Socialization 1 Final

Critical Thinking

Purposeful, goal-directed thinking that uses logic, evidence, and reasoning to make clinical decisions.

Clinical Reasoning

The process of gathering, analyzing, and synthesizing patient info to make care decisions.

Clinical Judgement

The decision or conclusion based on clinical reasoning and critical thinking.

nursing process

Assess
Diagnose
Plan
Implement
Evaluate

Assessment

Collect subjective & objective data to identify actual or potential health concerns.

Diagnosis

Analyze data to form NANDA-approved diagnoses (problem-focused, risk, health promotion, or syndrome)

Planning

Create SMART goals and prioritize problems (high, medium, low) to guide care.

Implementation

Perform interventions (nurse-, physician-, or collaboratively initiated) to meet patient goals.

SMART

a framework for writing effective nursing goals/outcomes in planning phase:

S: specific

M: measurable

A: achievable

R: relevant

T: time-bound

evaluation

Check if goals were met, partially met, or unmet; continue, modify, or terminate plan.

Problem-Focused Diagnosis

Problem r/t etiology AEB signs/symptoms

Ex: "Impaired gas exchange r/t fluid in lungs AEB low O2 sats"

AEB

as evidenced by

describe the proof or signs/symptoms that support your diagnosis.

risk diagnosis

"Risk for [problem] as evidenced by [risk factors]"
Ex: Risk for falls AEB impaired balance and age

Health Promotion Diagnosis

Focus on patient’s readiness to improve health
Ex: “Readiness for enhanced nutrition”

syndrome diagnosis

Cluster of issues with a shared cause/intervention
Ex: Post-trauma syndrome, Decreased cardiac output

nursing vs medical diagnosis

Nursing = holistic and time-limited
Medical = disease-based, permanent in chart

Maslow’s hierarchy of needs

1. physiological: food, water, sleep, oxygen

2. safety needs: shelter, security, job

3. love/belonging: relationships, support system

4. esteem: respect, confidence

5. self actualization: growth, purpose

culture

• Shared values, beliefs, behaviors, and norms

cultural assimilation

• Minorities adopt traits of the dominant culture

cultural shock

Disorientation in unfamiliar culture

stereotyping

Assuming everyone in a group is the same

ethnocentrism

Believing your culture is superior

cultural imposition

Forcing your beliefs on someone else

cultural competence

Respecting and integrating a patient’s cultural needs and beliefs into care

cuture of poverty

Day-to-day survival, hopelessness, lack of resources/support

transcultural assessment includes

• Beliefs, values

• Health-related practices

• Etiology of illness

• Help-seeking behaviors

professional values

Altruism, Autonomy, Human dignity, Integrity, Social justice

bioethics

Deals with moral issues in healthcare & research

nursing ethics

Ethical issues specific to nursing practice

feminist ethics

Focuses on power imbalances & oppression

ethical dilemma

Two or more equally compelling ethical choices

moral distress

Knowing the right thing to do but being blocked from doing it

advocacy

Representing patient interests, promoting autonomy, whistle-blowing if needed

criminal law

Offenses against public (e.g., drug diversion)

misdemeanor

Less serious crime, fine or <1 year jail

felony

Serious crime, >1 year prison

Torts – Intentional

Assault, Battery, False imprisonment, Defamation, Invasion of privacy, Fraud

torts: unintentional

Negligence, Malpractice

Informed Consent Requirements

Disclosure, Comprehension, Competence, Voluntariness

Incident Report

Documents unusual events objectively — used for quality improvement, NOT in the chart

roles of nurses in legal cases

Defendant (accused),
Fact witness (what you saw),
Expert witness (qualified opinion)

types of nursing assessments:

1. initial/comprehensive

2. focused

3. emergency

4. time-lapsed

initial/comprehensive

at admission; full baseline

focused assessment

when a new issue arises (ex: pain, wound)

emergency assessment

crisis (ex: stroke, cardiac arrest)

time-lapsed assessment

scheduled reassessments (e.g. rehab)

cognitive patient teaching

knowledge (ex: “Pt will state signs of infection”)

psychomotor patient teaching

skills (ex: “Pt will demonstrate insulin injection”)

affective patient teaching

attitudes/beliefs (ex: “Pt expresses motivation to stop smoking”)

Informed consent requires:

disclosure, comprehension, competence, voluntariness

are incident reports mentioned in chart?

no never!

Negligence

unintentional failure to act as a reasonable nurse would

assault vs battery

assault: threat

battery: touching

False imprisonment

restraints without orders/justification

Concept Mapping

A visual method for organizing and linking key patient data to identify patterns and nursing diagnoses.

Cognitive Outcome

Patient gains knowledge or intellectual skills (e.g., "Patient will list signs of infection").

Psychomotor Outcome

Patient demonstrates new skills (e.g., "Patient will correctly use an inhaler").

Affective Outcome

Patient’s attitudes, values, or beliefs change (e.g., "Patient expresses confidence about lifestyle change").

Nonmaleficence

Ethical principle meaning “do no harm.”

Health Care Proxy

Legal document that designates someone to make healthcare decisions for a patient if they become incapacitated.

MOLST Form

Medical Orders for Life-Sustaining Treatment — communicates patient wishes as actual medical orders.

Concept of Moral Distress

Emotional discomfort when a nurse knows the right action but is blocked by policies or constraints.

Whistle-blower

A nurse who reports unsafe or unethical practices — protected under law from retaliation.

Criteria vs. Standards in Evaluation

• Criteria: measurable behaviors/skills expected

• Standards: what the facility or profession expects (set by authority/policy)

Law

A standard or rule of conduct established and enforced by government, designed to protect the rights of the public.

4 sources of Law

1. constitutional

2. Statutory

3. Administrative

4. Common

constitutional law

guides legislation

statutory

passed by legislature (e.g. Nurse Practice Act)

administrative

made by agencies (e.g. BON rules)

common

developed by courts/judicial decisions

public law

between gov’t and people

private law

between individuals

ex. matrimony

Ways to ensure competence in nursing: (credentials)

1. accrediation

2. licensure

3. certification

accreditation

program meets standards

licensure

legal permit to practice

certification

extra recognition for advanced knowledge/skills

Grounds for License Suspension/Revocation

drug/alcohol abuse, fraud, criminal acts, negligence, or physical/mental impairment

Due Cause for Revoking License Requires:

• Notice of investigation

• Fair hearing

• Evidence-based decision

Elements of Malpractice

• Duty

• Breach of Duty

• Causation

• Damages

Categories of Malpractice Claims

• Failure to follow standards of care

• Improper equipment use

• Failure to assess, monitor, communicate, document, or advocate

OSHA Legal Regulations Cover safe use of:

• Electrical equipment

• Isolation techniques

• Radiation

• Chemicals

Risk Management Programs Designed to improve safety:

• Safety program

• Product safety

• Quality assurance

Living Will

States what care you want if you're terminally ill or permanently unconscious and can’t make decisions.

litigation

process of bringing and trying a lawsuit

plaintiff

person bringing suit

defendant

person being accused of a crime

› Presumed innocent until proven guilty

what can boards of Nursing do?

Administer the nursing practice act

› Set rules necessary to implement the act

› License nurses

› Can deny, suspend, revoke

› Discipline licensed nurses

Tort

a wrong committed by a person against another person or that person’s property; tried in civil court

› Intentional

› Unintentional

drug diversion triad

1. pressure/motivation: external and internal

2. opportunity

3. rationalization/justification

altruism

• concern for welfare and well-being of others

autonomy

• right to self-determination

human dignity

•  respect for inherent worth and uniqueness of individuals and populations

integrity

acting according to code of ethics and standards of practice

social justice

• upholding moral, legal, and human rights

autonomy

respect a persons freedom to choose whats right for them

justice

treat and provide care fairly to all pts

benefience

all choices for a patient are made with the intent to do good

PES

1. problem

2. etiology

3. solution