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82 Cards in this Set
- Front
- Back
What does nursing involve |
Thinking, caring, doing |
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Critical thinking |
A combination of reasoned thinking, an openness to alternatives, an ability to reflect, and a desire to seek truth |
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Critical thinking attitudes |
Independent thinking, intellectual curiosity, intellectual humility, intellectual empathy, intellectual courage, intellectual perseverance, fair mindedness |
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Critical thinking skills |
Refer to the cognitive processes used in complex thinking operations such as problem solving and decision making. |
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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. |
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Intellectual humility |
Aware that they do not know everything and admit when they are wrong |
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Intellectual empathy |
Try to understand feelings and perceptions of others |
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Fair mindedness |
Try to make impartial judgments and Treats all viewpoints fairly |
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Model |
Set of interrelated concepts that represent a particular way of thinking about something |
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Contextual awareness |
Deciding what to observe and consider aware of what's happening in the situation |
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Inquiry |
Applying standards of good reasoning to your thinking when analyzing the situation and evaluating your actions |
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Considering alternatives |
Exploring and imagining as many alternatives as you can think of for the situation |
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Analyzing assumptions |
Recognizing and analyzing assumptions you are making about the situation and examined the beliefs that underlie your choices |
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Reflecting skeptically in deciding what to do |
Questioning analyzing and reflecting on the rationale for your decisions |
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Steps of the nursing process |
Assessment, diagnosis, planning, implementation, evaluation |
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Theoretical knowledge |
Knowing why consists of information facts principles in evidence base theories |
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Practical knowledge |
Knowing what to do and how to do it consists of processes and procedures and is an aspect of nursing expertise |
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Self knowledge |
Self understanding you are aware of your beliefs, values, and cultural and religious biases |
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Ethical knowledge |
Knowledge of obligation or right or wrong |
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Nursing process |
Systematic problem solving process that guides all nursing actions |
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Caring |
Involves personal concern for people, events, projects, and things. Helps the nurse notice which interventions are effective |
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Full spectrum nursing |
Our unique blend of thinking doing caring and the patient situation |
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Assessment |
The systematic gathering of information related to the physiological psychological sociocultural developmental and spiritual status of an individual Kama group, or community |
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Subjective Data |
What the patient says Also called covert data or symptoms data |
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Objective data |
What professionals observe Also Called overt data Or signs data |
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Primary data |
Obtained directly from the client in what the client says or you |
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Secondary data |
Data obtained 2nd hand from medical record or care giver |
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Observation |
To gather and interpret patient and environmental data |
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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 |
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Interviewing |
Purpose full comment structured communication in which you question the patient in order to gather subjective data for nursing |
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Initial assessment |
Completed when the client 1st comes |
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On going assessment |
Performed as needed at any time after initial database is completed |
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Comprehensive assessment |
Also called a global assessment it provides holistic information About over all health |
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Focus assessment |
Performed to obtain data about an actual, potential, or possible problem that has been identified or is suspected |
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The Katz index of ADLS |
Assess independence in bathing, dressing, toileting, transfer, continence, and feeding |
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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 |
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Karnofsky performance scale |
Used in palliative care settings to assassin punctual abilities at the end of life |
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Directive interview |
Used to obtain facts, beneficial in emergency situation, a nurse controls Topic and uses close questions |
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Non directive interview |
Patient controls the subject matter, nurses use open ended questions, type of interview that promotes communication, builds rapport, patient expresses feelings |
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Maslow's hierarchy of need |
Most basic needs must be met before higher needs can be addressed |
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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 |
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Cues |
What the client says and what you observe |
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Inferences |
judgment and interpretations about what a cue means |
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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 |
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Health problem |
Any condition that requires intervention to prevent or treat disease or Illness |
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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 |
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Risk nursing diagnosis |
Problem may occur no signs or symptoms of the problem but risk factors are present that increase the patient's vulnerability |
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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 |
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Significant Data |
Cues |
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Cluster |
Group of cues that are related to each other |
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Etiology |
Factors causing or contributing to a problem |
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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 |
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Bias |
The tendency to slant your judgment based on personal opinion or on founded beliefs |
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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 |
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Taxonomy |
System for classifying ideas or objects based on characteristics they have in common |
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Diagnostic statement |
As a general rule, the problem suggest goals, and the etiology suggest interventions |
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Formal planning |
A conscious deliberate activity involving decision making critical thinking, and creativity |
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Informal planning |
Occurs while you are performing other nursing process steps |
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Initial planning |
Begins with the 1st patient contact |
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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 |
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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 |
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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 |
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NOC |
Nursing outcomes classification |
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Short term goals |
Expect patient to achieve within a few hours or days |
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Long term goals |
Wish to achieve over a longer. Such as a week, month, or longer |
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Nursing interventions |
Actions based on clinical judgment in nursing knowledge that nurses perform to achieve client outcomes |
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Direct care interventions |
Performed through interaction with the client |
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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 |
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Independent interventions |
Registered nurse are responsible for in do not require provider order |
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Dependent interventions |
Prescribed by a physician or nurse practitioner |
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Interdependent Interventions |
Carried out in collaboration with other health team members |
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Theory |
Set of interrelated concepts that describes or explain something |
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Evidence base practice |
Uses for in scientific data in identifies the most effective and cost efficient treatments for a particular disease, condition, or problem |
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5 Rights of delegation |
RightTask Right circumstance Right person Right direction Right supervision |
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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 |
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Evaluation data |
Collected after interventions are performed to determine whether client goals were achieved |
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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 |
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Processes Evaluation |
Focuses on the manner in which care is Given And the activities performed |
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Outcomes evaluation |
Focuses on observable or measurable changes in the patient's health status that result from care given |
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On going Evaluation |
Is performed while implementing care, immediately after an intervention, and at each patient contact |
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Intermittent evaluation |
Evaluation that is performed at specified times |
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Terminal evaluation |
Describes the clients whole status in progress toward goals At the time of discharge |