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The Nursing Process & Critical Thinking- Unit II
Terms in this set (72)
Open-mindedness, continual inquiry, perseverance, willingness to look at each unique patient situation, & determine which identified assumptions are true & relevant is ___________ thinking.
Critical thinkers require what types of attributes?
Habit of asking questions
Remaining well informed
Facing people's biases
Always being willing to reconsider & think clearly about issues
General Cognitive Thinking includes all of the following except:
a) Scientific Method
b) Problem Solving
c) Unperceptive thoughts
d) Decision Making
the analytical process for determining a patient's health problems
interpretation of cues
These are 5 steps to ____________ decision making .
1. Identify patient status
2. Knowledge about clinical variables
3. Judgment about the likely course of events
4. Any additional relevant data
5. Knowledgable about nursing therapy opinions
Diagnosis is the ____ step in the nursing process.
Implementation is the _____ step in the nursing process.
Evaluation is the ___ step in the nursing process.
Which are attitudes of critical thinking? [select all that apply]
a) thinking independently
b) risk taking
a, b, d, e, f
Database is part of which step of the nursing process?
patient's problems, perceived needs, & responses, health goals & values, expectation about healthcare systems
What are 6 sources of data?
necessary members of healthcare team
_______-ended questions prompt he patient to describe a situation in more than one or two words.
Active listening prompts such as "alright" "go on"
Phrases like "Is there anything else you can tell me?" or "What is bothering you?" are examples of ___________.
"Do you feel better today?" is an example of what kind of question?
"Tell me more about how that makes you feel." is an example of what kind of question?
What is a cue?
information you obtain through the use of senses
Functional Health Patterns
the theory or practice standard provides categories of info for you to assess
steps of the nursing process
does the patient experience other symptoms along with the primary symptoms
More focused on physiologic processes & disease process
a) medical diagnosis
b) nursing diagnosis
Directed toward a patient's RESPONSES to disease and illness, more holistic
a) medical diagnosis
b) nursing diagnosis
- life threatening!
- rapid assessment
- check ABC's! (airway, breathing status, and circulation
Methods of data collection
observing, interviewing, examining, researching
Observation data collection
- gather data by using all five senses all the time
- ongoing and descriptive!
Interviewing data collection
- using organized communication NOT therapeutic communication
- patient is ALWAYS the primary resource of info
Examination data collection
- vital signs
Research data collection
- diagnostic and lab data
- something you can MEASURE or OBSERVED
- ex: blood pressure, weight, pulse, etc.
Sources of data
- primary: patient!
- secondary: anybody or anything around patient (family, medical records, charts, etc.)
- symptoms, feelings, anything the patient SAYS or STATES
- ex: "I feel dizzy", "I am experiencing pain on my left side."
How do we organize/cluster data?
Gordon's functional health patterns
Gordon's functional health patterns:
Standardized NANDA names for the diagnoses
Components of a Nursing Diagnosis
Etiology (where does the problem originate from?)
Defining characteristics (signs & symptoms, EVIDENCE)
-A clinical judgement about individual, family, or group responses to actual & potential health problems or life processes
- Analyze data & draw conclusions
- ex: Impaired communication, Risk for aspiration, Risk for injury
What is contributing to or associated with the problem?CANNOT BE A MEDICAL DIAGNOSIS
Types of Nursing Diagnosis
actual, risk (potential), possible, health promotion/wellness, syndrome
Actual Nursing Diagnosis
-Client problem that is present at nursing assessment (based on presence of associated signs and symptoms - evidence)
- ex: Ineffective Breathing Pattern and Activity
- Problem has not happened, but if nurse does not intervene, it may occur!
- ex: Risk for Falls, Risk for Injury
basic two part statements (nursing diagnosis)
-etiological or related factor
- joined by words "related to"
- ex: Noncompliance (Diabetic Diet) related to denial of having disease
basic three part statements (nursing diagnosis) - PES Format
- usually actual diagnosis WITH evidence
- PES format
-Signs & symptoms, problem, etiology
Goal are ______ centered
- patient centered
- more specific, measurable, observable criteria
- how are we going to achieve goals?
- written sequentially
- REALISTIC for patient!
are examples of ___________.
Types of interventions
- nurse-initiated (independent)
- physician-initiated (dependent)
- collaborative (interdependent)
- health promotion
- action phase
- doing and documenting the activities that are the specific nursing
- reassessing the client
__________ differences influence how patients perceive health & wellness.
Sources of Diagnostic Errors
Labeling of Diagnosis
shifts in attention from one patient to another during the conduct of the nursing process
Independent Nursing Interventions
actions the NURSE indicates
Dependent Nursing Interventions
actions that require an order from a physician
Require interventions & knowledge from multiple healthcare providers
6 Important factors when choosing nursing interventions:
-characteristics of nursing diagnosis
-goals & expected outcomes
-evidence & research base
-feasible of interventions
-acceptability to patient
-your own capability
1.Correct Goal Statement _____
2.Correct Outcome Statement ______
3.Common Error (written as an intervention) _____
a. Patient will abulate in the hall 3X / day
b. Ambulate patient in hall 3X / day
c. Patient will ambulate independently for 3 days
1. = c
2. = a
3. = b
Nursing Care Plans include:
provides visually graphic way to show visual relationship between patients nursing diagnoses & interventions
-increases you knowledge about the patient
-helps in learning skills
-helps obtain resources needed to solve problem
When to consult:
-when you identify a problem you are unable to solve using personal knowledge, skills, & resources
- by nurse WITH client
- ex: ADLs, instrumental ADLS (shopping, banking, etc.), physical care techniques, lifesaving measures (CPR), counseling, teaching, preventive measures
- FOR client but NOT in front of client
- ex: managing the patient's environment, documentation, oral reporting, order transcription, telephone consult, product evaluation
any treatment based on clinical judgment & knowledge that a nurse performs to enhance patient outcomes
When preparing to perform an intervention:
-Reassess the patient
-Review & revise the existing nursing care plan
-Organize resources & care delivery approaches
-Anticipate & Prevent complications
-Implement the intervention
a measurable patient or family state, behavior, or perception largely influenced by & sensitive to nursing interventions
2 Components of Evaluation
#1 an examination of a condition or situation
#2 judgment as to whether change has occurred
Evaluation EXAMINES 2 factors:
1. Appropriateness of the intervention
2. Correct application of interventions
- planned, ongoing, purposeful activity in which client's and health care professionals determine:
1.) client's progress toward achievement of goals/outcomes
2.) the effectiveness of the nursing care plan
why is evaluation important?
- it is an important aspect of the nurse because conclusions drawn from the evaluation determine whether the nursing interventions should be terminated, continued, or changed
Assess to see if _____ have been met, then decide what to do next
primary purpose of the evaluating phase of the care planning process is to...?
determine whether desired outcomes have been met
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