Foundations Week 2, Exam 1: Nursing Process and Critical Thinking

what are the five steps of the nursing process

Assessment

Diagnosis

Planning

Implementation

Evaluation

gathering information about the patients conditions is what part of the nursing process

assess

identifying the patient's problems is what part of the nursing process

diagnose

setting goals of care and desired outcomes and actions is what part of the nursing process

planning

performing the nursing actions identified in planning is what part of the nursing process

implement

determining if goals and expected outcomes are achieved is what part of the nursing process

evaluation

example of a primary source when collecting patient information

the patient themselves

example of secondary sources when collecting patient information

family caregiver, spouse, mother, father, medical records, etc.

what are the two stages of assessment

1. Collection and verification of data from primary and secondary sources

2. Analysis of data, interpretation and validation to see if more data may be needed

what is subjective data

patient's verbal descriptions of their health problems, their own voice

(feelings, perceptions, self reported symptoms, etc.)

What is objective data?

findings resulting from direction observation or measurements

objective data is measured on the

basis of an accepted standard

what is the best source of assessment data

the patient (especially if they are conscious, alert, and orientated)

Name some sources of assessment data

patient, family caregiver, and significant others, health care team, medical records, records and literature, the nurse's experience

What is hands-off reporting

the transfer and acceptance of patient care responsibility and essential information from one caregiver to another

nursing health history

a key component of a comprehensive assessment that covers all health dimensions, a formal method used to collect data about a patient

dimensions in the patients health history

spiritual, intellectual, physical and developmental, emotional, and social

What is cultural competence?

Involves self-awareness, reflective practice, and knowledge of a patient's core cultural background and the ability to adapt

what is cultural humility?

Requires you to recognize your own knowledge limitations and cultural perspective and thus be open to new perspectives

PQRST method of pain assessment

P: provokes

Q: quality

R: radiate

S: severity, 0-10

T: time

psychosocial health history includes a patients

coping strategies and support systems

What is the review of systems components in health history?

An overall assessment of major body systems/functions, going through each body system with a list of questions to see what is wrong

record any subjective information by using

quotation marks

what is data collection in the assessment process

using information about a patients needs to adapt your data collecting

what is the interpretation aspect in the assessment process

critically interpreting the assessment data to determine whether abnormal findings are present, using cues and inferences

What are cues?

information you obtain through the use of your senses, the cues are the signs and symptoms you obtain through observation and measurements

What are inferences?

A conclusion reached on the basis of the cues you identified

what is the validation aspect of the assessment process

the comparison of data with another source to determine data accuracy

why do we use concept mapping to organize assessment data

it visually represents the connections among these multiple problems, it develops critical thinking skills by helping learners understand relationships with the patient's problems

a nursing problem/diagnosis is made when

a nurse identifies a health-related problem or the potential to develop a problem based on patient data

Medical vs. Nursing Diagnosis or Problems

Medical is the overall diagnosis. Nursing is symptoms- evidenced-based clinical judgment, we diagnose response...

ex:

medical: patient has pneumonia

nursing: patient has impaired gas exchange

do nurses treat medical diagnoses

No, you cannot order certain treatments or diagnose directly, it is outside the scope of practice

what is a medical diagnosis

Identification of a disease condition based on specific evaluation of signs and symptoms, medical history, and test results

What are collaborative problems?

a problem that requires both medicine and nursing interventions to treat

problem-focused nursing diagnosis

identify an undesirable human response to existing problems or concerns of a patient

risk diagnosis/nursing problem

problems that apply when there is an increased potential or vulnerability for a patient to develop a problem or complication

what are patient-centered goals

tool for promoting patient-centered care, which aims to recognize each patient's uniqueness and right to make decisions about their own healthcare

health promotion nursing problem statements

identify the desire or motivation to improve health status through a positive behavioral change

Define nursing diagnosis

a clinical judgement made by a RN to describe a patients response or vulnerability to health conditions or life events

what is a data cluster

a set of assessment findings/defining characteristics, allows you to focus on pattern recognition

data interpretation involves

placing a label on your data pattern or cluster to clearly identify a patient's response to health problems

3 Parts to a nurses problem statement

1. label

2. related factors

3. major defining characteristics

Risk Nursing Diagnoses: 2 parts

1. problem

2. associated risk factors

Health Promotion Diagnoses: 2 parts

1. diagnostic label

2. defining characteristics or assessment

Planning nursing care involves

-setting priorities based on patient problems

-identifying patient-centered goals and outcomes

-prescribing nursing interventions appropriate for each diagnosis

What is planning?

Reviewing a patient's nursing diagnosis and other collaborative problems, prioritizing nursing diagnosis and problems, setting outcomes to guide the plan of care, and choosing relevant interventions for patient care

what are goals

something you aim for that takes planning and work

what is priority setting

putting your nursing problems in preferential order to establish what is most important and the sequence of nursing interventions

critical thinking in setting goals

a broad statement that describes the desired change in a patient's condition, perceptions, or behavior

Goal predicts

the resolution of the problem, evidence of progress, or continued maintenance of good health or function

short term goals

an objective behavior or response that you want to be achieved in less than a week or a few hours

long term goals

behaviors you would want to be achieved in days, weeks, months

Goals are based on

standards of care or clinical guidelines established for minimal safe practice

patient collaboration is needed to

-Better prioritize goals of care and develop a realistic and relevant plan of care

interprofessional team collaboration

number of health professionals are on board, everyone communicated the needs of the patient to clarify needs and ensure care to better outcome, satisfaction, and safety... make interprofessional care plans

What is the SMART acronym when writing goals and expected outcomes?

Specific, Measurable, Attainable, Realistic, and Timed goals

what is a nursing outcome classification

a standardized system for measuring and evaluating the impact of nursing care on patient outcomes, links outcomes to international nursing diagnoses

what are expected outcomes

results that are anticipated to happen or hoped for

what is a nurse-sensitive patient outcome

a measurable patient, family, or community behavior or perception that is measured in response to nursing interventions

specific goals in SMART

outcomes and goals reflect a specific patient's behavior

measurable goals in SMART

need to measure the change

ex: level of pain

attainable goals in SMART

goal or outcome needs to be something you and the patient can agree on

realistic goals in SMART

realistic or relevant or else the patient wont buy into it.. they need to see it as something they can do

time goals in SMART

set a time for each goal and outcome to be met

Types of Interventions

- nurse initiated

- health care provider initiated

- other provider initiated

direct interventions/measures

you directly perform and interact with the patient, provided through patient interactions

ex: giving id, bathing, wound care,etc

indirect interventions/measures

treatments or produced you do away from patients but on their behalf

ex: call dietary to adapt patient's diet due to recent change, interprofessional collaboration, documentation

nurse-initiated intervention

something you can initiate without any order or direction from anyone else

ex: cloth and debrief to prevent something, health education

health care provider-initiated intervention

things you need an order to perform

ex: medication, insertion of catheter or starting IV

Other provider-initiated interventions

Orders from ot, pt, pharmacy, anyone other than the nurse or provider, therapies that require the combination of knowledge, skill, and expertise of multiple providers

factors to consider when choosing interventions

-Desired outcomes

-Characteristics of the nursing problem

-Research base knowledge

-Feasibility

-Acceptability

-Your competency/experience

what is the nursing intervention classification (NIC)

a valuable resource for selecting appropriate interventions and activities for your patient, a set of nursing interventions that provided a level of standardization to enhance communication

What are ADLs?

activities of daily living

what is a nursing care plan

a plan including the nursing diagnoses, goals and expected outcomes, and nursing interventions, and a section for evaluation findings... promotes continuity of care and better communicationw

Consulting with Health Care Professionals occurs mainly during what steps of the nursing process

the planning and implantation steps

What is consultation?

when you seek the expertise of a specialist to identify ways to handle specific problems in patient management or the planning and implementation of therapies

ISBAR approach to frame patient situations

identify the problem and then give the situation, background, assessment, and recommendation

scope of practice

activities permitted to be performed, implementation must be patient-centered, you need to learn how to intervene for a patient

standard interventions allow

nurses to act more quickly and appropriately, helping to capture patient care information

What is a care bundle?

group of interventions related to a disease process or condition

clinical practice guidelines and protocols

a systematically developed set of statements about appropriate health care for specific health care problems or clinical situations

Standing orders are

A preprinted document containing medical orders that also directs patient care in a specific clinical setting

Quality and Safety Education for Nurses (QSEN)

standard competencies in knowledge, skills, and attitudes for the preparation of future nurses

what do nurses use as evidence of the standard or care provided to patients

the ANA Standards of Professional Nursing Practice

When making decisions for implementation

1. review all possible nursing interventions

2. review all consequences for each action

3. determine the probability of consequences

4. judge the value of consequences to the patient

evaluation in the nursing process determines

whether a patients condition or well-being improved after interventions were delivered

the _____ are the criteria for judging the success in delivering nursing care

outcomes of the nursing practice

when examining results, it is

an ongoing and continuous process that includes a before and after comparison and subjective and objective data from those involved

the results of an evaluation help you determine if you should/can

1. discontinue a care plan

2. modify or revise a care plan

what are dependent nursing interventions

interventions that require an order from a health care provider

patient-centered care is only achieved when

a patient and family are actively involved in the evaluation process

successful collaboration involves

Interactions in which professionals work together cooperatively with shared responsibility and interdependence toward achieving patient outcomes

when documenting a patients response to your interventions describe

the interventions, the evaluative measures used, the outcomes achieved, and the continued plan of care

the critical thinking is an essential process for

safe, efficient, and skillful nursing intervention

Nursing Clinical Judgment Measurement Model (NCJMM)

recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action, evaluate outcomes (RAPGTE)

critical thinking is a continuous process characterized by

open-mindedness, continual inquiry, perseverance, ones willingness to look at each patient's situation uniquely, and the ability to determine which assumptions are true and relevant

Reflection

reviewing a situation to discover its purpose or meaning, thinking back to what went well, what went bad, and what you could do better to gain new knowledge and raise questions

what are the 3 levels of critical thinking

1. Basic

2. Complex

3. Commitment

what is a basic level 1 thinker

a thinker that trusts the experts and uses manuals to help in coming to a decision

what is a complex level 2 thinker

a thinker who uses its experience to anticipate how individualize a nursing procedure when problems arise