Key Terms- N210 Unit 2-Ch 15-17

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Evidence-based Knowledge

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knowledge based on research or clinical expertise

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Critical Thinking

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an active, organized, cognitice process used to carefully examine one's thinking and the thinking of others

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What are the skills of critical thinking?

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Interpretation, analysis, inference, evaluation, explanation, self-regulation

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Critical Thinking Skill-Interpretation

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be orderly in data collectio. Look for patterns to categorize data, and clarify any data you are uncertain about.

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Critical Thinking Skill- Analysis

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be open-minded as you look at information about a client. Do not make careless assumptions. Do the data reveal what you believe is true or are there other options?

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Critical Thinking Skill- Inference

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Look at the meaning and significance of findings. Are there relationships between findings? Do the data about the client help you see that a problem exists?

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Critical Thinking Skill- Evaluation

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Look at all sitiations objectively. Use criteria (expected outcomes, pain characteristics, leaning objectives) to determine results of nursing actions. Reflect on your own behavior

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Critical Thinking Skill- Explanation

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Support your findings and conclusions. use knowledge and experience to choose strategies you use in the care of clients.

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Critical Thinking Skills- Self-regulation

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Reflect on your experiences. Identify the ways you can improve your own performance. What will make you feel that you had been successful?

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Critical Thinking Concepts

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Include truth seeking, open-mindedness, analyticity, systematicity, self-confidence, inquisitiveness, and maturity

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Critical Thinking Concep- Truth seeking

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seek the true meaning of a situation, be courageous and about asking questions, be honest and objective about asking questions.

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Criticla Thinking Concept- Open-mindedness

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be tolerant of different views; be sensitive to the possibility of your own prejudices; respect the right of others to have different opinions

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Critical Thinking Concept- Analyticity

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Analyze potentially problematice situations; anticipate possible results fo consequences; value resaon; use evidence-based knowledge

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Critical Thinking Concept- Systematicity

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Be organized, focused; work hard in any inquiry

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Critical Thinking Concept- Self-confidence

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trust in your own reasoning processes

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Critical Thinking Concept- Inquisitiveness

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be eager to acquire knowledge and lean explanations even when applications of knowledge are not immediately clea. value learning for learnings sake.

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Critical Thinking Concept- Maturity

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multiple solutions are acceptable. Reflect on your own judgements; have cognitive maturity

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Basic Critical Thinking

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a leaner trusts that experts have the right answer for every problem. Thinking is concrete and based on a set of rules and principles.

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Complex Critical Thinking

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thinkers analyze and examine choices more independently. thinking abilities and initiative to look beyond expert opinion being s to change. willing to consider different options aside from routine procedures.

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Commitment (3rd level of Critical thinking)

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person anticipates the need to make choices without assistance from others.

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Scientific method

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a way to solve problems using reasoning. A systematic, ordered approach to gathering data and solving problems

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Effective problem solving

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involves evaluating the solution over time to make sure it is effective.

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Diagnostic Reasoning

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a process of determining a client's health status after you assign meaning to behaviors, physical signs, and symptoms presented by the client. And provides a clear perspective of a client's health status.

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Decision Making

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a product of critical thinking that focuses on problem resolution. Must recognize and define problem; weigh options; test possible options; consider consequences, and then make final decision

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inference

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the process of drawing conclusions from related pieces of evidence. Involves forming patterns of information from data before making a diagnosis.

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Clinical decision making

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making a problem-solving activity that focuses on defining client problems and selecting appropriate treatment. Requires careful reasoning so that you choose the options for the best client outcomes on the basis of the cleints conditions and the priority of the problem

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Nursing process

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a five-step clinical decision-making approach that includes assessment, diagnosis, planning, implementation, and evaluation.

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What is the purpose of the nursing process?

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to diagnose and treat human responses to actual or potential health problems

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Model of Critical Thinking

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Outlines five components of critical thinking: knowledge base, experience, critical thinking competencies, attitudes and standards.

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Model of Critical Thinking-Knowledge base

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varies according to education, and experience. Includes information and theory from the basic sciences, humanities, behavioral sciences, and nursing.

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Model of Critical Thinking- Experience

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begin to understand clinical situations, recognize cues of clients' health patterns, and interpret cues as relevant or irrelevant.

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Model fo Critical Thinking- Attitudes

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Eleven attitudes- confidence, thinking independently, fairness, responsiblity and authority, risk taking, discipline, perseverence, creativity, curiosity, integrity, and humility

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Intellectual Standards for Critical Thinking

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a guideline or principle for rational thought. (include preciseness, accuracy, and consistency)

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Professional Standards for Critical Thinking

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refer to eithical criteria for nursing judgements, evidence-based criteria used for evaluation, and criterial for professional responsibility. Promote the highest level of quality nursing care.

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Reflection

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the process of purposefully thinking back or recalling a situation to discover its purpose or meaning.

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Concept Map

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a visual representation of client problems and interventions that shows their relationships to one another.

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Purpose of Concept mapping

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to synthesize relevant data about a client, including assessment data, nursing diagnosis, health needs, nursing interventions, and evaluation measures

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Assessment

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the deliberate and systematic collection of data to determine a client's current and past health status and functional status and to determine the cleint's present and past coping patterns

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Two Steps of nursing assessment

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Collection and verification of data from a primary source and secondary source. The analysis of all data as a basis for developing a plan of individualized care.

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Purpose of an assessment

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to establish a database about the cleints perceived needs, health problems, and responses to these problems.

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Cue

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information that you obtain through use of the senses.

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Inference

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your judgement or interpretation of cues

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Gordon's 11 functional health patterns

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A theoretical model offering a holistic framework for assessment of any health problem. Include Health perception-health management; nutritional-metabolic pattern; elimination pattern; activity-exercise pattern; sleep-rest pattern; cignitive-perceptuatl pattern; self-perception-self-concept pattern, role-relationship pattern; sexuality-reproductive pattern; coping-stress tolerance pattern; value-belief pattern

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Health perception-health management pattern

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describes the cleints self-report of health and well-being; how client manages health; knowledge of preventive health practices

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Nutritional-metabolic pattern

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describes the clients' daily/weekly patter of food and fluid intake; actual weight, weight loss or gain

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Elimination Pattern

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describes the patterns of excretory function

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activity-exercise pattern

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describes the pattersns of exercise, activity, leisure, and recreation; ability to perform activities of daily living.

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sleep-rest pattern

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describes patterns of sleep, rest, and relaxation

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cognitive-perceptual pattern

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describes sensory-perceptual patterns; language adequacy, memory, decision-making ability

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self-perception--self-concept pattern

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describes the clients self-concept pattern and perceptions of self

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Role-relationship pattern

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describes the clients patterns of role engagements and relationships

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sexuality-reproductive pattern

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describes the client's patterns of satisfaction and dissatisfaction with sexuality pattern; clients reproductive patterns; premenopausal and postmenopausal problems

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coping-stress tolerance pattern

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describes the clients ability to manage stress; sources of support; effectiveness of hte patterns in terms of stress tolerance

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value-belief pattern

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describes patterns of values, beliefs and goals that guide the client's choices

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subjective data

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client's verbal descriptions of their health problems, and only the client can provide this data (includes feelings, perceptions, and self-report of symptoms)

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objective data

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observations or measurements of a client's health status. The measurement is based on accepted standard.

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Sources of Data

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Include: client, family and significant others, healthcare team, medical records, other records and literature, and nurse experiences.

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interview

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an organized conversation with the client. Initially it will include a health history and information about current illness.

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Orientation phase of Interview

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begins with introduction, and explanation of purpose. establish trust and confidence with client.

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Working phase of interview

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gather information about client health status, and obtain health history

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Nursing health history

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includes data about the client's current level of wellness, including a review of body systems, family and health history, sociocultural history, spiritual health, and menal and emotional reactions to illness.

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Termination phase of interview

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summarize the important points and ask the client whether the summary was accurate

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Open-ended questions

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prompts client to describe a situation in more than one or two words, and will lead to discussion

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back channeling

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indicates active listening by using prompts like all right, and go on, which indicate that you have heard what the client says and are attentive to hear the full story. Encourages teh client to give more detail

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Closed ended questions

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limit the clients response to one or two words (yes or no), provide way to quickly clarify, or get more information

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Review of Systems

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a systematic method for collecting data on all body systems.

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Validation of assessment data

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comparison of data with another sources to determine the data accuracy

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Data analysis

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involves recognizing patterns or trends in teh clustered data, comparing them with standards, and then coming to a reasoned conclusion about the client's responses to a health problem.

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Data documentation

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the last part of a complete assessment. observation and recording of client status is a legal and professional responsibility. nurse practice acts in all states mandate or require accurate data collections and recording as independent functions essential to the role of the professional nurse

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Medical Diagnosis

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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. (made by physicians)

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Nursing Diagnosis

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a clinical judgment about individual, family or community responses to actual and potential health problems. Is a statement that describes teh client's acutal or potential response to a health problem that the nurse is licences and competent to treat.

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Collaborative problem

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an actual or potential physiological complication that nurses monitor to detect the onset of changes in a clients status.

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Focus of a nursing diagnosis

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a clients actual or potential response to a health problem rather than on the physiological event, complication, or disease.

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defining characteristics

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the clinical criteria or assessment findings that support an actual nursing diagnosis

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clinical criteria

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objective or subjective signs and symptoms, clusters of signes and symptoms, or risk factors that lead to a diagnostic conclusion

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Actual nursing diagnosis

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describes human responses to health conditions or life processes that exist in an individual, family or community.

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Risk nursing diagnosis

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describes human responses to health conditions/life processes that will possibly develop in a vulnerable individual, family, or community

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Health promotion nursing diagnosis

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a clinical judgment of a person's, family's, or community's motivation and desire to increase well-being, and actualize human health potential as expressed in their readiness to enhance specific health behaviors, such as nutrition and exercise (readiness of enhanced...._

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Wellness nursing diagnosis

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describes the human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement (transition from a level of wellness to a higher level of wellness)

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Components of a nursing diagnosis

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diagnostic label followed by a related to factor, definition, risk factors, support

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Diagnostic label

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the name of the nursing diagnosis as approved by NANDA-I, and it describes the essence of the client's response to health conditions in as few words as possible. usually include a descriptor to give additional meaning

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Related Factors

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a condition or etiology identified from the client's asessment data and is associated with the clients actual or potential response to the health problem and can change by using nursing interventions.

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etiology

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should be within the domain of nursing practice and a condition that responds to nursing interventions

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Risk factors

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environmental, physiological, psychological, genetic, or chemical elements that increase the vulnerability of an individual, family, or community to an unhealthful even. and are component of every risk diagnosis. (cues to indicate a risk nursing dx is applicable to condition)

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Support of the Diagnostic statement

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nursing assement data needs to support the diagnostic lable, and the related to factors needs to support the etiology.

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Errors in collection of data

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lack of knowledge or skill, inaccurate data, missing data, disorganizaion

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Errors in interpreting

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inaccurate interpretation of cues, failure to consider conflicting cues, using an insufficient number of cues, using unreliable or invalid cues, failure to consider cultural influences or developmental stage(review data to validate that measureable, objective physical finding support subjective data)

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Errors in clustering

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insufficient cluster of cues, premature or early closure, incorrect clustering (identify nursing diagnosis from data, not the reverse)

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Errors in Labeling

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Wrong diagnostic label selected, evidence exists that another diagnosis is more likely, condition is a collaborative problem, failure to validate nursing diagnosis with client, failure to seek guidance (word diagnostic statement in appropriate, concise, and precise language using correct terminology reflecting the client's response to the illness or condition)T

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Tips for reducing erros in diagnostic statement

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Identify client response, not medical dx. Identify Nanda dx statement rather than the symptoms. Identify a treatable etiology rather than a clinical sign or chronic problem. Identify the problem caused by the treatment or dx study rather than the treatment or study itself. Identify cleint response to the equipment rather than the equipment itself. Identify client problem rather than the nursing intervention. Identify the client problem rather than the goal. Make professional rather than prejudicial judgments. Avoid legally inadvisable statments. Identify problem and etiology to avoid a circular statement. Identify only one client problem in the dx statement.