NURS 2900 exam 3

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
1. individual
2. behavior specific cognitions and affect
3. 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

1. Precontemplation
2. Contemplation
3. Preparation
4. Action
5. 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