realistic/acheivable |
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Nursing Intervention Classification (NIC)
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something a nurse can do without an order or can have a standing order
-nurse initiated -physician prescirved -collaborative (ie. a dressing change) don't have to write md prescribed things in nursing plan because they may change |
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Intervention Statements
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SMENE
State/Teach Match Evaluate Negotiate Evaluate |
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Implementation
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-Get organized
wth equipment, personnel, environment, ct., anticipate complications, id when you need assistance, know your competencies and others |
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Direct Nursing Interventions
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basic care
safety activities procedures medication administration intervening in complications counseling and teaching prevention |
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Indirect Nursing Interventions
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Communicate with team, charting, followup with appropriate depts, consult with md
Delegating, supervising, evaluating others |
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Evaluation
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Identify evaluate criteria and standards
Collect data to see if standards are met Interpret and Summarize interpretations Document findings Conclude, continue or revise plan. Can have partially met goals ie will be continued at convalescent/home care |
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PIE note includes
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problem
intervention evaluation |
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Evaluate Outcome Success
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Health is defined by the pt.
Examine the goal statement Asses the ct. Compare outcome to ct. response Judge the degree to which is was met. If not fully met, what needs to conintue Id reasons for not achieving outcomes Are you moving in the rt. direction? |
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Revising the Plan of Care
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DC
Continue Modify by reasses, nursing dx, outcomes, interventions utilization review- does the pt. need to be in the hospital |
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Nonverbal Communication
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Nonverbal (rapport, eye contact, movement, body position, touch, physiologic parameters including flushing, sweating, etc.)
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Enhancing pt. response
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USE open ended questions
DON'T USE: closed questions, yes/no questions, leading questions, multiple questions |
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How to facilitate good communication
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-Non questioning comments/remarks
-"I see" "Go on" "Tell me more" "Ummm" -Reflection -Body language (nods, eye contact, leaning forward) -Silence -Refocus if pt is rambling -Summarize- allows you to check accuracy of understanding, clarifies the pt's perspective |
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Common Traps in Interviewing
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-giving advice
-accepting ambiguous answers -failure to get the overall picture first -premature focusing on details -providing false reassurance -using authority (should use collaborative approach) -too much jargon -leading or biased questions -interrupting or talking too much -"why" questions are bad -encourage pt's to write questions down |
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Types of Health Histories
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Complete: most comprehensive, usually done the first time you see a pt.
Focused History: done for an acute problem, only components of the history and the physical exam that relate to CC Interim History: Chronicles events since last visit, usually a "Follow up" |
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etiology
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causal relationship between a problem and its associated risk factors
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diagnosis
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statement or conclusion regarding the nature of a phenomenon
a clinical judgement about an individual, family etc response to a health problem or risk of one |
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health promotion diagnosis
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this relates to the ct.'s preparedness to implement behaviors to improve their health condition
in other words, how ready is the pt to start getting healthier |
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risk nursing diagnosis
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problem does not exist but risk factors do!
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wellness diagnosis
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i.e. readiness for enhanced spiritual wellbeing
describes human responses to levels of wellness |
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What are the three components of a nursing diagnosis?
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1- the problem and definition
2-the etiology 3- the defining characteristics also a nursing diagnosis is something the nurse is licensed to treat |
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Qualifiers
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important in nursing dx
these are words that have been added to NANDA labels to give more meaning deficient impaired decreased ineffective compromised (to make vulnerable to a threat) |
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defining characteristics of a nursing diagnosis
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the cluster of signs or symptoms that fall under a particular diagnosis
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independent functions vs. dependent functions
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independent-unique to nursing
dependent-physician orders for stuff for nurses to do |
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Analyzing data involves three steps
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1- compare data against standards
2-cluster the clues (generate tentative hypotheses) 3-identify gaps and inconsistencies |
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syndrome diagnosis
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a dx that is associated with a cluster of other diagnoses
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Variations of the nursing dx
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-Can have unknown etiology
-can use the phrase "complex factors" when there are a lot of etiologies -Can use the word possible with the problem, ie. possible low self esteem -the phrase "secondary to" can be used but often refers to disease process ie. secondary to diabetes |
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Potential Complication
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A collaborative problem
Example Potential Complication of Head Injury: Increased Intracranial Pressure |
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Avoiding Errors in Diagnostic Reasoning
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-Verifiy: diagnoses are only tentative until they are verified
-Build a good knowledge bases and acquire clinical experience -Have a good working knowledge of what is normal -Consult resources -Base diagnoses on patterns not isolated incidents -Critical Thinking |
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nursing intervention definition
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any treatment by a nurse that is done to enhance pt outcome
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Initial Planning
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should be initiated as soon as possible after the initial assessment
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Planning
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-prioritize problems/diagnoses
-formulate goals/desired outcomes -select nursing |
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Ongoing Planning
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used to determine
-whether the ct status changed -to set priorities for the shift -to decide which problems to focus on during the shift -coordinate nurse activities so that more than one problem can be addressed at each client contact |
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Discharge Planning
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process of anticipating and planning for needs after discharge
many pts are discharged still needing care |
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informal v formal care plan
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informal-strategy of action in the nurse's mind
formal-wrriten or computerized guide that organizes info about the ct's care |
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standardized care plan
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formal plan that specifies care for a certain group of pts ie. MI patients
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individual care plan
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made to meet the needs of a specific ct.
nurse can mix and match standard and individual- actually has to determine what pt needs need which |
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standards of care vs. standardize care plan
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standards of care- part of the agency records and usually not part of the pt's care plan. may be referred to in the care plan
Standardized care plans: -are kept with the ct's care plan, become a part of the ct's medical record -provide detailed interventions- can contain deletions or additions -typically written in nursing process format -frequently include checklists, blank lines, etc to allow them to be individualized |
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Standing order
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A written document about policies, rules, regulations, or orders regarding ct. care- gives nurses to carry out authority in certain situations
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The parts/sections of a care plan
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1-problem/nursing diagnoses
2-goals/desired outcomes 3- nursing interventions 4- evaluation |
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rationale
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evidence based principle given as the reason for selecting a particular nursing intervention
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multi-disciplinary care plan
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standardized plan that outlines the care required for ct.s with predictable, medical conditions
also called collaborative care plans, critical pathways also includes med treatments from other providers |
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Ten Guidelines for Writing Nursing Care Plans
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1-Date and Sign the Plan
2-Use category headings (such as nursing dx, evaluation, etc) 3-use standardized/approved medical abbreviations 4. Be specific 5. Refer to procedure books or other info rather than listing all the steps such as see unit procedure book for tracheostomy care 6. Tailor the plan to unique characteristics of the client, such as preferences of time 7. Ensure the plan has preventative and not just restorative measures 8. Ensure that the plan contains ongoing assessment of the ct and specifically when 9. Include collaborative activities ie nutritionist 10. Include plans for ct's discharge and home care needs-nurse begins discharge plans as soon as admitted, teaching plans too |
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The planning process
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1-setting priorities
2-establishing ct goals/outcomes 3-selecting nursing interventions/activities 4-writing individualized care plans |
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Setting priorities in the planning process
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often use Maslow's hierarchy of needs
1-Client's health values and beliefs 2-Ct's priorities 3-resources available 4-urgency of the health problem 5- medical treatment plan |
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indicator
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the specific pt state that is most sensitive to nursing interventions and for which measurement procedures can be defined
ie mobility level, the indicator would be walking |
