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124 Cards in this Set
- Front
- Back
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critical thinking |
/included reasoning both outside and inside of the clinical setting, clinical reasoning and clinical judgments are key pieces of clinical thinking in nursing |
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ANA definitions of nursing |
-provisions of a caring relationship that facilitates health and healing -attention to human experiences and responses to health and illness within the patients physical and social environments -integration and assessment of data with knowledge gained from an appreciation of the patient or group's subjective experience |
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characteristics of person-centered practice |
-all team members are considered caregivers -care is based on continuous healing relationships -care is customized and reflects patients needs and choices -patient safety is a visible priority -transparency (do not hide anything from the pt.) -all caregivers cooperate with the common goals of the patient -patient is the source of control for their own care |
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critical thinking |
includes reasoning in and out of clinical setting **recognizing that an issue exist, analyzing info, evaluating info, and making conclusions -continuous process characterized by open-mindedness, continual inquiry, combined with a willingness to look at each patient situation and determine which assumptions are true and relevant |
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clinical reasoning |
internal, within ones' self, thinking about the patient's care |
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clinical judgement |
-the result from both clinical reasoning and clinical thinking -the conclusion or enlightened opinion at which a nurse arrives following a process of observation, reflexion and analysis of observable or available information or data |
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clinical decision making in nursing practice |
-requires critical thinking -clinical decision-making skills separate professional nurses from technical and ancillary staff -patients often have problems for which no textbook answer exist -nurses seek knowledge, act quickly, and make sound clinical decisions |
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five components of critical thinking |
-knowledge base -experience -nursing process competencies -attitudes -standards |
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concepts for a critical thinker |
-truth seeking -open-mindedness -analytic approach -systematic approach -self-confidence -inqusitiveness -maturity |
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problem solving technqiues |
-trial and error -scientific -intuitive -creative thinking |
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why do bad decisions happen? |
-bias -failure to consider the situation -impatience |
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how to develop critical thinking skills |
-reflective journaling -concept mapping |
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reflective journaling |
-a tool used to clarify concepts through reflection by thinking back or recalling situations |
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concept mapping |
a visual representation of patient problems and interventions that illustrate an interrelationship |
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name the parts of the nursing process |
-assessment -diagnosis -planning -implementing -evaluation **ADPIE |
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what is the nursing process for |
**the fundamental blue print for how to care for patients -standard of practice, when followed correctly, protects nurses from legal problems related to nursing care -systematic problem-solving process that guides all nursing actions |
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when did the nursing process originate |
1955, BUT was not included in the ANA standards of practice until 1973 |
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characteristics of the nursing process |
-systematic -dynamic (always changing, fits every patient) -interpersonal (patient focused) -outcome oriented -universally applicable -continuous -accurate -relevant -client-focused |
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components of the "assessment" part of the nursing process |
-preparing for data collection -collecting data -indentifying cues and making inferences -validating data -clustering relating data and identifying patterns -reporting and recording data |
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how to collect data for the assessment portion of the nursing process |
-documents - patients record -history- relevant past and current -assessment -lab/diagnostic test |
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acceptable sources of data for the "data collection" portion of the nursing process |
-client -family, friends, caregivers -healthcare team members -records -report -scientific literature -nurse's experience |
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how to differentiate data |
-important data vs. the whole package -cues- imformation obtained through use of the senses -inferences- judgement or interpretation of cues |
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2 types of data included in nurse's assessment |
-objective -subjective |
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define objective data give examples |
objective data doesn't change, it is what the nurse observes (fact) "what the nurse can actually observe" examples- observed behaviors, signs, NURSE: seen, heard, felt, smelled |
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define subjective data give examples |
subjective data is information the patient is providing, can change **must be provided by the client examples- sensations, feelings, values, beliefs, attitudes, perception |
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methods to collect data |
-interviewing -observing -examining |
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how to organize and validate data |
organize- ASSESSMENT sheets, computerized or paper validate- back your assessment up with objective data, CHART all information |
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how does the nurse record subjective data from a patient? |
put everything the patient says in quotation marks *do NOT generalize or form judgements |
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characteristics of the "diagnosis" step in the nursing process |
-the reasoning process used in interpreting assessment data -analyze data -identify health problems, risks, strengths -determine risk factors to be managed -formulate diagnostic statements |
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list the two types of diagnoses |
-medical diagnoses -nursing diagnoses |
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define and describe medical diagnoses |
-Identification of a disease condition based on physical signs, symptoms, previous medical history, and results of diagnostic tests and procedures -physicians, PAs, NP's can write medical diagnoses, and treat those diseases |
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define and describe nursing diagnoses |
classifies health problems within the domain of nursing -clinical judgment about a patient's responses to actual and potential health problems, that the nurse is licensed and competent to treat **different from a medical diagnoses by individualizing diagnosis to each patient and involving patient in the process. |
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define collaborative problem |
-actual or potential physiological complications that the nurses monitor to detect the onset of changes -requires working with other disciplines |
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how to formulate a nursing diagnosis |
-formal statement of the clients health status, containing both the problem and the etiology -statement of nursing judgement -relates to the nurses independent functions (list of available diagnoses provided by NANDA) |
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NANDA |
north american nursing diagnosis association |
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how is a nursing diagnosis written (what order) |
-nursing diagnostic label (problem) -related factors (etiology) -defining characteristics (symptoms) |
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components of the nursing diagnosis (ND) nursing diagnostic label (problem) |
-name of diagnosis ex. impaired physical mobility -descriptors ex. impaired, compromised, decreased, deficient, imbalanced, increased |
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components of the nursing diagnosis (ND) related factors (etiology) |
-reason the patient is displaying the ND -use critical thinking to individualize the dx. and interventions -related to sleep deprivation, related to decreased mobility **always within the realm of nursing practice, NOT medical, condition that responds to nursing interventions INCORRECT ex.- impaired comfort r/t appendectomy CORRECT ex. acute pain r/t impaired skin integrity at incision site |
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components of the nursing diagnosis (ND) defining characteristics (symptoms) |
example- pain rating of 8 on a scale of 1-10, wincing when turning, guarding, blood glucose levels >500, forgetting names of family members |
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way to remember how to write a nurse diagnosis (ND) |
PES -problem (impaired dentition) -etiology (r/t poor oral hygiene) -symptoms (as evidenced by reluctance to visit the dentist, and frequent c/o mouth pain ex. impaired dentition related to poor oral hygiene as evidenced by reluctance to visit the dentist, and frequent c/o mouth pain |
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steps in the "planning" phase of the nursing process |
-establish priorities -identify expected patient outcomes -select evidence-based nursing intervention -communicate the plan of care |
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planning phase of the nursing process -prioritize the problem |
based on Maslow's Hierarchy of care 1. physiological (food, air, temperature, water, elimination, rest, pain avoidance, manipulation, exploration, sex, activity 2. safety and security- protection 3. love and belonging- closeness 4. self-esteem 5. self-actualization |
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how to write patient outcomes |
be S.M.A.R.T s-specific m-measurable a-attainable r-realistic t-time-bound |
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nursing outcomes classification (NOC) |
-standardized language used to describe patient outcomes -current list includes 490 outcomes -linked with NANDA diagnosis -short term vs. long term |
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nursing outcomes classification (NOC) measuring patient outcomes that are influenced by nursing care examples |
examples- Patient reports pain at level <2 within 72 hours post-op goal - patient will report pain level of 0 by discharge |
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select nursing interventions |
-standards of care -protocols -policies -procedures -standing order can be- independent, dependent, or collaborative |
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indirect care interventions |
treatments performed away from the patient but on behalf of the patient |
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direct care interventions |
treatments performed through interactions with the patient |
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independent nurse interventions |
-nurse initiated -does NOT require an order from another healthcare provider -governed by each state's Nurse Practice Act
example- elevating an edematous extremity, assisting a patient with mouth care, ect. |
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dependent nurse interventions |
-physician-initiated -DOES require an order from another healthcare provider example- administering ordered meds, inserting a foley catheter, administering a fluid bolus, preparing the patient for an ordered test/procedure |
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nursing interventions collaborative |
-requires combined skills of multiple health care providers -can be a combination of BOTH independent and dependent interventions *NEVER automatically implement an ordered intervention- 1st determine whether it is appropriate for the patient or not. sometimes the orders can be incorrect or not appropriate for the patient. |
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choosing nursing interventions |
-safe and appropriate -achievable -congruent with client's values, beliefs, and culture -congruent with other treatment -based on evidence based nursing knowledge -within the standards of care |
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how do you start a nursing intervention |
-start with a verb (action verb) to guide nursing care example- teach, evaluate, perform, assess, apply, encourage, measure, obtain, administer, identify, describe, avoid, remove, demonstrate, review, initiate, maintain, assist |
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the nursing process Implementing |
-do it -continue data collection modify plan of care as needed -document |
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skills needed for implementation |
-cognitive skills- critical thinking skills -interpersonal skills -technical skills |
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cognitive skills |
-applying critical thinking skills in the nursing process -know rationales for interventions; understand normal vs. abnormal physiological and psychological responses |
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interpersonal skills |
-develop a trusting relationship -express a level of caring -communicate |
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psychomotor skills |
-integration of cognitive and motor skills example- giving an IM injection -competent, consistent psychomotor skills is essential in building patient trust |
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delegating implementation |
-the nurse is responsible for determining the correct caregiver to whom care should be implemented -the nurse is responsible for all care that is delegated -the nurse must be aware of the scope of practice of all members of the health care team -know and learn the difference between CNA I and CNA II scopes of practice |
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the nursing process evaluation (what does this include) |
-measure how well the patient has acheived the desired outcomes -identify factors contributing to the patient's success or failure -modify the plan if indicated |
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evaluation goals |
-indicates resolution of a ND -more BROAD -summaries what will be accomplished when patient has met all expected outcomes example- patient remains free from new developing pressure ulcers during hospital stay |
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evaluation expected outcomes |
-end result that is measurable, desirable, observable, and translates into observable patient behaviors example- patient will describe risk factors for impaired/compromised tissue integrity |
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documenting the nursing process |
-if it wasn't documented, it wasn't done -keep accurate, timely assessment info -document all diagnoses and plans in appropriate charting area -interventions -response |
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intuitive problem solving |
direct understanding of a situation based on background of experience, knowledge, and skill that makes expert decision making possibleq |
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potential errors in decision making include |
-bias (placing excess emphasis on first data received, avoiding information contrary to one's opinion, making decisions to support past choices) -failure to consider the total situation (using inaccurate data, not identifying the problem, using unrealistic goals) -impatience (failing to identify multiple solutions, incorrectly implementing the decision, not using appropriate resources) |
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qualitative research methods |
-phenomenonology -grounded theory -ethnography -historical |
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evidence-based practice |
problem-solving approach to making clinical decisions, using the best evidence available, blends both science and art |
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parts of research |
-abstract -intro -method -results -discussion -references |
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asking clinical questions in PICO format what is PICO? |
P-patient, population, problem of interest I-intervention of interest C-comparison of interest O-outcome of interest |
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time-lapsed assessment |
an assessment that is scheduled to compare a patient’s current status to baseline data obtained earlier |
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initial assessment |
comprehensive nursing assessment resulting in baseline data that enables the nurse to make a judgment about a patient’s health status, ability to manage one’s own health care, and need for nursing, and to plan individualized, holistic health care for the patient |
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assessing is |
the systematic and continuous collection, analysis, validation, and communication of patient data, or information. |
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parts of the nursing process assessment |
-preparing for data collection -collecting data -identifying cues and making inferences -validating data -clustering related data and identifying patterns -reporting and recording data |
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when nurses make nursing assessments: |
they do NOT duplicate medical assessments. Medical assessments target data pointing to pathological conditions, whereas nursing assessments focus on the patient's response to health problems |
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focused assessment |
different than a initial assesment during a focused assessment, the nurse gathers data about a specific problem that has already been identified. helpful Q's include: -what are you signs and symptoms? -were you doing anything different than usual when the symptoms started? -what makes your symptoms better or worse? |
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when would emergency assessments need to be conducted |
-patient choking in the dining hall -patient bleeding perfuseley in the waiting area |
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things to "not" use during a patient interview |
-exploratory questions "tell me more about your sleeping patterns" -no leading questions - "you don't smoke do you?" |
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example of a cue |
"the patient does not respond when I speak to him on his left side" -this is a cue letting the nurse that something must be wrong the judgement you reach about the cue (the patient's hearing may be impaired on the left side) is an inference |
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inferences may be validated multiple ways |
-physical examining, using proper equipment and procedure -clarifying statements -sharing your inferences with other members of the team -checking your findings through research -checking consistency of cues |
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patient variables that can negatively affect an interview |
-patient anxiety -pain -language barrier -previous negative experience with a nurse -unrealistic expectations of healthcare providers |
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common problems of data collection |
-database innappropriately organized -pertinent data omitted -irrelevant or duplicate data collected -erroneous or misinterpreted data collection -failure to establish rapport -interpretation of data is recorded rather than observed behavior -failure to update database |
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how to phases of assessment set the stage for diagnosis |
assessment- collect data, identify cues and make inferences, validate data, cluster related data and prioritize (based from Maslow's), identify patterns, report and record data critical reasoning- analyzing, synthesizing, reflecting, making judgments, and drawing conclusions **after doing this, nurse is ready to diagnose ADPIE |
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a nurse obtains a nursing history by: |
interviewing the patient |
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The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant’s skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed? |
-quick priority |
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The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: “Why are you doing a history and physical exam when the doctor just did one?” Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply. |
-“The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths.” “We need to check your health status and see what kind of nursing care you may need.” “We need to see if you require a referral to a physician or other health care professional. |
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When you receive the shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What action is appropriate? |
perform and conduct a focused assessment of skin integrity |
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When a nurse enters the patient’s room to begin a nursing history, the patient’s wife is there. What should the nurse do? |
introduce self and ask the patient if he would like his wife to stay in the room **do NOT assume either way, you must ask to patient |
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gordon's functional health patterns |
begin with the patient’s perception of health and well-being and progress to data about nutritional–metabolic patterns, elimination patterns, activity, sleep/rest, self-perception, role relationship, sexuality, coping, and values/beliefs |
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The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the first thing the nurse should do? |
first validate to see if the temperature was accurate |
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4 components of the nursing process DIAGNOSIS |
-label -definition -defining characteristics -related factor |
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what is the second step of the nursing process |
diagnosis; begins after the nurse has collected and recorded patient data |
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purposes of the nurse diagnosis |
-identify how a person, group, or community responds to actual or potential health and life processes -identify factors that contribute to or cause health problems -identify resources or strengths the person, group, or community can draw on to prevent or resolve problems |
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steps leading up to creating the nurse diagnosis |
-creating a list of suspect problems or diagnosis -ruling out similar problems/diagnosis -naming actual and potential problems/diagnosis and clarifying what's causing or contributing to them -determining risk factors that must be managed -identifying resources, strengths, and areas for health promotion |
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collaborative problems |
certain physiologic complications that nurses monitor to detect onset or changes in the status -nurses manage collaborative problems using physician prescribed medications and nurse interventions to minimize the complications of the event -primary responsibility for nurses -prescription for tx comes from nursing, medicine, and other disciplines |
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5 types of nursing diagnosis |
-actual -risk -possible -wellness -syndrome |
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actual nursing diagnosis |
represents problems that have been validated by the prescence of major defining characteristics 4 components- label, definition, defining characteristics, and related factor |
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example of actual nursing diagnosis |
label- imbalanced nutrition: more than body requirements definition- intake of nutrients that exceed metabolic needs defining characteristics- concentrating food intake at the end of day, dysfunctional eating pattern, eating to internal responses rather than hunger cues related factors- excessive intake in relation to metabolic need |
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risk nursing diagnosis |
clinical judgments that a person, family, or community is more vulnerable to develop the problem than others in the same situation |
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"possible" nursing diagnosis |
statements describing a suspected problem for which additional data is needed -example for this on page 266 |
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wellness diagnoses |
clinical judgments about a person, group, or community in transition from a specific level of wellness to a higher level of wellness 2 cues must be present for a valid wellness diagnosis- typically deal with healthier pts. 1. desire for higher level of wellness 2. an effective present status or function |
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structure of a wellness diagnosis |
one part statement that contains the label "readiness for enhanced" followed by the desired higher-level wellness examples- readiness for enhanced family coping, readiness for enhanced health maintenance |
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syndrome nursing diagnosis |
compromise a cluster or actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation example- rape-trauma syndrome or post-trauma syndrome |
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the "dont's" of writing a nursing diagnosis |
-do not use the words "due to" -do not include the medical diagnosis -do not include value judgments (laziness) -having both clauses say the same thing -do not state something is a problem when it cannot be changed -writing the diagnosis in terms of needs "pt. needs assistance" |
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the nursing diagnosis is written in terms of |
a patient problem, alteration in health state, or patient strength for which nursing provides the primary therapy |
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what a nursing diagnosis is NOT |
-medical dx (diabetes) -medical pathology (hypoglycemia) -diagnostic test (fasting blood glucose) -therapeutic patient needs (needs to learn...) -therapuetic nursing goals ("to develop therapeutic diabetic self-care behaviors) -a single sign or symptom -a unvalidated nursing inference |
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nursing diagnosis should ALWAYS focus on |
-patients needs NEVER a nurses goal, ALWAYS focus on patient |
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after a nursing diagnosis has been formulated, next step is to |
validate |
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questions to validate a nursing diagnosis |
-is my patient data sufficient, accurate, and supported by nursing research -does my synthesis of data (significant cues) demonstrate the existence of a pattern -is the subjective and objective data used to determine the existence of a pattern characteristic of the health problem I identified -is it based on scientific nursing knowledge and clinical expertise? -is my nursing diagnosis able to be preventative, reduced, or resolved by independent nursing action? -is my degree of confidence over 50% that other qualified practicioners would formulate the same nursing diagnosis based on my data? |
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common errors of nursing diagnosis |
-premature diagnosis based on incomplete data -erroneous diagnosis resulting from an inaccurate database or faulty data analysis -routine diagnosis resulting from the nurse's failure to tailor data and and analyze unique needs of the patient -errors of omission |
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________ describes 5 types of nursing diagnoses: actual, risk, possible, wellness, and syndrome |
NANDA-I |
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most nursing diagnoses are written as either |
-2 part statements listing the patient's problem and its cause OR -3 part statements that also include the problem's defining characteristics |
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primary benefit of a nursing diagnosis |
-individualized patient care |
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A registered nurse is writing a diagnosis for a 28-year-old male patient who is in traction due to multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process? |
-nurse analyzes collected data -nurse points out patient's strenghths -nurse identifies community resources to help family cope *tips**- look for key words throughout answer choices, (assess, plan, collect patient data -- are all part of other nursing processes) |
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A nurse is caring for an older adult patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses for this patient? Select all that apply. |
-impaired gas exchange -ineffective airway clearance -risk for septic shock **tips** (do NOT include medical diagnoses, diagnoses need to include actual or potential health problems that can be prevented or resolved by independent nursing interventions, look out for collaborative problems- "potential complication-sepsis is collaborative |
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After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse interprets and analyzes the patient data. Which of the four basic conclusions has the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self-esteem? |
possible problem |
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A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bedrest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagnostic statement? |
-related to prescribed bed rest *etiology= cause of problem |
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A nurse is counseling a 60-year-old female patient who refuses to look at or care for a new colostomy. She tells the nurse, “I don’t care what I look like anymore, I don’t even feel like washing my hair, let alone changing this bag.” The nurse diagnoses Altered Health Maintenance. This is an example of what type of problem? |
-nursing problem |
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To determine the significance of a blood pressure reading of 148/100, it is first necessary for the nurse to: |
compare this reading to standards |
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When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label “constipation.” Which of the following comments is the nurse most likely to hear from the instructor? |
“Hold on a minute . . . Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue.” |
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A nurse makes a clinical judgment that an African American male patient in a stressful job is more vulnerable to developing hypertension than White male patients in the same or similar situation. The nurse has formulated what type of nursing diagnosis? |
risk |
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two part nursing diagnosis |
problem statement or diagnosis label-- etiology |
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A nurse is writing nursing diagnoses for patients in a psychiatrist’s office. Which nursing diagnoses are correctly written as two-part nursing diagnoses?(1) Ineffective Coping related to inability to maintain marriage(2) Defensive Coping related to loss of job and economic security(3) Altered Thought Processes related to panic state(4) Decisional Conflict related to placement of parent in a long-term care facility(1) and (2)(3) and (4)(1), (2), and (3)All of the above |
all of the above |
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3 part nursing diagnosis |
problem statement or diagnosis label -- etiology - action |
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consultation |
pro
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