Clinical Judgment, Teaching and Learning, Sensory-Perception (NUR 101)

Nursing Process

A systematic method for nurses to plan and implement patient care to achieve desired outcomes, including collecting information, identifying problems, developing a plan, carrying out the plan, and evaluating results.

LPN role in the Nursing Process

To gather and report information that suggests problem-focused or potential health problems, contribute to care plans, provide basic therapeutic and preventative measures, patient education, record information, and evaluate care.

RN role in the Nursing Process

Examines data to formulate a nursing diagnosis, completes the initial comprehensive assessment, and may implement revisions to the care plan.

ADPIE

An acronym representing the five steps of the Nursing Process: Assessment, Diagnosis (Analysis), Planning, Implementation, and Evaluation.

Assessment

Careful and deliberate observation of a patient’s health status to collect information, determine normal and abnormal function, and identify risk factors.

Initial Comprehensive Assessment

The first thorough evaluation of a patient's health status, typically completed by the Registered Nurse.

Nursing Diagnosis

A clinical judgment made by a Registered Nurse, interpreting data collected during assessment, which includes the problem name, cause and related factors, and defining characteristics (signs and symptoms).

Planning (Nursing Process)

Involves setting priorities, defining expected outcomes or goals, determining specific nursing interventions, and recording the plan of care.

SMART Goals (Patient Outcomes)

An acronym for Specific, Measurable, Agreed Upon, Realistic (or Relevant), and Timely, used to ensure patient goals are effective and attainable.

Implementation

The act of carrying out the plan of care, performing interventions, monitoring patient status, and documenting observations and responses.

Evaluation (Nursing Process)

Assessment and review of the quality and suitability of the care given and the patient’s response to that care, comparing expected outcomes with actual outcomes.

Prioritization of Needs

Ranking patient problems by their seriousness, importance, or immediacy, often guided by frameworks like Maslow's Hierarchy of Needs.

Maslow's Hierarchy of Needs

A theory of psychological health predicting that humans must satisfy basic needs (physiological, safety) before progressing to higher-level needs (love/belonging, esteem, self-actualization).

Critical Thinking

Intentional, contemplative, and outcome-directed thinking that is clear, accurate, precise, relevant, significant, logical, fair, and broad-based, evaluating assumptions, inferences, and consequences.

Critical Reasoning

A specific term referring to the assessment and management of patient problems at the point of care.

Scientific Method

A step-by-step process used to gain knowledge and answer questions, including making observations, asking questions, forming a hypothesis, conducting an experiment, analyzing results, and drawing conclusions.

Patient Teaching

An essential nursing activity involving sharing information and educating patients about their plan of care, medications, pain management, nutrition, rehabilitation, community resources, follow-up, and signs of complications.

LPN role in Patient Education

To implement an established teaching plan or protocol as assigned by an RN, physician, or other qualified professional, and participate in teaching and counseling within their scope of practice.

Informal Teaching

Unplanned patient education that occurs spontaneously at the bedside.

Formal Teaching

Planned patient education that requires a structured plan, with potential teaching needs identified at admission and evaluated throughout treatment.

Cognitive Domain (Learning Style)

Learning by listening, reading, facts, and descriptions, involving the use of mental processes.

Affective Domain (Learning Style)

Processing information that appeals to the patient's feelings, beliefs, or values, involving emotional engagement.

Psychomotor Domain (Learning Style)

"Hands-on" learning by doing, a type of kinesthetic learning.

Pedagogy

The science of teaching children or individuals with limited cognitive ability.

Andragogy

The science of teaching adults.

Geragogy

The science of teaching older adults.

Teach-Back Method

A communication technique where the healthcare provider asks the patient to explain information or demonstrate a skill in their own words to confirm understanding.

Ptosis

Drooping of the upper eyelid.

Proptosis

Extended or protruding upper eyelid, often associated with exophthalmos.

Nystagmus

Uncontrolled, involuntary movement of the eyeball.

Corneal Light Reflex

A test of extraocular function that assesses the alignment of the eyes by observing the reflection of light on the corneas.

Cover-Uncover Test

A procedure used to detect strabismus (eye misalignment) by covering one eye and observing the movement of the other, then uncovering to see if it moves back.

Cardinal Positions of Gaze

The six primary positions of the eye used to test and assess the function of the six extraocular muscles and their cranial nerve stimulation.

Snellen Chart

A chart with letters of decreasing size used to test far visual acuity.

Jaeger Chart

A card with paragraphs of text in various font sizes used to evaluate near visual acuity.

Ishihara Polychromatic Plates

A series of plates with colored dots forming numbers or patterns, used to test for color blindness (color vision deficiency).

Color Blindness (Color Vision Deficiency)

An error in the production of photopigments in the cones of the eye, causing difficulty in distinguishing between colors, particularly red and green.

Strabismus

Eye misalignment, where the eyes do not look in the same direction at the same time.

Tinnitus

A buzzing, ringing, or whistling sound in one or both ears that is not caused by external sound.

Whisper Test

A non-invasive hearing screening to detect hearing loss by having a patient repeat whispered words or numbers, testing one ear at a time.

Conductive Hearing Loss

Hearing loss caused by problems with the transmission of sound waves through the outer or middle ear.

Sensorineural Hearing Loss

Hearing loss caused by damage to the inner ear (cochlea) or the auditory nerve.

Rinne Test

A hearing test using a tuning fork to compare bone conduction and air conduction of sound, helping to differentiate between conductive and sensorineural hearing loss.

Weber Test

A hearing test using a tuning fork placed on the patient's head to determine if sound is heard equally in both ears or lateralizes to one side, indicating type and location of hearing loss.

Romberg Test

A test of balance that assesses the inner ear's role in maintaining equilibrium by observing a patient's sway with eyes closed.