Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
70 Cards in this Set
- Front
- Back
|
Nursing Process (ADPIE)
|
Assessment
Diagnosis Planning Implementation Evaluation |
|
|
Critical Thinking
|
Acquired through learning and experience
Focuses on options for solving problems and making decisions -Reflection -Language -Intuition |
|
|
Reflection
|
Thinking over encounters
Internalizing work Questioning meaning and solutions |
|
|
Language
|
Connected to organized thought
Inner dialogue and critical reflection |
|
|
Intuition
|
Pattern recognition
Gut instinct (based on experiences, knowledge and reflective practice) |
|
|
Decision Making
|
Recognizing that an issue exists
Analyzing info Evaluating info Making conclusions |
|
|
Critical Thinking in Practice
|
Identifies and challenges assumptions
Imagines and explores alternatives Considers ethical principles Applies reason and logic Asks questions Becoming well-informed Acknowledges personal biases |
|
|
Critical Thinking Skills
|
Interpretation (Determining what's going on)
Analysis Inference (Reasoning through the situation) Evaluation (Pulling all the pieces together) Explanation (A goal) Self-regulation (Ensuring we are staying current in our practice) |
|
|
Levels of Critical Thinking
|
1. Basic
2. Complex 3. Commitment |
|
|
Components of Critical Thinking
|
Specific Knowledge Base
Experience Competencies Attitudes Standards of Critical Thinking |
|
|
Dispositions
|
Truth-seeking
Being open-minded Thinking analytically Being systematic Self-confidence Being inquisitive Cognitive maturity |
|
|
Competencies of Critical Thinking
|
General - Scientific Method, Problem Solving, Decision Making
Specific - Diagnostic reasoning and inference, Clinical decision making, Nursing process |
|
|
Assessment
|
Establishes a database of the client's perceived needs, health problems and responses
Uncovers experiences, health practices, goals, values and expectations Collection and verification of data & analysis of all data |
|
|
Subjective Assessment
|
Client's verbal descriptions/perceptions of condition
|
|
|
Objective Assessment
|
Observations of clinical measurements or assessments obtained by observation or clinical assessment
|
|
|
Methods of Data Collection
|
1.) Interview
2.) Health History 3.) Physical Examination 4.) Impending Factors |
|
|
Diagnosis
|
Data Analysis
Problem Identification Label the Essence of the Problem Nursing Diagnosis |
|
|
Nursing Diagnosis
|
A clinical jugement about individual, family or community responses to actual and potential health problems or life processes
Focuses on the nursing needs of the client |
|
|
Types of Nursing Diagnosis
|
Actual
Risk Wellness |
|
|
Planning
|
Priorities
Goals (need a time frame & realistic; client centred) Interventions (nursing care plan) |
|
|
Implementation
|
Nurse-initiated and physician-initiated treatments
Providing direct and indirect nursing care interventions to clients Require multiple health care providers |
|
|
Evaluation
|
Allows nurses to determine whether nursing interventions are successful in improving a client's condition or well-being
1.) Examination of condition or situation 2.) Judgement as to whether change has occurred Positive when you meet desired outcomes, meaning interventions were effective -Data -Diagnosis -Etiologies -Plans -Interventions |
|
|
What actions can a nurse take to accurately measure sleep and pain for clients?
|
Pain: pain/face scale
Sleep: Asking them how much sleep they're getting compared to how much sleep they normally get |
|
|
Basic Critical Thinking
|
Concrete thinking: rules/steps/principles
Limited experience to individualized procedures One solution seen for complex problems Following a procedure step by step |
|
|
Complex Critical Thinking
|
Basic Critical thinking needs to have been obtained
Outweigh benefits and risks in each situation Alternative and sometimes conflicting solutions to problems exist |
|
|
Commitment
|
Accountability
Nurses choose action belief based on the alternative available Focuses on result of decision and determination of whether action was appropriate |
|
|
Diagnostic Reasoning
|
Collect patient data and then logically develop a clinical judgement
|
|
|
Clinical Decision Making
|
Facing a clinical problem or situation and choosing a course of action from several options
-Judgement -Critical and reflective thinking -Action -Application of scientific and practical knowledge |
|
|
Inference
|
Interpreting the meaning of cues
Identify meaningful clusters of information |
|
|
Interview
|
Organized conversation with a client that begins by establishing a therapeutic relationship
Aids in the investigation and discussion of the client's health care needs 1.) Orientation 2.) Working 3.) Termination |
|
|
Open-ended questions
|
Encourage clients to describe their health histories in detail
|
|
|
Closed-ended questions
|
Present a list of possible choices for the client
|
|
|
Nursing Judgement
|
Critically assess a client
Validate data Interpret the information gathered Look for diagnostic cues |
|
|
Goals
|
Providing clear direction for the selection and use of nursing interventions
Providing focus for evaluation of the effectiveness of the intervention |
|
|
Client-Centred Goal
|
Singular
Observable Measurable Time-limited Mutual Realistic |
|
|
Expected outcome
|
Objective criterion for goal achievement
|
|
|
Nursing Interventions
|
Actions
Frequency Quantity Method Specify the person to perform them |
|
|
Consultation/Collaboration
|
Increase your knowledge about a client's problem
Help you learn skills and obtain the resources needed to solve the problem |
|
|
Clinical Guidelines/ Protocols
|
Evidence-informed documents that guide decisions and interventions for specific health care problems
|
|
|
Counseling
|
Direct care method
Helps clients use problem solving to recognize and manage stress Facilitate interpersonal relationships |
|
|
Preventative Nursing Actions
|
Assessment
Promotion of the client's health potential Application of prescribed measures Health teaching Identification of risk factors for illness &/or trauma |
|
|
Evaluative Measures
|
Assessment skills or techniques to collect data for evaluation
Determine whether a pattern of change exists -Examine the outcome criteria -Assess the client's actual behavior/response -Compare the outcome criteria with the actual behavior/response -Judge the degree of agreement |
|
|
Self-Concept
|
Integrated set of conscious and unconscious attitudes and perceptions about the self
-Identity -Body image -Role performance |
|
|
Identity
|
Internal sense of individuality, wholeness, and consistency of a person over time and in various circumstances
Distinguishes us from others Influenced by age, gender, social class, ethnicity, and culture |
|
|
Body Image
|
Mental picture of a person's own body and is not necessarily consistent with a person's actual body structure or appearance
|
|
|
Stressors on Body Image
|
Changes in physical appearance
Structure Functioning caused by normal development change or illness |
|
|
Self-esteem
|
Emotional appraisal of self-concept and reflects the overall sense of being capable, worthwhile, and competent
|
|
|
Stressors on Self-esteem
|
Developmental and relationship changes
Illness Surgery Accidents Responses of other individuals to changes resulting from these events |
|
|
Role Stressors
|
Originate in unclear or conflicting role expectations and may be aggravated by illness
|
|
|
Nursing interventions for self-concept disturbance
|
Increasing the client's self-awareness
Encouraging self-exploration Aiding in self-evaluation Helping formulate goals for adaptation Assisting the client in achieving those goals |
|
|
When does developing self through modeling, imitation and socialization happen?
|
Ages 1-3
|
|
|
Reinforcement-Extinction
|
Certain behaviors become common or are avoided, depending on whether they are approved and reinforced or are discouraged and punished
|
|
|
Identification
|
When an individual internalizes the beliefs, behavior, and values of role models into a person, unique expression of self
|
|
|
Identity confusion
|
Not maintaining a clear, consistent, and continuous consciousness of personal identity
|
|
|
Stages of Development
|
[Birth-1] Trust
[1-3] Autonomy [3-6] Initiative [6-12] Industry [12-20] Identity [20-40] Intimacy [40-60] Generativity [60-older] Ego Integrity |
|
|
Gate-Control theory of pain
|
Suggests that pain impulses pass through a “gate” when it’s open and impulses are blocked when it’s closed
Gating mechanisms along the CNS |
|
|
Assessments of Pain
|
COLDERRA
-characteristics -onset -location -duration -exacerbation -radiation -relief -association PQRST -provoking factors -quality -radiation -severity -timing Scale of 0-10 |
|
|
Types of Pain
|
Referred
Superficial Deep/Visceral Radiating |
|
|
Referred Pain
|
Felt in a part of the body separate from the source of pain
|
|
|
Superficial Pain
|
Localized and of short duration
|
|
|
Deep/Visceral Pain
|
Diffuse and may radiate in several directions
Duration varies |
|
|
Radiating Pain
|
Feels as though it travels down the body part
|
|
|
Controlling Painful Stimuli
|
Manage the patient's environment
Positioning Changing wet clothes and dressings Monitoring equipment, bandages, and hot/cold applications Preventing urinary retentions and constipation |
|
|
Pain-relief interventions for gate-controlled pain
|
Back massage
Relaxation Music Etc. |
|
|
REM sleep
|
1 stage
Vivid dreams |
|
|
NREM
|
4 stages
Sleep with little/no eye movement Less likely to report vivid dreams Slowing of heart rate Decrease in body temperature and BP Large, slow brain waves |
|
|
Functions of Sleep
|
Lowers sympathetic system and increases parasympathetic system
Increases hormone release Restorative and protective functions Maintenance of biological functions: protein synthesis and cell division for renewal of tissues Dreams: important for learning memory and adaptation |
|
|
Rest contributes to...
|
Mental relaxation
Freedom from anxiety State of mental, physical and spiritual activity |
|
|
Sleep Hygiene
|
Avoid late afternoon naps
Decrease consumption of caffeine, tobacco and alcohol Exercise regularly, but not prior to bedtime Eat regular meals, don't go to bed hungry, and decrease consumption of liquids in the evenings Maintain regular sleep/wake schedule, even on weekends Maintain the bedroom as an environment solely for sleep Ensure a sleeping environment that is comfortable and quiet |
|
|
Importance of consistency of bedtime routines
|
All individuals have their own biological clock and sleep-wake cycle; when that sleep-wake cycle is disrupted it can negatively influence the patient's overall health
|
