Foundations Exam 2

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critical thinking

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-an intentional higher level reasoning process, intellectually delineated by one's worldview, knowledge, experience w/ skills, attitudes, standards as a guide for rational judgement/ action (fundamentals bk, p 163)

-in nursing practice: a discipline-specific, reflective reasoning process that guides a nurse in generating, implementing, and evaluating approaches for dealing with client care/ professional concerns (fund. bk. p 163)

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critical thinking cont.

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-an active, organized, cognitive process used to carefully examine one's thinking and the thinking of others (ppt lecture)

-recognizing an issue exists, analyzing information, evaluating information, and making conclusions (ppt lecture)

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10 habits of the mind (fund. bk p 163)

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1. confidence = assurance in one's own self
2. contextual perspective= considerate of whole situation
3. creativity= new/ better solutions for HC outcomes
4. flexibility= capacity to adapt
5. inquisitiveness= eagerness to know/ understand
6. intellectual integrity= seeking truth
7. intuition= insightful sense of knowing w/out reason
8. open-mindedness= viewpoint- receptive to divergent views/ sensitive to biases
9. perseverance= pursuit of a path w/ determination to overcome obstacles
10. reflection= contemplation for purposes of deeper understanding/ self-evaluation

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7 critical thinking skills (fund. bk. p 163)

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1. analyzing= seperating a whole into parts to discover their nature, fxn, relatnshps
2. applying standards= judging accdg to standards/ rules
3. discriminating= categorizing/ ranking based on recognition of similarities/ diffs
4. information seeking= searching for evidence, facts, knowledge
5. logical reasoning= inferences/ conclusions supported by evidence
6. predicting= envisioning a plan & consequences
7. transforming knowledge= changing/ converting the condition, nature, form, or fxn of concepts among contexts

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Kataoka-Yahiro and Saylor Critical Thinking Model

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1. basic critical thinking= student thinks concretely, set of rules/ principles; follows step-by-step w/out deviation from plan
2. complex critical thinking= student analyzes/ examines choices independently; learn to think beyond & synthesize knowledge
3. commitment=

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creativity (fund. bk. p 164)

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-thinking that results in the development of new ideas/ products

-ability to develop/ implement new/better solutions for healt care outcomes

-assess problem and be knowledgeable re. facts/ underlying principles that apply

-nurses able to: generate many ideas rapidly, be flexible yet natural, create original solutions to problems, be independent/ self-confident even under pressure, demonstrate individuality

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behaviors demonstrating CT characteristics/ attitudes (p 165)

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-self-aware -genuine -self-disciplined -healthy
-careful/ prudent -confident/ resilient
-honest/ upright -curious/ inquisitive
-alert to context -analytical/ insightful
-logical/ intuitive -open/ fair-minded
-sensitive to diversity -creative -realistic/ practical
-reflective/ self-corrective -proactive -courageous
-patient/ persistent -flexible -empathetic
-improvement-oriented

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techniques in CT: critical analysis

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-set of questions = set of criteria for judging an idea
-determine essential info vs superfluous info
-not all criteria/ questions applied to every situation
-SOCRATIC QUESTIONING: tech. use to look beneath the surface, recognize/examine assumptions, search for inconsistencies, examine mult. points of view, differentiate btwn knowledge/ beliefs (box 10-4)

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techniques for CT: inductive reasoning

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-generalizations are formed from a set of facts or observations
-certain bits of info, when viewed together, suggest a particular interpretation
-moves from specific to general
-ex: after touching several hot flames----conclude all flames are hot
-ex: nurse observes client w/ dry skin, poor turgor, sunken eyes, dark urine determined to be dehydrated-----conclude that presence of those signs indicate other pts. are dehydrated

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techniques for CT: deductive reasoning

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-moves from general premise to specific conclusion
-ex: general premise that the sum of angles of all triangles is 180----conclude my specific triangle sum of all angles must be 180
-ex: general premise that children love PB sands.----offer my specific child pt. a PB sand.

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types of statements: Facts (table 10-1, p 166)

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-can be verified through investigation

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types of statements: inferences

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-conclusions drawn from the facts, going beyond facts to make a statement about something not currently known

-ex: if blood volume is decreased, the blood pressure will drop

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types of statements: judgements

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-evaluation of facts or information that reflect values or other criteria; a type of opinion

-ex: it is harmful to the client's health if the BP drops too low

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types of statements: opinions

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-beliefs formed over time; include judgements that may fit facts or be in error

-ex: nursing intervention can assist in maintaining the client's BP w/in normal limits

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attitudes that foster CT: independence, fair-mindedness, insight into egocentricity, intellectual humility

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-based on the assumption that a rational person is motivated to develop, learn, grow, and be concerned w/ what to do or believe (fund. bk. p 166)
-a critical thinker works to develop the following attitudes/ traits

1. independence= think for yourself; open-minded, not rigid about prior beliefs/ techniques; not easily swayed by opinions of others; take responsibility for own views

2. fair-mindedness= assessing all vwpts w/ same standards, not basing judgements on personal bias or prejudice
-helps one to consider opposing pts. of vw
-try to understand new ideas fully b4 rejecting/ accepting them
-open to possibility that new evidence could change mind

3. insight into egocentricity= possibility that personal biases/ social pressures/ customs could unduly affect thinking
-actively examine own biases/ bring to awareness each time think/ make decision

4. intellectual humility= having an awareness of the limits of one's own knowledge
-willing to admit what do not know
-willing to seek new knowledge, rethink conclusions in light of new knowledge

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attitudes that foster CT continued: intellectual courage, integrity, perseverance, confidence, curiosity

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5. intellectual courage to challenge status quo/ rituals
6. integrity= apply same rigorous standards of proof to own knowledge/ beliefs as applied to others
-readily able to admit/ evaluate inconsistencies w/in their own beliefs
7. perseverance= CT is lifelong endeavor- finding effective solutions to client/ nursing probs.
-resist temptation to find quick/ easy answer
-continue to address issue until resolved
8. confidence= cultivate attitude of confidence in the reasoning process/ examine emotion-laden arguments using standards for evaluating thought: is that argument fair? is it based on sufficient evidence?
9. curiosity= values tradition but not afraid to examine traditions to validate

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Universal Intellectual Standards (table 10-2)

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-clarity: what is an example of this?
-accuracy: how can I find out if that is true?
-precision: can I be more specific?
-relevance: how does that help w/ the issue?
-depth: what makes this a difficult problem?
-breadth: do I need to consider another pt. of vw?
-logic: does that follow from the evidence?
-significance: which of these facts most important?
-fairness: am I considering the thinking of others?

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the nursing process (p 168)

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systematic, rational method of planning/ providing individualized nursing care:
assessing
diagnosing
planning
implementing
evaluating

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problem solving

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-the nurse obtains information that clarifies the nature of the problem and suggests possible solutions
-then carefully evaluates possible solutions/ chooses best one to implement
-situation is carefulle monitored over time to ensure initial/ continued effectiveness
-problem solving in one situation contributes to nurse's body of knowledge for problem solving in similar situations
-commonly used approaches: trial/ error, intuition, research process

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decision making

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-choosing best action to meet desired goal
-several mutually exclusive choices are available or there is an option to act or not act
-used in situations when problem-solving not used
-decisions regarding: value, confidentiality, time mgmt, scheduling, priority, delegating
-also assist client to make decisions: provide info/ resources for the client
-ex. Table 10-3, p 169

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concept mapping (fund. bk. p 172)

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-technique that uses graphic depiction of linear and nonlinear relationships to represent critical thinking
-aka mind mapping
-must be evaluated for both understanding and misconception because influenced by maker's prior knowledge
1. hierarchal- descending order of importance
2. spider- interrelatedness of concept/ attributes
3. flowchart- sequence or cause-and-effect
4. systems- inputs/ outputs

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the nursing process (fund. bk. p 178)

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-a systematic, rational method of planning & providing individualized nursing care
-its purpose is to id client's health status, id actual/ potential HC probs/ needs, establish plans to meet id'd needs, and deliver specific nursing interventions to meet those needs
-phases are not seperate entities but overlapping, continuing subprocesses; each phase affects the others

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assessing
=systematic and continuous
=focus on client's response to a health prob.
=should include client's percvd needs, health probs, related experiences, health practices, values, lifestyle

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-collect data
-organize data
-validate data
-document data

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diagnosing
=interpret assmt data
=identify strengths/ probs

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-analyze data
-identify health problems, risks, and strengths
-formulate diagnostic statements

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planning

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-prioritize problems/ diagnoses
-formluate goals/ desired outcomes
-select nursing interventions
-write nursing interventions

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implementing

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-reassess the client
-determine nurse's need for assistance
-implement the nursing interventions
-supervise delegated care
-document nursing activities

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evaluating

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-collect date R/T outcomes
-compare data w/ outcomes
-relate nursing actions to client goals/outcomes
-draw conclusions about problem status
-continue, modify, or terminate the client's care plan

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assessing: data collection

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-process of gathering info about client's health status
-systematic and continuous---prevent omission of significant data and reflect changing health status

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subjective data (fund. bk. p 183)

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-aka covert data, symptoms
-apparent only to the person affected, can be described or verified only by that person
-ex: itching, pain, feelings of worry, sensations, feelings, values, beliefs, attitudes, perceptions

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objective data

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-aka signs, overt data
-detectable by an observer
-can be measured or tested against a standard
-can be seen, heard, felt, smelled- obtained by observation or physical exam
-ex: discoloration of skin, BP
-should validate subjective data

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types of assessment: initial assessment (table 11-3)

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-purpose- to establish a complete database for problem identification, reference, and future comparison
-timing- performed w/in specified time after admission
-ex: nursing admission physical exam

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types of assessment: problem-focused assessment

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-purpose- to determine the status of a specific problem identified in an earlier assessment
-timing- ongoing process integrated w/ nursing care
-ex: hourly assessment of I/O in ICU setting
-ex: assessment of ability to perform self-care while assisting client to bathe

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types of assessment: emergency assessment

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-purpose- to identify life-threatening problems; to identify new or overlooked problems
-timing- during any physiological or psychological crisis of the client
-ex: rapid assessment of airway, breathing status, and circulation during cardiac arrest
-ex: assessment of suicidal tendencies or potential for violence

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types of assessment: time-lapsed assessment

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-purpose- to compare the client's current status to baseline data previously obtained
-timing- several months after initial assessment
-ex: reassessment of client's functional health patterns in a home care or outpatient setting, or in a hospital, at shift change

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data collection methods: observing
(fund. bk. p 186)

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a) noticing the data
b) selecting, organizing, and interpreting the data
-distinguishing data in a meaningful manner
-observation must be organized- nothing significant missed

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data collection methods: interviewing
(fund. bk. p 186)

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-a planned communication or a conversation w/ a purpose

-ex. of purposes: get/ give info, id probs of mutual concern, evaluate change, teach, provide support, provide counseling/ therapy

-ex: nursing health history (part of nursing admission assessment)

2 types of interviewing:
1. directive interview= highly structured, elicits specific info, nurse controls interview, used frequently when time is ltd.

2. nondirective interview= aka rapport-building interview= nurse allows client to control the purpose, subject matter, pacing

-combo of directive and nondirective is usually appropriate during gathering of info

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3 stages of interviewing

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1. opening: sets the tone for interview
-establish rapport= creating goodwill and trust
-orient interviewee= explain purpose/ nature of interview, ex: what info is needed, how long it will take, what is expected of client, how info will be used, client has right not to provide data

2. body: client communicates what he/she thinks, feels, knows, and perceives in response to questions from the nurse

3. closing: nurse terminates interview when info needed has been obtained
-closing important to maintaining rapport, trust, and facilitating future interactions

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data collection methods: examining
(fund. bk. p 190)

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-physical exam= systematic method that uses observation (i.e. the senses: sight, hearing, smell, touch) to collect data R/T detecting health problems

-head-to-toe approach (aka cephalocaudal approach): begins at head, neck, thorax, abdomen, extremities, ends at toes

-body systems approach: respiratory, circulatory, nervous system, etc

-assess all body parts, compares findings bilaterally

-may focus on a specific problem area noted during nursing assessment (i.e. inability to urinate)

-may find it necessary to resolve complaint before completing the exam

-screening examination (aka review of systems)= brief review of essential functioning of various body parts/ systems; data are measured against norms or standards such as ideal height, weight, norm body temp. or BP levels

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assessing: organizing data

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-using a written or electronic format to organize assessment data systematically- referred to as the nursing health history, nursing assessment, or nursing database form

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assessing: validating data

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-info gathered during assessment phase must be complete, accurate, factual bc diagnoses/ interventions are based on this

-validation= act of verifying data to confirm it is accurate/ factual

-ensure assessment info is complete
-ensure obj/subj data agree
-obtain addl date that may have been overlooked
-differentiate btwn cues & inferences
-avoid jumping to conclusions/ focusing in wrong direction to id probs

-not all date requires validation
-as a rule- the nurse validates when there are discrepancies btwn subj/ obj data or when client's statements differ at different times

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guidelines for validating data

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-compare subj and obj data to verify the client's statements w/ your observations

-clarify any ambiguous/ vague statements

-be sure your data consists of cues, not inferences

-double-check data that are extremely abnormal

-determine presence of factors that may interfere w/ accurate measurement

-use references/ resources to explain phenomena

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cues

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-subjective or objective data that can be directly observed by the nurse

-what client says or what the nurse can see, hear, feel, smell, measure

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inferences

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-the nurse's interpretation or conclusions made based on the cues

-ex: nurse observes the cues that an incision is red, hot, swollen; the nurse infers that the incision is infected

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assessing: documenting data

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-completion of assessment phase

-documentation should include all data collected about client's health status

-recorded in factual manner, not interpreted by nurse

-record subj. data in client's own words, using quotation marks

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NANDA International

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-define, refine, and promote a taxonomy of nursing diagnostic terminology of general use for professional nurses

-includes more than 200 nursing diagnoses labels for clinical use and testing

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nursing diagnosis
=a clinical judgement about responses to actual and potential health problem/ life processes. A nursing diagnosis provides basis for choosing nursing interventions to achieve outcomes for which the nurse is accountable

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=a statement or conclusion regarding the nature of a phenomenon

-describe a continuum of health states: deviations from health, presence of risk factors, areas of enhanced personal growth

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status of nursing diagnoses

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-refers to the actuality or potentiality of the diagnosis or categorization of the diagnosis

1. actual
2. health promotion
3. risk
4. wellness

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the diagnostic process: analyzing data

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involves the following steps
1. compare data against standards/ identify significant cues

2. clustering cues/ grouping cues- are patterns present? isolated incident? or significant?
-involves making inferences
-interprets possible meaning of cues
-labels w/ tentative diagnostic hypothesis

3. identify gaps/ inconsistencies in data- final check that data are complete/ correct
-inconsistencies= conflicting data- possible sources are measurement error, expectations, unreliable reports

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the diagnostic process: identifying health problems, risks, and strengths

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-nurse/ client together id strengths/ probs
-decision-making process
-determine if problem is nursing or medical diagnosis or collaborative
-establish client's strengths, resources, ability to cope

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the diagnostic process: diagnostic statements

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-two-part = NANDA label + etiology

-three-part (PES)= Problem+etiology+s/s

-PES can't be used for risk diagnosis bc client doesn't have S/S

-one-part statements: wellness diagnoses and syndrome diagnosis

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planning: nursing care plan

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organized into 4 sections:
1. problem/ nursing diagnosis
2. goals/ desired outcomes
3. nursing interventions (delegating)
4. evaluation

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collaborative care plans aka critical pathways or mutidisciplinary care plan

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-a standardized care plan that outlines the care required for clients w/ common, predicatable, medical conditions

-sequence the care given each day

-organized w/ column for each day: outlining interventions to carry out and client outcomes to achieve for that day

-do not include detailed nursing activities

-should be drawn from but don't replace standards of care and standardized care plans

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guidelines for writing nursing care plans

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1. date/ sign the plan

2. use category headings: "nursing diagnosis", "goals/ desired outcomes"

3. use standardized/ approved medical or English symbols and key words

4. be specific

5. refer to procedure bks or other resources rather than including all the steps in the written plan

6. tailor the plan to unique characteristics of client

7. incorporate preventetive/ health maintenance, not just restorative

8. include ongoing assessment of client

9. include collaborative/ coordinated activities

10. include plans for DC and home care needs

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planning: nursing care plan

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1. set priorities

2. establish client goals/ desired outcomes: description of what nurse hopes to achieve by implementation

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desired goals/ outcomes=
-derived from nursing diagnoses, primarily diagnostic label

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-for every nursing diagnosis, nurse must write desired outcomes, that when acheived, directly demonstrates resolution of problem

1. provide direction for nursing interventions

2. serve as criteria for evaluating progress

3. enable to determine when prob. is resolved

4. help motivate by providing sense of acheivement

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components of goals/ outcome statements

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1. subject, a noun= the client, any part of client, any attribute (i.e. client pulse or urinary output)

2. verb= an action the client is to perform (do, learn, experience, administer, show, walk)

3. conditions/ modifiers= explain what, when, where, or how - added to verb

4. criterion= indicates the standard by which performance is evaluated or the level at which client will perform specified behavior (time, speed, accuracy, distance, quality)(how long? how well? how far?