Exam 2 - Ch 15-20 The Nursing Process Potter Perry Fundamentals Of Nursing

Front 1

The reflective, systematic, goal-directed, thought process that serves as a basis for creative decising making in nursing.

Back 1

critical thinking

Front 2

The nursing profession uses critical thinking to -

Back 2

make astute observations, analyze data, draw sound conclusions

Front 3

Examples of decision making models that use critical thinking -

Back 3

The scientific meathod
Differential Diagnosis - narrow down to a few possible diagnoses and focus data collection on eliminating one and/or strengthening another to hone in on correct diagnosis
The Nursing Process - 5 steps: Assess, Diagnose, Plan, Implement, Evaluate (ADPIE) to systematically approach patient care in a way that consciously evaluates interventions to reveal best treatment path for each patient.

Front 4

What 6 skills are used to critically think?

Back 4

Interpretation, Analysis, Inference, Evaluation, Explanation, Self-regulation

Front 5

What are the 5 components of critical thinking

Back 5

Knowledge Base
Experience
Competency in using the Nursing Process
Attitudes
Standards

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Attitudes for critical thinking

Back 6

Confidence, independent thinking, fairness, accountability, risk taking, discipline, perserverance, creativity, curiosity, integrity, humility

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5 Steps in the Nursing Process

Back 7

ADPIE -
Assess
Diagnose
Plan
Implement
Evaluate

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Assess

Back 8

The data collection phase

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Primary and secondary sources of Assesment data

Back 9

Primary - the patient
Secondary - medical records, close family/friends, health care team, other records, nursing/medical/pharmacological literature

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Data types -

Back 10

Subjective - The client's verbal description of his or her health problem. Includes feelings, perceptions, self-report of symptoms
Objective - Observations, measurements. i.e. vital signs, lab results, nursing assessment

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Methods of data collection

Back 11

The interview
structured database format
problem-oriented approach
3 Phases
Orientation phase
Working phase
Termination phase

create a comfortable interview environment and use open and closed-ended questions strategically

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11 Components of nursing health history

Back 12

Biographical info
Reason for seeking care
Expectations
History of Present Illness
Health history (all previous medical conditions)
Lifestyle factors
Family History
Psychosocial history (coping mechanisms, support, recent loss, abuse)
Review of systems (establish normal/abnormal functioning of every sys)
Environmental History
Physical Examination

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Key elements of nursing data documentation

Back 13

Clear and concise
Timely, thorough and accurate
Record both subjective (use quotes when possible) and objective data
Avoid generalization or judgement

Front 14

Step 2 of the nursing process - (Nursing) Diagnosis - is

Back 14

A clinical judgement about individual, family, or community responses to actual and potential health problems or life processes

A statement that describes an actual or potential response to a health problem that a nurse is licensed to treat.

Holistic - not necessarily disease-focused.

Front 15

A nursing diagnosis is different from a Medical Diagnosis. Describe the qualities of a medical diagnosis.

Back 15

Identification of a disease process
Based on specific evaluation of physical signs, history, and diagnostic testing or procedures.
Physicians treat diseases described in medical diagnostic statements (myocardial infarction, diabetes mellitus)

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Origin of Nursing Diagnosis

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First introduced in 1950
First incorporated into ANA Standards of Practice in 1971
NANDA (North American Nursing Diagnosis Association) established in 1982
NANDA - International established in 2003

Front 17

What is the purpose of using nursing diagnoses?

Back 17

To maintain a common language for client needs.
Enables nurses to communicate what they do
Distinguishes the nurse's role from that of a physician, etc.
Gives focus to scope of nursing practice
Fosters development of nursing knowledge

Front 18

What are the 4 types of Nursing Diagnoses?

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Actual Diagnosis (i.e. Impaired Gas Exchange)
Risk Diagnosis (i.e. Risk for infection)
Health Promotion Diagnosis (Readiness for …)
Wellness Diagnosis

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3 components of a nursing diagnosis

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Diagnostic label
Etiology "related to"
Evidence "as evidenced by"
Example: Acute pain related to uterine contractions as evidenced by moaning, facial grimacing, and pain scale rating of 10/10

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Diagnostic label

Back 20

Name of the nursing diagnosis approved by NANDA-I
Describes client response
Includes descriptors (impaired, compromised, decreased, deficient, delayed, effective, imbalanced, impaired, increased)

Front 21

How to risk factors relate to nursing diagnoses?

Back 21

They serve as cues to indicate a "Risk" nursing diagnosis.

Front 22

Etiology portion of nursing diagnosis

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"Related to"
Supports diagnosis
must be a condition that responds to nursing intervention
should not include medical diagnosis

Front 23

Evidence portion of nursing diagnosis

Back 23

"as evidenced by"
related factors to support diagnosis
use data from assessment

Front 24

In Step 3 of nursing process - Planning - the nurse:

Back 24

Outlines client goals
Sets Priorities
Develops expected outcomes
Develops a nursing plan of care

Front 25

Guidelines for formulating goals and expected outcomes -

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Must be client-centered and mutually agreed upon by patient and nurse
Each goal and outcome should address only one behavior
Must be observable
Must be measureable
Time-limited
Realistic

Front 26

In order to achieve patient goals, nurse must have:

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Buy-in from the patient
Time-management and organizational skills
Appropriate use of resources
Priority setting
Client adherence

Front 27

Step 4 of nursing process - Implementation:

Back 27

Begins after plan of care is developed
Involves nursing interventions
Interventions should be evidence-based and current.
May involve direct or indirect nursing care
Standard nusing interventions may be in the form of clinical practice guidelines and protocols, standing orders, or NIC interventions

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Interventions

Back 28

What nursing care will you provide to help the patient meet his or her goals?

Front 29

3 types of interventions

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Independent
Dependent
Collaborative

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Step 5 of nursing process - Evaluation

Back 30

Determines whether nursing care was effective
Were expected outcomes met?

Front 31

How to conduct evaluation

Back 31

Collect evaluative data
Interpret and summarize findings
Document your findings
Revise plan of care

Front 32

Nurse's Role in overall evaluation

Back 32

Use self-reflection to evaluate individual practice
Participate in facility-based QI activities that evaluate the quality of nursing care
Maintain data to ensure the valuing of nursing services
Participate in resesearch on the efficacy of nursing interventions

Front 33

Types of Care Plans

Back 33

Institutional Care Plan
Computerized Care Plan
Critical Pathways
Concept Maps

Front 34

Critical thinking

Back 34

is an active, organized, cognitive process used to carefully examine one's thinking and the thinking of others

Front 35

Describe the 6 SKILLS of critical thinking

Back 35

Interpretation - be orderly when collecting data, look for patterns to categorize data and clarify an data you are uncertain about.
Analysis - Be open-minded and see if the data leads you down a path other than your expected one.
Inference - Look at the meaning and significance of findings. Find relationships
Evaluation - Look at all situations objectively and use criteria to determine results of nursing actions
Explanation - Support findings and conclusions
Self-regulation - Reflect on your experiences and identify ways to improve.

Front 36

Kataoka-Yahiro and Saylor developed a critical thinking model that incldues 3 levels of critical thinking:

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Basic - Experts are right, follow procedure for best way
Complex - More independent, knows when procedure can be adjusted to better-suit patient needs.
Commitment - Identifies an appropriate solution based on independent thinking and implements it, accepting full accountability for outcomes.

Front 37

Diagnostic reasoning

Back 37

A process of determining a client's health status after you assign meaning to the behaviors, physical signs and symptoms presented by the client. Begins right away with interaction - nurse is constantly examining the meanings behind every observation.

Front 38

Inference

Back 38

is part of diagnostic reasoning. This is the process of drawing conclusions from related pieces of evidence.

Front 39

Clinical decision-making

Back 39

requires careful reasoning so that you choose the options for the best client outcomes on the basis of the client's condition and the priority of the problem.

Front 40

14 intellectual standards for critical thinking

Back 40

clear, precise, specific, accurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate, fair

Front 41

Why is CONFIDENCE an important attitude of critical thinking -

Back 41

Instills confidence in care you can provide. A goal of confidence helps to ensure that you have well-prepared yourself for the activity

Front 42

Why is RISK TAKING an important attitude of critical thinking -

Back 42

If your knowledge causes you to question a health care provider's order, do so. Be willing to respectfully advocate for client even when it may cause some conflict with collegues' views.

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Why is DISCIPLINE an important attitude of critical thinking -

Back 43

It helps you to: be thorough in whatever you do; use evidence-based criteria; take time to be thorough; manage time wisely. A disciplined thinker misses few details and follows an orderly or systematic approach.

Front 44

Why is PERSEVERANCE an important attitude of critical thinking -

Back 44

It helps you to: be cautious of an easy answer; if facts don't seem clear or complete, always clarify information; if a pattern of problems seems to be occuring, bring co-workers together to work toward a solution rather than let the pattern continue.

Front 45

The standards of professional responsibility that a nurse tries to achieve are those cited in the

Back 45

Nurse Practice Acts, institutional practice guidelines, and professional organizations' standards of practice.

Front 46

Reflection

Back 46

is the process of purposefully recalling a situation to discover its purpose or meaning.

Front 47

Concept map

Back 47

a visual representation of client problems and interventions that shows their relationships to one another.

Front 48

Assessment

Back 48

is the deliberate and systematic collection of data to determine a client's current and past health status and functional status and to determine the client's present and past coping patterns.

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Nursing Assessment includes 2 steps

Back 49

1 - Collection and verification of data from primary and secondary sources.
2 - The analysis of all data as a basis for developing nursing diagnoses, identifying collaborative problems and developing a plan of individualized care.

Front 50

The purpose of assessment is to -

Back 50

establish a database about the client's perceived needs, health problems, and responses to these problems. In addition, the data reveal related experiences, health practices, goals, values, and expectations about the health care system.

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Cue

Back 51

is information that you obtain through the use of the 5 senses

Front 52

inference

Back 52

is your judgement or interpretation of cues.

Front 53

Gordon's 11 functional health patterns describe -

Back 53

Areas of overall health including: sleep, nutrition, activity, stress, values, elimination, understanding of health needs

Front 54

Orientation phase

Back 54

Establish trust and confidence, collect demographic data, explain confidentiality policies, least personal.

Front 55

Working phase of interview

Back 55

Nursing health history, begins exploring current illness, expectations of care.

Front 56

Closed-ended questions

Back 56

require short (usually "yes" "no") answers and are used to clarify previous information or provide additional information.

Front 57

Back-chaneling

Back 57

use of active listening prompts such as "all right" "go on" or "uh-huh" to indicate that you have heard what the client said.

Front 58

Psychosocial history

Back 58

receals the client's support system which often includes spouse, children, other family members, close friends.

Front 59

Validation of assessment data

Back 59

is the comparison of data with another source to determine data accuracy. For example, you observe a client crying and make certain assumptions about the client's anxiety or pain however, you validate this with the client to confirm - it is possible that they are concerned about something unrelated to the current treatment.

Front 60

Data analysis

Back 60

involves recognizing patterns or trends in the clustered data, comparing them with standards and then coming to a reasond conclusion about the client's responses to a health problem

Front 61

3 steps of analysis

Back 61

Recognize a pattern or trend based on relevant cues
Compare observations to normal standards
Make a reasoned conclusion

Front 62

Collaborative problem

Back 62

is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a client's status.

Front 63

expected outcomes

Back 63

measureable, critera to evaluate goal achievement - achievement of all expected outcomes supports the conclusion that a goal has been met.

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goal

Back 64

an aim, intent, or end. A goal is a broad statement that describes the desired change in a client's condition of behavior. All nursing goals are time-limited. While it may be broad, the goal still only describes 1 particular behavior or response. Example: Client achieves improved pain control before surgery.

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client-centered goal

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a specific and measureable behavior or response that reflects a client's highest possible level of welleness and independence in function. Goal describes only 1 particular behavior or response.

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Short-term goal

Back 66

Expected to be achieved in a short time - typically less than 1 week.

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Long-term goal

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Expected to take a long time to achieve - typically more than 1 week but could be shorter in some cases.

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independent nursing interventions

Back 68

Nurse-initiated interventions are

Front 69

When choosing interventions, consider these 6 factors

Back 69

Characteristics of diagnosis
Goals and expected outcomes
Evidence Base
Feasibility
Acceptability to the client
Your own competency

Front 70

Nursing care plan

Back 70

enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care.

Front 71

Critical Pathways

Back 71

are multidisciplinary treatment plans that outline the treatments or interventions clients need to have while thiey are in a health care setting for a specific disease or condition.

Front 72

Implementation

Back 72

4th step of the nursing process, formally begins after the nurse develops a plan of care. In this stage, the nurse initiates interventions that are aimed at achieving the goals and expected outcomes laid out in the planning phase.

Front 73

Psychomotor skills

Back 73

require the integration of cognitive and motor activities - having both the knowledge and dexterity to perform nursing procedures. Example: correctly giving an injection requires both "book knowledge" and "hands-on" skills.

Front 74

Indirect care

Back 74

treatment performed away from the client but on behalf of the client or a group of clients. Examples: Safety, infection control, documentation, interdisciplinary collaboration.

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Physical care techniques

Back 75

techniques that require hands-on skills such as properly turning and positioning a client, performing invasive procedures, administering medications, providing comfort measures.

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Anticipating and preventing complications

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know the risks of any treatment before you begin and take steps to avoid complications. Note any client conditions (obesity, hemiplegia, etc.) that may cause this particular client to be more suceptable to certain complications.

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Controlling for adverse reactions

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an adverse reaction is a harmful or unitended effect of a medication, diagnostic test, or therapeutic intervention. Anticipate the potential adverse reactions to a particular intervention and be alert for early signs.

Front 78

You conduct evaluative measures to determine if you met ___________

Back 78

You conduct evaluative measures to determine if you met expected outcomes, not if nursing interventions were completed.

Front 79

evaluative measures

Back 79

the same as assessment skills but used to evaluate a client's response.

Front 80

When does evaluation occur

Back 80

It is continuous - we are always watching for outcomes both positive and negative.

Front 81

Evaluation involves 2 components

Back 81

Examination of a condition or situation
Judgement as to whether change has occurred or not