nurs 226 crit thinking and nursing process review

occurs when you gather and evaluate information

critical thinking

observation, reflection, experience, reasoning, communication

utilized with critical thinking

being aware of what is going on around you at any given time

situational awareness

focus and intention, must be present and not distracted, evaluate immediate situation and determine safety risks

requirements for situational awareness

decision making that involves critical thinking and is used in every patient encounter: processing all info and deciding how to act with the info provided

clinical judgement

systematic, dynamic, interpersonal, outcome oriented, universally applicable

nursing process steps

part of an ordered sequence of activities

systematic

great interaction and overlapping 5 steps

dynamic

human being is always at the heart of nursing

interpersonal

nurses and patients work together to identify outcomes

outcome oriented

a framework for all nursing activities

universally applicable

the process of clinical reasoning using ADPIE

the nursing process

assessment, diagnosis, planning, implementation, evaluation

ADPIE

full comprehensive history of the patient

comprehensive health assessment

completed shortly after the patient is admitted

initial assessment

assessment to help identify new or overlooked problems

focused assessment

short and focused assessment to gain important info

priority assessment

helps identify life threatening problems

emergency assessment

scheduled assessment: compares patient’s current status to the baseline

time-lapsed assessment

data that is measurable

objective data

info that the patient tells you

subjective data

onset, location, duration, characteristics, associated manifestations, relieving, treatment

OLDCART

impact on ADLs, coping strategies, emotional responses

ICE

subjective and objective data that is identified

cues

judgement made from the cues

inference

keep data free from error, bias, and misinterpretation

validating assessment data

once organized look for patterns: forming hypotheses from the patient’s data and making a decision based on what the data suggest

clustering data and identifying patterns

begins after the nursing history and collection of data, goal of identifying health and life processes, factors that contribute to health problems and identifying resources to resolve problems

diagnosis

clinical judgement about the individual, family, or community response to potential health problems

nursing diagnosis

identifies diseases and describes problems for which the physical or advanced practice nurses directs the primary treatment

medical diagnosis

clinical judgement concerning an undesirable response to health condition

problem-focused nursing diagnosis

concerns vulnerability for developing an undesirable human response to a health condition

risk diagnosis nursing diagnosis

concerns motivation and desire to increase well-being

health promotion nursing diagnosis

problem, etiology, defining characteristics

formulating a nursing diagnosis

establish priorities and identify expected patient outcomes and communicate plan of care

outcome identification and planning

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

maslow’s hierarchy of needs

subject, verb, conditions, performance criteria, target time

writing parts that measure outcomes

evidence-based interventions and include patient and family

plan interventions

nurse-initiated, physician-initiated, and collaborative

types of interventions

carry out plan, continue data collection and document care, can modify plan of care if needed

implementation

assess patients before performing nursing actions, reasses for status changes and monitor patient responses: ASSESS, REASSESS, REVISE, RECORD

planning implementation

determine patient’s new or continuing need for assistance, promote self-care and assist patient to achieve outcomes

implementing plan of care

measure how well the patient has achieved desired outcomes, identify factors that contribute to the patient’s success and failure. modify if needed

evaluating

identifying criteria, collecting data, interpreting findings, document judgment, terminate, continue, or modify the plan

five elements of evaluation

decide how well the outcome was met, list patient data that support decision, action based on patient response to care plan

evaluative statements