nursing process and critical thinking Exam 2

what is the nursing process

ADPIE

assessing

collecting, validating, and communicating patient data

Diagnosing

analyzing patient data to identify patient strengths and problems

Outcome Identification/Planning:

specifying patient outcomes and related nursing interventions

implementing

: carrying out the care plan

evaluation

: measuring the extent to which patient achieved outcomes

types of nursing assessments

Initial
problem focused
emergency
time lasped

what in initial in the nursing assessment

stablish a complete database and provides reference base for problem identification, reference, and future comparison

what in problem focused in the nursing assessment

ongoing process to determine the status of a specific problem identified in an earlier assessment; short focused prioritized assessment; "flag" risks

what is emergency in the nursing assessment

occurs during physiologic or psychological crisis to identify life threatening problem and identify new or overlooked problems

What is a time-lapsed assessment?

occurs weeks to months after the initial assessment and compares current status to baseline to reassess health status

what is the assessment checklist

preparing for data collection
collecting data
identifying cues and making inferences
validating data
clustering related data and identifying patterns
reporting and recording data

objective data

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

what is subjective data

information perceived by the affected person

what is objective data examples

directly or indirectly observed through measurement
inspection
palpation
percussion
auscultation
respiration in 16 per min
bp
apical pulse
irregular or reg
Xray film

what is some example for sub data

data elicited from pt
pt fam
client records
other health care proff.
client interview
caring ability and empathy
listening skills
- i have a head ache
- it frightens me

nursing diagnosis parts

diagnosis problem
Nausea/vomiting/diarrhea
>3 liquid stools in 24 hours, 250 ml of green emesis, dry mucous membranes

Types of Nursing Diagnoses

problem focused
risk diagnosis
health promotion diagnosis

Nursing adpie
planning purpose

design a plan of care with and for the patient that results in prevention, reduction, or resolution of the health problem and attainment of the patient's health expectations

what is the
Nursing adpie
planning method

Develop goals & outcomes then design interventions to accomplish them

what is the outcome identification and planning

establish priorities
identify expected pt outcomes
select evidence-based nursing interventions

planning
what are the steps to care planning 1

- Collect and assess data
• Diagnose problems and potential problems• - Decide on outcome - an expected conclusion to a patient health problem determined after data interpretation•
--Outcomes and plans are determined by the nurse AND the patient/family (short term and long-term goals)•
-Develop interventions to achieve goals• -Implement and evaluate interventions
• Revise and repeat steps as needed

what is goals

are what you want the patient to do or accomplish - not what you are going to do!

what is interventions

must relate to the goals you set which must relate to the problems you diagnosed.

Outcomes
To be measurable, outcomes should have the following:

-Subject - the patient or some part of the patient•
-Verb - the action the patient will perform•
-Conditions - the particular circumstances in or by which the outcome is to be achieved •
-Performance criteria - The expected patient behavior or other manifestation in observable, measurable terms• -Target time - when the patient is expected to be able to achieve the outcome• -Examples:•
"During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL."•
--"At the next visit, 12/23/20, the patient will correctly demonstrate relaxation exercises (4-7-8 breathing and progressive muscle relaxation)."

The Nursing Interventions Classification (NIC) project

defines a nursing intervention as "any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes"

what are the 3 types of intervention

independent
dependent
collaborative

what is the independent intervention

-Nurse initiated interventions
○In realm of independent nursing practice
○No MD order required

what is the dependent interventions

Physician initiated interventions ○Require MD orders

what is the collaborative interventions

Coordination of multiple professional

evaluation is what

is a form of assessment - instead of assessing the patient, you are assessing how well they have met their goals.
If they aren't meeting their goals, you are assessing why. You may need to modify your goals or your interventions if they are not appropriate.

what is critical thinking

Purposeful, goal-directed thinking based on scientific knowledge
●It involves seeking and weighing alternatives and selecting the best one to meet the desired outcome ●Uses a logical process to gather information, analyze it, and take purposeful action based on the evaluation
●Nurses need to think critically to make complex decisions, adapt to new situations, and continually update their knowledge and skills.

Cognitively skilled nurses are critical thinkers.

why do nurses think critically

●To solve complex patient problems in a logical and clear manner (being thinkers, not just doers)
●To provide safe, competent, and skillful nursing care to meet the needs of patients, families, and communities
●To make reliable observations, draw sound conclusions, create new information, evaluate lines of reasoning, improve self-knowledge
●It is mandated for accreditation of schools of nursing (the profession believes it is essential)

NCBSN operational definition

Clinical judgment is defined as the observed outcome of critical thinking and decision-making. It is an iterative process that uses nursing knowledge to observe and assess presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care.

NCBSN developed a clinical judgement model that

builds on and expands the nursing process. The evidence-based Clinical Judgment Measurement Model (NCJMM) identifies cognitive skills needed to make appropriate clinical judgments and will be the basis for the Next-Generation NCLEX-RN.

Cognitive skills needed for appropriate clinical judgements:

Recognize cues
●Analyze Cues
●Prioritize hypotheses
●Generate solutions
●take action
●Evaluate outcomes

novice nurses thinking pattern

Knowledge is organized as separate facts
●Focus too much on actions, forgetting to assess before acting
●Need clear cut rules
●Unaware of resources
●Hindered by anxiety and lack of self-confidence
●Rely on step-by-step procedures (focus on procedures rather than the patient's response to the procedures)
●Uncomfortable if patient's needs alter the performance of activities
●Question and collect data more superficially
●Follow standards and policies as written
●Learn best when partnered with a supportive mentor or preceptor

what is the mnemonic for prioritization

•A-Airway
•B-Breathing
•C-Circulation (any issue, heart, blood, brain, tissue)
•D-Diagnoses (consider issues with diagnoses)

•P-Pain
•L-Lab issues
•M-Medication Issues
•T-Teaching
•F-Fall precautions/Safety
•D-Drains and tubes (IV, foley, wound drain)