Section 2 Unit 3 & 6 Nursing Process

Front 1

What is critical thinking?

Back 1

1.) Disciplined, self-directed thinking which implies the perfection of thinking appropriate to a particular mode or domain of thinking.
2.)Thinking that displays master of intellectual skills and abilities.
3.)The art of thinking about your thinking while you are thinking in order to make your thinking better: more clear more accurate more defensible."

Front 2

How does a critical thinker look at a particular problem?

Back 2

They look at a particular problem and then reflect back on previous nursing or life experience as they clearly define the problem, analyze the data, and determine appropriate interventions to solve the problem.

Front 3

Define critical thinking

Back 3

(each situation depends on relevant knowledge and previous experience)

Critical thinking is an intellectually disciplined process of actively and skillfully :
conceptualizing
applying
analyzing
synthesizing
and/or:
evaluating information gathered from:
observation
experience
reflection
reasoning or
communication as a guide to belief and action.

Front 4

What do critical thinking skills assist the nurse to do?

Back 4

to look at all aspects of a situation and then arrive at a conclusion.

Front 5

Supporting critical thinking

Back 5

-Independent
-Fair minded
-Insight into egocentricity
-Courage to challenge
-Integrity
-Perseverance
-Confidence
-Curiosity

Front 6

Define critical thinking as a process:

Back 6

define a problem, select pertinent information for a solution, recognize stated and unstated assumptions, formulate and select relevant hypotheses, draw conclusions, judge the validity of inferences.

Front 7

What is the outcome of critical thinking?

Back 7

Forming a conclusion and stating a justification for that conclusion.

Front 8

What is one of the leading causes of errors in making clinical decisions or judgments?

Back 8

The collection of inaccurate or incomplete data.

Front 9

What are the steps in the nursing process?

Adam Drank Punch In England

Back 9

1.)Assessment
2.) Diagnosis (what is the problem)
3.)Planning (outcome or goal)
4.)Implementing ( to reach the goal)
5.)Evaluation

Front 10

EXAMPLE of process steps:

Back 10

You have ASSESSED an increase in weight following the Christmas holidays.
You self DIAGNOSE Alteration in nutrition: more than body requirements.
You PLAN to lose 10lbs.
You IMPLEMENT an exercise and diet regime.
After 4 weeks you EVALUATE your weight loss.

Front 11

What is a process defined as?

Back 11

the steps necessary to accomplish a goal.

Front 12

What is the goal in nursing?

Back 12

Care of the client within the health care environment.

Front 13

The nursing process is used as?

Back 13

a way of organizing nursing actions in health care delivery. It is a systematic, problem-solving approach to client care.

Front 14

What are the nurse's actions based on?

Back 14

Reasoning and scientific knowledge.

Front 15

Why is assessment such a critical phase?

Back 15

Because all of the other steps in the process depend on the accuracy and reliability of the assessment.

Front 16

Assessment is based on concepts of what?

Back 16

1.)Physiology-functions of body
2.)Pathophysiology-how normal processes are altered by disease.
3.)psychology
4.)social adjustment

Front 17

ASSESSMENT

1.)What are the different types of data collected during the assessment phase?

Back 17

1.)subjective- opinions or statements made directly from the client
2.) purely factual observations made by the nurse.

Sources of data: (primary or secondary) Client, support people, client records, health care professionals, literature.

Front 18

ASSESSMENT

2.)Identify methods of data (information) collection

Back 18

The principle methods of data collection are observing, interviewing, and examining.


review the client's chart
ask pertinent questions
nursing health history
physical assessment
primary care provider's history
lab & diagnostic tests
past surgical procedures
chronic diseases
pain
nausea

Front 19

ASSESSMENT

3.) Discuss the aspects of conducting an interview

Back 19

Directive/Nondirective combination is usually appropriate.

Determine areas of concern used open ended questions rather than a question in which the reply could be a Yes, or a No answer. Open ended questions begin with a What or a How ? "HOW have you been feeling today?" "What brought you to the hospital?" "How did you feel in that situation?" "What would you like to talk about today?"
Use neutral questions rather than leading questions.

"Why do you think you had the operation"" rather than, "Your stressed about surgery tomorrow, aren't you?'

Talk when the client is physically comfortable and free of pain. Sit a t 45degree angle from the bed rather than behind a table or standing at the foot of the bed.

Front 20

ASSESSING by Kelly

Back 20

1.)Complete Assessment
2.)Analyze information
3.)Cluster data to help with problem identification
4.)Always incorporate critical thinking.

**Cluster abnormal findings from assessment and look it up in Nurse's pocket guide.

Front 21

What are two major potential health problems in the hospital?

Back 21

The risk for injury and infection.

Front 22

What is a nursing diagnosis?

Back 22

The statement of a client problem derived from the systematic collection of data and its analysis.

.."a clinical judgment about individual, family, or community responses to actual or potential health problems"

IT IS NOT A MEDICAL DIAGNOSIS

Front 23

What are the three parts to a nursing diagnosis?

Back 23

1.)Statement regarding the problem. ex.) think of the previous weight gain example. (Alteration in nutrition, more than body requirements.")
2.)Related factors or etiology (what is causing the problem to occur?)
3.)Defining characteristics or manifestations. (How do we know that problem existed to begin with?)

Front 24

Can "at risk" be in the nursing diagnosis?

Back 24

Yes, risk for injury or risk for infection alert the nurse that there is a potential problem and w/out interventions the patient might suffer harm."

Front 25

define etiology? (related to)

Back 25

what is causing this problem to occur.

Front 26

AEB (as evidenced by)

Back 26

as manifesited by

Front 27

An example of nursing diagnosis is Deficient knowledge, ineffective coping, imbalanced nutrition, all of these are considered to be human responses to the medical diagnosis what?

Back 27

Diabetes mellitus

Front 28

List the 5 types of nursing diagnosis:

Back 28

actual, risk, wellness, possible, and syndrome

Front 29

Describe an actual diagnosis:

Back 29

A client problem that is present at the time of the nursing assessment.
Ex.) Ineffective Breathing Pattern and Anxiety. An actual nursing diagnosis is based on the presence of associated signs and symptoms.

Front 30

Describe a risk diagnosis:

Back 30

a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurse's intervene. Ex.) All people entering a hospital have some possibility of acquiring an infection; however a client with diabetes or a compromised immune system is at higher risk than others. Therefore, the nurse would label "Risk for infection" to the client's health status.

Front 31

Describe a Wellness Diagnosis:

Back 31

"Describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement" (NANDA International) Ex.) Readiness for Enhanced Spiritual Well-being or Readiness for enhanced Family Processes.

Front 32

Describe a Possible Nursing Diagnosis:

Back 32

one in which evidence about a health problem is incomplete or unclear. A possible diagnosis requires more data to either support or refute it. Ex._ An elderly woman who lives alone is admitted to the hospital. The nurse notices that she has no visitors and is pleased with attention and conversation from the nursing staff. Until more data is collected the nurse may write a diagnosis of Possible Social Isolation related to unknown etiology.

Front 33

Describe syndrome complex:

Back 33

A diagnosis that is associated with a cluster of other diagnosis. Currently six syndrome diagnoses are on the NANDA International list. Risk for Disuse Syndrome, for example, may be experienced by long -term bedridden clients. Clusters of diagnoses associated with this syndrome include Impaired Physical Mobility, Risk for Impaired Tisse Integrity, Risk for activity Intolerance, Risk for Constipation, Risk for Infection, Risk for Injury, Risk for powerlessness, Impaired gas exchanges, and so on.

Front 34

We have assessed our patient (assessment) and we have identified our nursing problem (diagnosis) now what do we need to do?

Back 34

Establish goals (What we hope to achieve by our nursing actions)

Front 35

What is NANDA?

Back 35

North American Nursing Diagnostic Terminology

purpose: to define, refine, and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses. Taxonomy is a set of categories.

Front 36

Planning begins with the first client contact and continues until when?

Back 36

Until the nurse/client relationship ends, usually at discharge.

Front 37

Essentially, what takes place when we are planning or setting goals?

Back 37

Prioritize problems/diagnoses
Formulate goals or desired outcomes
Select nursing interventions
Write nursing interventions

Front 38

Planning/Goals

What is a nursing care plan?

Back 38

A care plan is a written or computerized document that indicates the priorities and nursing indications for a patient.

Front 39

PLANNING

What is the differences between informal, formal, standardized, an individualized care plans?

Back 39

Informal-in the nurse's mind.
Formal nursing plan- written or computerized guide that organizes information about the clients care.
standardized-formal plan for groups of clients with same needs.
individualized- tailored to meet the unique needs of a specific client.

Front 40

PLANNING
Priorities-Group illnesses by high, medium, or low priority.

Back 40

High priority: Life -threatening problems, such as loss of respiratory or cardiac function.
Medium priority: acute illness and decreased coping ability (could result in delayed development or cause destructive physical or emotional changes.
Low Priority: arises from normal developmental needs or that requires only minimal nursing support.

Front 41

What aid's nurse's when setting priorities?

Back 41

MASLOW'S HIERARCHY

Front 42

In Maslow's hierarchy of needs what needs come first?

Back 42

Physiological: air, food, water, sex, etc.

These needs are basic to life and receive higher priority than the need for security or activity.

Front 43

Is it necessary to resolve all high priority diagnoses before addressing others?

Back 43

No, it is not necessary. The nurse may partially address a high-priority diagnosis and then deal with the real diagnosis.

Front 44

Which needs are met first and which are second?

Back 44

Physiological, then safety.

Front 45

What are the guidelines for writing goals/desired outcomes?

Back 45

1.)Date and sign the plan
2.)Use category headings "Nursing Diagnoses," Goals/Desired outcomes." "Nursing Interventions," and "Evaluation." Include a date for the evaluation of each goal.
3.)Use standardized/approved medical or English symbols and key words rather than complete sentences to communicate your ideas unless agency policy dictates otherwise.
4.)Be specific use specific times rather than ex.) change dressing q shift.
5.)Refer to procedure books rather than including all of the steps on a care plan. Ex.) "See unit procedure book for tracheostomy care."
6.)Tailor the plan to the unique characteristics of the client by ensuring that the client's choices, such as times of care and method of use, are included.
7.)Ensure that the nursing plan incorporates preventative and health maintenance aspects as well as restorative ones.
8.) Ensure that the plan contains interventions for ongoing assessment of the client. ex.)Inspect incision q8h.
9.)Include collaborative and coordination activities in the pl

Front 46

How to plan individualized care:

Back 46

Using data acquired during assessment phase, the nurse can individualize the care given in the implementing phase, tailoring the interventions to fit a specific client rather than applying them routinely to categories (ex. all clients with pneumonia

Front 47

Describe the process of choosing nursing interventions:

Back 47

NANDA has a standardized language to describe the interventions that we are to perform. (NIC) Nursing Interventions Classification

level 3 in the (NIC) is interventions. All NIC interventions have been linked to NANDA nursing diagnosic labels. The nurse can look up a client's nursing diagnosis to see which nursing interventions are suggested. There are several to choose from, so the nurse selects based on her judgment and knowledge of the client.

Front 48

What is critical when implementing?

Back 48

-Provide safe care that is based off scientific principle
-Question when necessary
-adapt as needed to your patient.

Front 49

EVALUATION:

Back 49

Did it work?
If you state your patients goal is to have a pain level of 2 and your intervention is to administer pain medication as prescribed by the health care provider...........
-You would evaluate the patients pain after administration

Front 50

EVALUATION is a planned, ongoing, purposeful activity in which clients and health care professionals determine, what?

Back 50

a.)The clients progress toward achievement of goals/outcomes
b.)the effectiveness of the nursing care plan

Front 51

DOCUMENTATION
What are the different types?

Back 51

charting
documenting
recording
report

*Most documentation occurs in the patient chart

Front 52

What are the legal and ethical considerations?

Back 52

-Confidentiality
-Restricted access
-Institution owned
-Computer considerations
-HIPPA

Front 53

What are the types of documentations?

Back 53

SOAP
S- subjective
O- objective
A- assessment/progress
P- plan

PIE
P- problems
I- interventions
E- evaluations

Front 54

Guidelines for effective written recordings that meet legal and ethical standards.........

Back 54

1.)Use FACTS. If you chart "physician notified," include time called, facts you gave and his or her response.
2.)Do not use pat phrases. Be specific and use individual assessment parameters. Do not chart global assessment such as "IV running."
3.)Be professional when you chart. Do not make interpretations; state what happened, for instance, "suggested to physician that client requires heart monitor and physician responded "case does not warrant a monitor." If this client were later to be involved in a lawsuit, these notes indicate that the nurse was observant, alert, and aware that the client might be in danger.
4.)Do not use words such as mistake or accident; write specifically what occurred and what actions were taken.
5.)Do not use tentative or vague statements such as appears or apparently.
6.)Use correct language and medical terms. Do not use slang, pat phrases, or abbreviations that are not generally accepted.
7.)Use correct grammar and spelling.
8.)Do not chart for someone else.
9.)Do not chart a

Front 55

Rules for Documenting client care data.

Back 55

1.)Document from first hand knowledge-if you chart for other caregivers, you may have errors or inaccurate data. The exception is when you are charting for nonprofessional personnel.
2.)Document clearly and legibly in black or blue ink, not felt pen or pencil.
3.)Give clear, concise and unambiguous information. Go back to the client to clarify or validate if info. is incomplete. Avoid vague expressions or cliches in charting, i.e., slept well.
4.)Select neutral terms or describe observed behaviors, rather than value judgments or generalizations. For example, rather than "client was drunk," use "noted alcohol odor on breath and speech was slurred."
5.)Correct errors by drawing a single line through the error, write the words mistaken entry (ME) above it, and then initial the error. The error must be readable. Ink eradication, erasures, or use of occlusive materials is not acceptable. The word error is no longer advised because juries tend to associate the word error with an actual nursing care mistake

Front 56

A new form of narrative charting,

(AIR)

Back 56

A.) Assessment
I) Interventions
R.) Response

Front 57

Identify the characteristics of a helping relationship

CARING

Back 57

Nursing theories propose ideals of caring:
-Nursing is congruent with caring
-Caring is the act of giving and receiving.
-Nurses continually grow in their ability to care.
-Caring can be specific to occupation and culture
-Caring is the preservation of "human dignity." (Watson,1999)
-Caring is attending to clients needs.

Front 58

How do we care?

Back 58

-Entering into a mutual relationship
-Know the client
-Nursing presence
-Empowering the client
-Compassion/Empathy
-Competence

Front 59

How do we maintain a caring practice?

Back 59

By caring for yourself and self reflection.

Front 60

Describe a caring and therapeutic relationship.

Back 60

1.)A relationship that benefits the patient
2.)Is purposeful and goal directed
3.)Is nonjudgmental

Front 61

What are some ways to communicate in a therapeutic and caring way?

Back 61

Use active listening (focused on the speaker)
Humor (breaks the ice)
Flexibility (takes things in stride
Trust (do what you say you are going to do)

Front 62

[Edit]
[Delete]


Identify the characteristics of a helping relationship

Therapeutic communication (major techniques)

Back 62

Acknowledgment "I hear what you're saying," acknowledges a statement without agreeing with it. "Yes, go on." "Uh huh."
Clarification- ex. "Are you saying...(repeat message.)
Feedback "You changed the bag on your colostomy very well." "When you say that, it makes me feel uncomfortable," (If client is unkind to nurse.)
Focus- "You were telling me how hard it is to talk to your doctor." "You said the Doppler test is frightening."
Incomplete sentences- Encouraging the client to continue.."Then your life is...."
Listening-Consciously receiving the clients message, listening eager, actively, seriously.
Minimal verbal activity. Keeping your own verbalization minimal and letting the client lead the conversation.
Mutual fit or Congruence- Creating harmony of verbal and nonverbal messages. A client is crying and the nurse says, "I'll sit with you a while." and puts his/her hand on the client's shoulder.

Or the client says that he or she feels fine,"You say you feel fine, but you look like you are in pain."
Nonve

Front 63

Non therapeutic or blocks to communication

Back 63

Changing the subject
False reassurance
Giving advice...If I were you..you should.....
In congruence..."I'd like to talk to you, but I am just too busy. Said while nurse is turning away from the client.
Assumptions: The nurse finds the suicidal patient smiling and tells the staff he's in a cheerful mood and much better.
Invalidation Ignoring or denying another person's presence, thoughts, or feelings. Client,"Hi how are you" Nurse,"I can't talk right now, I'm on my way to lunch."
Overloading Talking rapidly, changing subjects, and giving more information than can be absorbed at one time.
Social response- responding in a way that focuses attention on the nurse instead of the client.
Underloading-Remaining silent and unresponsive, not picking up cues and failing to give feedback. Ex. Nurse asking,"I hope your pain is better" as he or she smiles and walks away.
Value judgments- giving one's own opinion, moralizing, or implying one's own values by using words such as nice, good, bad, right, wrong, should, and o

Front 64

What is important with regard to caring and HIPPA? What is considered "personal information?"

Back 64

While we are caring we must still respect the patient's privacy?

Personal information: symptoms, diagnoses, treatments. May only be released with consent of the client.

Front 65

What are the guidelines for communicating with a patient?

Back 65

We are entering into a mutual relationship that is patient centered.
Know the client/holistic approach.
Use good body language
Be aware of the patients total needs, not just physical.

Front 66

Why is communication so important? (JCHO)

Back 66

SAFETY GOAL #2

Improve effectiveness of caregiver communication
-read back
-approved abbreviations
-critical test results-"hands off"
-SBAR (situation, background, assessment, recommencations!

Front 67

The nurse as a delegator:

Back 67

Delegator retains responsibility
Must know what can and can not be delegated
Dictated by state Nurse Practice Acts
NCSBN developed the five rights of delegation:
Right person
Right task
Right circumstance
Right supervision
Right evaluation

Front 68

SBAR

Back 68

Situation:
Primary problem
Background:
Client background
Assessment:
Assessment findings to support “situation”
Recommendations:
Continuity of care

Front 69

What are some other factors that effect communication?

Back 69

Positioning of client or nurse
Comfort zone
Environment
Trust
Language and culture
Age and gender
Illness
Education
Visual and hearing acuity

Front 70

What are the 3 phases in a nurse-client relationship?

Back 70

Initiation/Orientation phase- Identify problems. expectations, and relevant issues (cultural and spiritual) that need to be addressed. Identify impairments: hearing, speaking, development, or psychological.
Continuation or Active working Phase- Develop a working relationship, while meeting the client's needs. Begin with resolving the problems.
Termination phase: Upon discharge, follow the plan you began with the client when he was admitted. Anticipate problems the client will face when he goes home. Complete discharge and teaching.

Front 71

Your patient states, “I can’t even eat a little of this lunch.” Which statement demonstrates the therapeutic communication technique of reflection:
“Why don’t we talk about you lack of appetite?”
“What could you eat?”
“How long have you been unable to eat?”
“You seemed surprised about you lack of appetite?”

Back 71

Only answer D demonstrates reflective thinking. The other answers are attempted to gain further information re: the lack of appetite

Front 72

Teaching encompasses a large role for nursing

What are some things that nurses are responsible for teaching?
What are they not responsible for teaching?

Back 72

Fill in!!