Studied by 1 person
critical thinking
the process of intentional and reflective judgement about nursing problems where the focus is on clinical decision making to provide safe and effective outcomes
critical thinking skills
objectively gathering information recognizing the need for more information evaluating the credibility of sources recognizing gaps in one's own knowledge listening carefully and reading thoroughly separating relevant from irrelevant info/data organizing information in meaningful ways making inferences and drawing conclusions visualizing potential solutions
nursing process
a systemic problem solving process that guides all nursing actions
purpose of the nursing process
to help the nurse provide goal directed, client centered care
the phases of the nursing process (ADPIE)
assessment, diagnosis, planning, implementation, evaluation
general survey
the overall impression of the client; it begins at first contact and continues throughout the exam includes: first impressions facial characteristics body type and posture dress, grooming, hygiene cultural considerations signs of distress
nursing assessment
the systemic gathering of information related to the physical, mental, spiritual, socioeconomic, and cultural status of an individual, group, or community
medical assessments
focuses on disease and pathology
nursing assessments
focus on the client's response to illness
nursing interview includes
purposeful and structured communication and questioning the client; the purpose is to gather subjective data for the nursing database
basic physical assessment techniques
inspection, palpation, percussion, auscultation
palpation
to examine by touch
percussion
a method in which the body surface is struck to elicit sounds that can be heard or vibrations that can be felt
auscultation
listening to sounds within the body
nursing diagnosis
using critical thinking skills to identify patterns in the data and draw conclusions about the client's health status; includes strengths, problems, and factors contributing to the problems; a statement of client's response to a health problem that nurses can identify, prevent, or treat independently
types of nursing diagnoses
actual, risk, health promotion
actual nursing diagnosis
the patient has enough signs or symptoms for the nurse to identify a specific diagnosis; judgment about a current patient health problem
risk nursing diagnosis
describes a problem response that is likely to develop if the nurse and patient do not intervene to prevent it
health promotion nursing diagnosis
a clinical judgement of motivation, desire, and readiness to enhance well-being and actualize human health potential
analyzing data includes
identify significant data cluster cues identify data gaps and inconsistencies draw conclusions about health status make inferences identify problem etiologies verify problems with patient
prioritizing problems
places problems in order of importance but does not mean that you mush resolve one problem before attending to another
components of the nursing diagnosis
diagnostic label, etiology, defining characteristics
how to choose a diagnostic label
identify the domain that seems to fit the cue cluster; narrow search to most likely class
formal planning
a conscious deliberate activity involving decision making, critical thinking, and creativity
informal planning
making mental notes or plans
why is a written nursing care plan important?
ensures care is complete provides continuity of care promotes efficient use of nursing efforts provides a guide for assessing and charting meets requirements of accrediting agencies
planning client goals
describe the changes in client health status you hope to achieve
planning client outcomes
can be influenced by nursing intervention (nursing sensitive)
planning interventions
review diagnoses and outcomes select standardized interventions individualize to meet patient needs
what are nursing interventions?
actions or measures that are based on clinical judgement and nursing knowledge, reflect direct and indirect care, and are individualized and culturally sensitive
independent interventions
tasks that nurses can perform without input from another discipline
dependent interventions
prescribed by primary care provider and carried out by nurse
interdependent interventions
carried out in collaboration with other health team members such as physical therapists social workers dietitians and physicians
evaluation includes
the client's progress toward goals effectiveness of nursing care plan quality of care in the healthcare setting
linear nursing process
a step-by-step depiction of nursing work that mirrors the scientific process; helps nurses think through the connections between each step; provides a framework that helps nurses identify their contribution to care
circular nursing process
the understanding that every step may be happening all at once and the nurse my be addressing multiple client needs at the same time
holistic caring process
the process of the nurse and client coming together in a mutual and professional interaction/relationship
assessment
the holistic nurse collects comprehensive data pertinent to the person's health and/or the situation; of the whole person; is a continuous process that involves scientific and intuitive approaches
intuitive thinking
collection and evaluation of information and patient data from a right brain mode; emerges with the nurse is open and present to the patient's subtle cues; engages the full us of self for communicating with the whole other person
intuitive perception
knowing something immediately without consciously using reason
intuition
perceived knowing of things and events without the conscious use of rational process; using all senses to receive information
clinical intuition
the process by which we know something about a client that cannot be verbalized, or is verbalized poorly, or for which the source cannot be determined; required intuitive thinking and being present
diagnosis
the holistic nurse analyzes assessment data to determine the diagnosis or issue expressed as actual or potential patterns, problems, needs, and/or health issues
planning
developing a plan with strategies and alternatives to attain expected outcomes; respects the client's experience and the uniqueness of each healing journey; uses both biomedical treatments and conventional car in conjunction with complementary/integrative care and therapies
planning/outcomes identification
the holistic nurse identifies expected outcomes for an individualized care plan for the person and/or situation; based on client's values and beliefs, preferences, age, spiritual practices, environment, ethical considerations, and situation; partners with the person to identify realistic goals based on the person's present and potential capabilities and quality of life
impelmentation/intervention
the holistic nurse implements the identified plan in partnership with the person; recognizes that the therapeutic use of self is one of the best ways a nurse can intervene and promote healing for clients
evaluation
the holistic nurse in partnership with the client evaluates progress toward attainment of outcomes while recognizing and honoring the dynamic and holistic nature of the healing process
reflective practice in holistic nursing
is a mindful process of self-observation in the midst of an experience as well as after; helps nurses resolve values and nursing practice contradictions to gain new self-insights and empowerment, and to respond more congruently in future patient care situations
theory if integral nursing
is grounded in Nightingale's theoretical concepts related to environment and holistic nursing care; is a comprehensive way to organize multiple phenomena of the patient experience related to four perspectives of reality
first component of the theory of integral nursing
healing; the central component in this theory; it includes knowing, doing, and being and is a life long journey and process of brining aspects of oneself into harmony and stages of knowing
second component of the theory of integral nursing
metaparadigm of nursing
third component of the theory of integral nursing
patterns of knowing
fourth component of the theory of integral nursing
four-quadrants
fifth component of the theory of integral nursing
all quadrants, all levels
subjective quadrant (I) includes
individual, interior, intentional, personal
objective (It) quadrant includes
individual, exterior, biological, behavioral
inter-subjective (We) quadrant includes
interior, cultural, shared values
inter-objective (Its) quadrant includes
exterior, systems, structures
Dossey's theory of integral nursing
promotes multi-dimensional nurse thinking; focuses on the inter-relationships between the physical, psychological, cultural, and social dimensions of patient care; contains aspects of the four quadrants in each component of the nursing process; it helps nurses care for the whole patient using the four quadrants to guide nursing care
psychosocial theory
understanding people as a combination of psychological and social events
psychosocial theories
Erik Erikson- developmental Maslow's Hierarchy of Human Needs and Motivations
self concept
one's overall view of oneself
dynamic self
who we are can change through influences
factors that can influence a person's self concept
gender, family, community, etc.
locus of control
a person's tendency to perceive the control of rewards as internal to the self or external in the environment; impacts how a patient will respond to the nurse and/or treatment
internal locus of control
the perception that one controls one's own fate
external locus of control
the perception that chance or outside forces beyond your personal control determine your fate
components of self-concept
body image, role performance, personal identity, self-esteem
role strain
conflicts that someone feels within a role; reality is different than expectation
interpersonal role conflict
mismatch in role expectations between individuals; your views vs others views
interrole conflict
a person's experience of conflict among the multiple roles in his or her life; competing demands
personal identity
your view of yourself as a unique human being
self esteem
how well a person likes his or herself
ideal self + real self
self-esteem; the closer the ideal self and real self the stronger a person's self esteem
additional interventions to promote self-esteem, self-concept, and self-love
establish therapeutic nursing relationship encourage independence, positive self-talk, and monitor self-criticism use positive and reaffirming language help develop realistic goals encourage activities that offer opportunity for success role model communication refer as needed to groups and resources
anxiety
an emotional state of high energy, with the stress response as the body's reaction to it; threat is known or unknown
fear
the central nervous system's physiological and emotional response to a serious threat to one's well-being; threat is known and present
mild anxiety
heightened perception and senses; muscle tension in the jaw and neck; restlessness and uneasiness; often occurs before a test or competion
moderate anxiety
perceptual field narrows; focuses on self and need to relieve discomfort; increased HR and BP; higher pitched voice
severe anxiety
very narrow perceptual field; unable to focus on on specific task; limited problem solving skills; headache, rapid HR, dizziness, nausea
panic anxiety
severe; misperceive environmental cues; wild responses; dilated pupils; labored breathing; very low problem solving
coping mechanisms
patterns of behavior used to neutralize, deny, or counteract anxiety
defense mechanisms
denial and displacement--> can become maladaptive and lead to phobias, OCD, and dissociative disorders; psychosis
depression
prolonged feeling of helplessness, hopelessness, and sadness that lasts for most of day for nearly every day for at least two weeks
symptoms of depression
fatigue, difficulty concentration, feelings of guilt, insomnia, and irritability; feelings (affect), cognition (thoughts), behavior, lifestyle effects, physiological effects
depression NANDAs
hopelessness; powerlessness; suicide risk; situational and chronic low self-esteem; physical and behavioral problems associated
risk for suicide
most important intervention is assessment; about 80% give some prior verbal or indirect cues; involve the healthcare team
health
a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity
health promotion
finding ways to help develop a state of physical, spiritual, and mental well-being; motivated by the desire to increase well-being
health protection
motivated by the desire to avoid illness
three levels of activities for health protection
primary, secondary, tertiary
primary activities
activities designed to prevent or slow the onset of disease including having a health diet, exercise, immunizations, meditation/prayer
secondary activities
screening activities and education for detecting illness in the early stages, including annual physical exams and well child checks, BP screenings, diabetes screening, cholesterol screening
tertiary activities
focuses on stopping the disease from progressing and returning the client to a pre-illness phase, includes recovering from a procedure or surgery, PT, OT, speech therapy
Pender's Health Promotion Model
three groups of variables that affect health promotion
individual
behavior specific cognitions and affect
behavioral outcome based on 7 assumptions that reflect nursing and behavioral science perspectives: assumptions 1-2 concern the interpersonal environment assumptions 3-7 are characteristics of people
Transtheoretical Model of Change
Precontemplation
Contemplation
Preparation
Action
Maintenance
precontemplation stage
patients have no intention to change behaviors in the near future because they are unaware of problems
contemplation stage
patients are seriously thinking about overcoming a problem, but haven't made a commitment to action
preparation stage
individuals are intending to take action in the next month and are reporting small changes
action stage
the plan is implemented, which requires considerable commitment of time and energy
