Fundamentals of Nursing Exam 1

ANA

American nurses association

Who is at the center of the healthcare team

the person

Critical thinking should be

disciplined, comprehensive, well-reasoned

Purpose of thinking

your thoughts should always be directed toward the goal

Critical thinking

Knowing how to focus your thinking to get the results you need

Clinical reasoning

the thought processes that allow you to arrive at a conclusion

Clinical judgement

the results of critical thinking

Situational awareness

recognizing something isn’t right

Critical thinking steps

1) identify the goal of thinking

2) assess adequacy of knowledge

3) address potential problems (no biases)

4) consult helpful resources

5) critique judgement/decision

Trial-and-error nursing problem is not

generally used (only when inserting an IV)

Trial-and-error involves

testing solutions until one is found that works

Scientific nursing process

systematic, seven-step process

Intuitive nursing process

direct understanding of a situation based on a background of experience, knowledge, and skill that makes expert decision making possible

Tanner Model

Noticing, Interpreting, Responding, and Reflecting

Nursing Process

Assessing, Diagnosing, Planning, Implementing, Evaluating

Characteristics of the nursing process

systemic, dynamic, interpersonal, outcome oriented, universally applicable

Assessing

collecting, validating, and communicating patient data

Diagnosing

analyzing patient data to identify patient strengths and problems

Planning

specifying patient outcomes and related nursing interventions

Implementing

carrying out the care plan

Evaluating

Measuring extent to which patient achieved outcomes to direct future nurse-patient interactions

Systematic

part of an ordered sequence of activities

Dynamic

great interaction and overlapping among the five steps

Interpersonal

human being is always at the heart of nursing

Outcome oriented

nurses and patients work together to identify outcomes

Universally applicable

a framework for all nursing activities

Concept Mapping

instructional strategy that requires learners to identify, graphically display, and link key concepts

Concept mapping steps

1) collect patient problems and conerns on a list

2) connect and analyze the relationships

3) create a diagram

4) keep in mind key concepts: the nursing process, holism, safety, and advocacy

Cues

something that clues you in

Inferences

critical thinking to come up with a conclusion

Medical assessments target data pointing to

pathologic conditions

Nursing assessments focus on the

patient’s response to health problems

Initial assessments

performed shortly after admittance to a healthcare facility to establish a complete database for problem identification and care planning.

Initial assessment forms the

complete database

Focused assessment

may be performed during initial assessment or as routine ongoing data collection to gather data about a specific problem already identified or to identify new or overlooked problems

Quick priority assessments

short, focused, prioritized assessments completed to gain the most important information needed first

Emergency assessment

performed when a physiologic or psychological crisis presents; identifies life-threatening problems

Time-lapsed assessment

performed to compare a patient’s current status to baseline data obtained earlier; to reassess health status and make necessary revisions in care plan

Triage assessment

determine the extent and severity of patients problems and recommend appropriate follow-up

Maslow’s hierarchy

physiological, safety, love and belonging, esteem, and self-actualization

Objective data

observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them; data the nurse observed

Subjective data

information perceived only by the affected person; from the patient

Primary source of data

patient

Secondary sources of data

family and significant others, patient record, medical history, physical examination, progress notes, consultations, reports of laboratory and other diagnostic studies, reports of therapies by other healthcare professionals, nursing and other healthcare literature

Nursing interview

preparatory phase, introduction, working phase, termination

During nursing interview

sit with patient eye-to-eve level and develop a trusting relationship

Inspection

the process of performing deliberate, purposeful observations, in a systematic manner (look at patient)

Palpation

use of sense of touch to assess skin temperature, turgor, texture, and moisture as well as vibrations within the body (with abdomen, last thing you want to do is palpate)

Percussion

the act of striking one object against another to produce sound

Auscultation

the act of listening with a stethoscope to sounds produced within the body

Problem statements focus on

unhealthy responses to health and illness; may change from day to day

Steps of data interpretation and analysis

1) recognizing significant data: comparing data to standards

2) recognizing patterns or clusters

3) identifying strengths and current or potential problems

4) identifying potential complications

5) reaching conclusions

6) partnering with the patient and family

Risk nursing diagnoses

a client is vulnerable to developing a potential health problem

Types of nursing diagnoses

problem-focused, risk, health promotion

Nursing diagnoses contain

diagnostic label, related factors, and defining characteristics

Problem identifies what is

unhealthy about patient; what is wrong

Etiology identifies

factors maintaining the unhealthy state; what is causing the problem

Formulation of nursing diagnoses

problem, etiology, signs and symptoms

Nursing diagnosis describes

patient problems nurses can treat independently

Medical diagnosis describes

problems for which the physician directs the primary treatment

Collaborative problems

managed by using physician-prescribed and nursing-prescribed interventions

Major process of planning is to come up with

goals

Goals of planning step

-establish priorities

-identify and write expected patient outcomes

-select evidence-based nursing interventions

-communicate the nursing plan of care

Three elements of comprehensive planning

initial, ongoing, discharge

Initial planning is developed by the nurse who

performs the nursing history and physical assessment

Initial planning

addresses each problem listed and identifies appropriate patient goals

Discharge planning starts

the minute the patient enters the hospital

Ongoing planning is carried out by

any nurse who interacts with patient

Ongoing planning

keeps the plan up to date, manages risk factors, promotes function, states problem statements more clearly, develops new problem statements, makes outcomes more realistic and develops new outcomes as needed, identifies nursing interventions to accomplish patient goals

Discharge planning is carried out by the nurse who

worked most closely with the patient

Discharge planning

uses teaching and counseling skills effectively to ensure that home care behaviors are performed competently

Physiological needs

impaired gas exchange

safety needs

risk for falls

Love and belonging needs

social isolation

Self-esteem needs

risk for chronic low self-esteem

Self-actualization needs

impaired religiosity

Cognitive outcomes

describes increases in patient knowledge or intellectual behaviors

Psychomotor outcomes

describes patient’s achievement of new skills

Affective outcomes

describes changes in patient values, beliefs, and attitudes

Outcome statements need to be SMART

Specific

Measurable

Attainable

Realistic

Time-bound

Patient outcomes should not be expressed as a

nursing intervention

Nurse-initiated nursing interventions

autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes

Physician-initiated nursing interventions

actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders

Collaborative

treatments initiated by other providers and carried out by a nurse

Purposes of implementation

help the patient achieved valued health outcomes, promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning

Before implementing

always assess and reassess after to see if anything has changed

Alfaro’s rule

assess, reassess, revise, record

Five rights of delegation

Right task- falls within the delegatee’s job description

Right circumstance- the patient must be stable

Right person- the licensed nurse, employer and delegate assures that the delegate has the skills to perform the task

Right directions and communication- the licensed nurse must communicate specific directions to the delegate and assure that they fully understand the task

Right supervision and evaluation- the licensed nurse is responsible for monitoring and following up with the delegate upon completion of the task

Evaluation step

nurse and patient together measure how well the patient has achieved the outcomes specified in the care plan and the nurse identifies factors that contribute to the paitent’s ability to achieve expected outcomes and, when necessary, modified the plan of care

Criteria

measurable qualities, attributes, or characteristics that identify skills, knowledge, or health status

Standards

levels of performance accepted by and expected of the nursing staff or other health team members

Types of outcomes

cognitive, psychomotor, affective, physiologic

Cognitive outcomes

increase in patient’s knowledge

Psychomotor outcomes

patient’s achievement of new skills

Affective outcomes

changes in patient’s values, beliefs, or attitudes

Physiologic outcomes

physical changes

Evaluation outcomes have to have a

time frame

Four steps crucial to improving performance

1) discover a problem

2) plan a strategy using indicators

3) implement a change

4) assess the change and/or plan a new strategy if outcomes are not met

Health

a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity

Morbidity

how frequently a disease occurs