Pre – Exam #1 Summary and Worksheet

What is the Nursing Process portion of clinical reasoning/critical thinking demonstrated by?

Nursing diagnoses are

1) Phases in Nursing Process

1) Assessment Phase

2) Phases in Nursing Process

2) Diagnosis

3) Phases in Nursing Process

3) Planning Phase

4) Planning Phases in Nursing Process

4) Implementation phase

5) Planning Phases in Nursing Process

5) Evaluation Phase

What is the Assessment phase?

1st Step and involves critical thinking skills/data collection of subjective (stated by patient or family member) and objective symptoms(observed)

What is the Diagnosis phase?

2nd step, employing clinical judgement about the patient’s response to a health problem to assist in the planning & implementation of patient care that encompasses Maslow’s Hierarchy of need.

What is the planning Phase?

3rd step is where patient-specific goals and outcomes are formed. The nursing care plans (NCP) are essential in this phase of goal setting.

What Is the Implementation phase?

4th step, involves ACTION/Nursing Interventions in NCP to assist the patient

What is the Evaluation Phase?

5th step, When you intervene/implement care you must reassess or evaluate to ensure desired outcome has been met.

When is reassessment needed?

May be needed frequently depending upon overall patient condition

What is The Nursing Care Plan? (NCP)

Provides a course of direction for patient-specific / personalized care tailored to the individual’s unique needs. This includes the overall patient condition and co-morbid conditions that affect the NCP construction

What does The NCP do?

Enhances communication, documentation, reimbursement, and continuity across healthcare continuum.

Maslow's Hierarchy of Needs

People must satisfy lower, fundamental needs before they can focus on higher-level psychological needs

Level 1 of Maslow's Hierarchy of Needs

Basic Physiological needs:

• Nutrition (water and food)

• Elimination (Toileting)

• Airway (suction)

• Breathing (oxygen)

• Circulation (pulse, cardiac monitor, blood pressure) (ABC's)

• Sleep

• Sex

• Shelter

• Exercise

Level 2 of Maslow's Hierarchy of Needs

Safety and Security:

• Injury prevention (side rails, call lights, hand hygiene, isolation, suicide precautions, fall precautions, car seats, helmets, seat belts)

• Fostering a climate of trust and safety (therapeutic relationship)

• Patient education (modifiable risk factors for stroke, heart disease).

Level 3 of Maslow's Hierarchy of Needs

Love and Belonging:

• Foster supportive relationships

• Methods to avoid social isolation (bullying)

• Employ active listening techniques

• Therapeutic communication

• Sexual intimacy.

Level 4 of Maslow's Hierarchy of Needs

Self-Esteem:

• Acceptance in the community

• Workforce

• Personal achievement

• Sense of control or empowerment

• Accepting one's physical appearance/Body habitus

Level 5 of Maslow's Hierarchy of Needs

Self-Actualization:

• Empowering environment

• Spiritual growth,

• Ability to recognize the point of view of others

• Reaching one's maximum potential

Patient Specific goals should be _____

S.M.A.R.T

S in S.M.A.R.T

Specific

M in S.M.A.R.T

Measurable/Meaningful

A in S.M.A.R.T

Attainable/Action-oriented

R in S.M.A.R.T

Realistic/Result Oriented

T in S.M.A.R.T

Timely/Time-oriented

What is a major patient oriented characteristic of the nursing process?

(being) Client-Centered

When a LVN is preforming a Nursing process “assessment”, what critical thinking is used to differentiate important information vs unimportant information?

• Inductive Reasoning

• Deductive reasoning

• Clinical Reasoning

• Socratic Questioning

When the LVN completes the focused physical assessment and realizes the patient has a more acute condition, what is the best clinical reasoning action for the nurse?

1) COMMUNICATION: Notify Supervising RN or primary care provider and reassess patient care plan

What is an example of the nurse demonstrating creativity to encourage a patient preform an activity that the patient resist doing periodically?

Integrate activity into something the patient enjoys

What is the purpose of performing an assessment?

• Establish Baseline

• Compare Changes in pt Status

• Monitor Specific issues

What problem solving actions are needed when the patient appears withdrawn?

• Use Active listening

• Reorientation (introduction every time you enter room)

• Avoid forcing interaction

• Assess for underlying causes

What problem solving actions are needed when the patient is exhibiting childlike behavior?

• Assess for underlying cause

• Communicate at patients level of understanding

When using the nursing process, what is the correct LVN response to the patient having altered state of health?

• Begin with assessment on how to proceed

• Use Primary source

• encourage expression of feelings/behavior

• recognize the sick role

When the SVN is assigned to a patient with a difficult diagnosis (ex: Mastectomy) what CT components can the SVN review to promote therapeutic communication?

• Interpret verbal & nonverbal cues (see fear rather than “non-compliance”)

• Therapeutic nursing techniques (active listening!)

• Caring & Comforting Behaviors

• Integrate CT (Reflect on who should be involved and how it will effect care priorities)

When post-operative patient declines oral fluids due to nausea, what should be the care plan priority?

1) Assess Fluid status (urine output)

2) Administer IV fluids

3) Gradual reintroduction of oral fluids (small sips, ice chips)

4) Monitor and record

5) Provide Comfort measures (mouth care to alleviate dry mouth)

When a GVN (Graduate Vocational Nurse) performs a skill that has been learned in school and observed by other nurses preforming differently, what action by the GVN Indicates they are using CT skills?

1) Evaluate the other methods

2) Consult Evidence based practices (review facility policy, don’t follow blindly)

3) Reflect and make judgements

What is the name of the CT competency used in the nursing profession?

Cultural competence (context matters!)

When the LVN learns that nurse jewelry or clothing may cause patients harm (ex: infection), what is the best CT action for the LVN?

Intellectual Humility (take off jewelry to minimize infection)

What is the correct order for planning activities?

1) Set priorities

2) choose intervention

3) establish outcomes

4) write care plan

When the LVN receives reports that a patient is a “complainer”, What CT action by the LVN demonstrates effective clinical reasoning?

1) Assessment (identify any unmet needs or discomfort)

2) Engage in open-communication w/ patient

3) Evidence-based practice (review common causes of complaints and look for interventions)

4) Avoid assuming

When the SVN has a patient assigned with a pending diagnostic procedure that the SVN is unfamiliar with, what action by the SVN indicated application to CT concepts?

1) Analysis (break down info given) AND Synthesis (integrate existing knowledge to form understanding)

2) Research and Inquiry (seek additional information)

3) Ask questions (to healthcare team and implications for patient care)

4) Reflective practice (look on own knowledge and skills & see where improvement is needed)

What is the goal for the LVN who used CT in The Nursing process

1) Interpret assessment data (Tailor to patient instead of generalizing)

2) Continually reassess during implementation

3) Contribute active observations and interventions that support evaluation of care-plan.

4) Work within LVN’s scope of practice

How do CT skills assist the LVN during the assessment phase?

• Reliable observations

• Distinguish relevant and irrelevant data

• Validate data

• Organize and categorize data

• Recognize assumptions and identify gaps

Which CT technique does the LVN use when patient has general complaints, dizziness, and lower extremity weakness?