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82 Cards in this Set

  • Front
  • Back

What does nursing involve

Thinking, caring, doing

Critical thinking

A combination of reasoned thinking, an openness to alternatives, an ability to reflect, and a desire to seek truth

Critical thinking attitudes

Independent thinking, intellectual curiosity, intellectual humility, intellectual empathy, intellectual courage, intellectual perseverance, fair mindedness

Critical thinking skills

Refer to the cognitive processes used in complex thinking operations such as problem solving and decision making.

Independent thinking

Critical thinkers do not believe everything they are told in don't just go along with the crowd nurses should challenge actions, practices comer and policies having little logical support.

Intellectual humility

Aware that they do not know everything and admit when they are wrong

Intellectual empathy

Try to understand feelings and perceptions of others

Fair mindedness

Try to make impartial judgments and Treats all viewpoints fairly

Model

Set of interrelated concepts that represent a particular way of thinking about something

Contextual awareness

Deciding what to observe and consider aware of what's happening in the situation

Inquiry

Applying standards of good reasoning to your thinking when analyzing the situation and evaluating your actions

Considering alternatives

Exploring and imagining as many alternatives as you can think of for the situation

Analyzing assumptions

Recognizing and analyzing assumptions you are making about the situation and examined the beliefs that underlie your choices

Reflecting skeptically in deciding what to do

Questioning analyzing and reflecting on the rationale for your decisions

Steps of the nursing process

Assessment, diagnosis, planning, implementation, evaluation

Theoretical knowledge

Knowing why consists of information facts principles in evidence base theories

Practical knowledge

Knowing what to do and how to do it consists of processes and procedures and is an aspect of nursing expertise

Self knowledge

Self understanding you are aware of your beliefs, values, and cultural and religious biases

Ethical knowledge

Knowledge of obligation or right or wrong

Nursing process

Systematic problem solving process that guides all nursing actions

Caring

Involves personal concern for people, events, projects, and things. Helps the nurse notice which interventions are effective

Full spectrum nursing

Our unique blend of thinking doing caring and the patient situation

Assessment

The systematic gathering of information related to the physiological psychological sociocultural developmental and spiritual status of an individual Kama group, or community

Subjective Data

What the patient says Also called covert data or symptoms data

Objective data

What professionals observe Also Called overt data Or signs data

Primary data

Obtained directly from the client in what the client says or you

Secondary data

Data obtained 2nd hand from medical record or care giver

Observation

To gather and interpret patient and environmental data

Crop acronym

Client look for obvious signs of distress such as pain or crying


Room scan for safety hazards, look at machines in lines


Observe examine the client thoroughly


People who are the people in the Room and what are they doing

Interviewing

Purpose full comment structured communication in which you question the patient in order to gather subjective data for nursing

Initial assessment

Completed when the client 1st comes

On going assessment

Performed as needed at any time after initial database is completed

Comprehensive assessment

Also called a global assessment it provides holistic information About over all health

Focus assessment

Performed to obtain data about an actual, potential, or possible problem that has been identified or is suspected

The Katz index of ADLS

Assess independence in bathing, dressing, toileting, transfer, continence, and feeding

Lawton instrumental ADL scale

Assesses a person's ability to independently perform the more sophisticated tasks of everyday life such as shopping planning and preparing meals or paying bills

Karnofsky performance scale

Used in palliative care settings to assassin punctual abilities at the end of life

Directive interview

Used to obtain facts, beneficial in emergency situation, a nurse controls Topic and uses close questions

Non directive interview

Patient controls the subject matter, nurses use open ended questions, type of interview that promotes communication, builds rapport, patient expresses feelings

Maslow's hierarchy of need

Most basic needs must be met before higher needs can be addressed

Recording assessment data

Document as soon as possible


Write neatly in in black ink


Use proper spelling and grammar


Use only agency approved abbreviations


Right patients own words


Use concrete specific information rather than vague generalities such as normal adequate good and tolerated well


Record cues not inferences

Cues

What the client says and what you observe

Inferences

judgment and interpretations about what a cue means

Diagnosis

Use critical thinking skills to identify patterns in the data and draw conclusions about the client's house status and is the basis for planning clients and our goals and interventions

Health problem

Any condition that requires intervention to prevent or treat disease or Illness

Nursing diagnosis

A statement of claim health status that nurses can identify prevent or treat independently and as stated in terms of human responses to disease, injury, or other stressors

Risk nursing diagnosis

Problem may occur no signs or symptoms of the problem but risk factors are present that increase the patient's vulnerability

Possible nursing diagnosis

Problem maybe present however you do not have enough doubt this is support the diagnosis. Alerts other nurses to continue to collect data and confirm or rule out the problem

Significant Data

Cues

Cluster

Group of cues that are related to each other

Etiology

Factors causing or contributing to a problem

Patient preference

Give high priority to problems the patient things are most important if they do not conflict with basic survival needs or medical treatments

Bias

The tendency to slant your judgment based on personal opinion or on founded beliefs

Stereotypes

Judgment and expectations about an individual based on the personal beliefs you have about a group of people when you have little or no actual experience with the group

Taxonomy

System for classifying ideas or objects based on characteristics they have in common

Diagnostic statement

As a general rule, the problem suggest goals, and the etiology suggest interventions

Formal planning

A conscious deliberate activity involving decision making critical thinking, and creativity

Informal planning

Occurs while you are performing other nursing process steps

Initial planning

Begins with the 1st patient contact

On going planning

Refers to changes made in the plan as you evaluate the patient's responses to care or as you obtain new data and make new nursing diagnosis

Discharge planning

Is the process of planning for self care in continuities of care after the patient uses the health care setting it is used to promote the patient's progress toward health management and begins at initial assessment

Patient goals

You should involve the patient as much as possible in goal setting because gold human is more likely if the goals are realistic and important to the client

NOC

Nursing outcomes classification

Short term goals

Expect patient to achieve within a few hours or days

Long term goals

Wish to achieve over a longer. Such as a week, month, or longer

Nursing interventions

Actions based on clinical judgment in nursing knowledge that nurses perform to achieve client outcomes

Direct care interventions

Performed through interaction with the client

Indirect care interventions

Performed away from the client but on behalf of them such as consulting with other health care team members and making referrals

Independent interventions

Registered nurse are responsible for in do not require provider order

Dependent interventions

Prescribed by a physician or nurse practitioner

Interdependent Interventions

Carried out in collaboration with other health team members

Theory

Set of interrelated concepts that describes or explain something

Evidence base practice

Uses for in scientific data in identifies the most effective and cost efficient treatments for a particular disease, condition, or problem

5 Rights of delegation

RightTask


Right circumstance


Right person


Right direction


Right supervision

Evaluation

Planned on going systematic activity in which you will make judgments about the client's progress toward desired health outcomes the effectiveness of nursing care plans a quality of nursing care in the health care setting

Evaluation data

Collected after interventions are performed to determine whether client goals were achieved

Structure Evaluation

Focuses on the setting in which cares provided, explores the effect of organizational characteristics on the quality of care, in the required standards and data about policies, procedures camo fiscal resources come up physical facilities, and equipment, and number of qualifications of personnel

Processes Evaluation

Focuses on the manner in which care is Given And the activities performed

Outcomes evaluation

Focuses on observable or measurable changes in the patient's health status that result from care given

On going Evaluation

Is performed while implementing care, immediately after an intervention, and at each patient contact

Intermittent evaluation

Evaluation that is performed at specified times

Terminal evaluation

Describes the clients whole status in progress toward goals At the time of discharge