Carrington College fundamentals test 1 with complete verified solutions already graded A+

6 standards of practice

assessment, diagnosis, outcome identification, planning, implementation, evaluation

Critical thinking is

The ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process

A continuous process characterized by open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant

Recognizing that an issue exists, analyzing information, evaluating information, and drawing conclusions

If reflection inuitive

No

Components of critical thinking

specific knowledge base, experience, competencies, attitudes, standards

Levels of critical thinking

Basic, Complex, Commitment

General critical thinking

scientific method, problem solving, decision making

Specific critical thinking

includes diagnostic reasoning, clinical inference, and clinical decision making.

The use of diagnostic reasoning involves a rigorous approach to clinical practice and demonstrates that critical thinking cannot be done

haphazardly

The nursing process organizes your approach while delivering nursing care. To provide the best professional care to patients, nurses need to incorporate nursing process and:

critical thinking skills

Developing critical thinking skills

reflective journaling, meeting with colleagues, concept mapping

What to chart

Patient information, nursing care delivered, outcomes of care, plan of care, policies and procedures, administrative records

When to chart?

As soon as possible after any pertinent interaction with patient.

What is considered pertinent interaction with patient?

Assessments, interventions, care provided, patient's response to care, patient education

Research has shown charts are specifically deficient

In patient education

12 basic rules of documentation

Date and time with each entry

Chronological order

If you mistakenly omit an entry write the time the documentation is being done marked by late entry

Never erase or use whiteout, don't attempt to completely scratch out an entry

Document as close to the time care was given

Never document in advance

Document only on patients you have cared for yourself

Be objective in charting

Be specific

Avoid labeling or judging people in the documentation

Accurate assessment on flow sheet

Use problem oriented approach (identify problem, what was done, and patient's response to care)

Make notes if other disciplines are contacted

Only use approved abbreviations and check spelling

Why do patients sue?

To obtain compensation for perceived harm/injury

To obtain information

To retaliate, vent anger or frustration,

To "prevent this from happening to others"

family (to advocate on behalf of injured or deceased)

Negligence, wrong medication, etc

What is negligence?

Failure to provide the prevailing standard of care to a patient, which results in injury, damage, or loss to the patient

Elements required to support negligence

Duty exists, duty or standard of care was breached, breach in care caused or contributed to patient harm

Suggestions for documentation

Prioritize and be organized

Find a place you will not be interrupted

Have a customized "brain"

Document every patient immediately after contact

Make sure patient load is mixed not all critical

In over what percent of sentinel events root cause was communication

70%

Causes of communication breakdown

Different communication styles

High level of activity

Frequent interruptions

No standardization in organizing essential information

Loss of information

Barriers in communication between physician and RN

Differences in training

Style of communication

Past experiences

Level of empowerment

Tone of voice and lack of respect

God complex

3 elements of face to face communication

Body language (55%)

Tone of voice (38%)

Words (7%)

Effective communication

Be complete

Use layman's terms

Be concise

Be brief

Use eye contact

Professionalism

Administer quality care

Be responsible and accountable

Nursing is defined as a profession because

nurses practice autonomy

Florence Nightingale

First practice epidemiologist

Organized first nursing school

Improved sanitation in battlefield hospital

Theory components

Phenomenon, concepts, definitions, assumptions

Peplau

interpersonal relationships

Henderson

14 basic needs of the whole person

Framing nursing care are the needs of the individual.

Good life or death

Orem

self-care deficit

Leininger

transcultural nursing

Neuman

Based on stress and the patient's reaction to the stressor

Role of nursing is to stabilize the patient or situation.

Roy

Adaptation Model

Benner and Wrubel

Caring is central to the essence of nursing

Watson Nursing Theory

A relational caring for self and others based on moral/ethical/philosophical foundations of love and values

Cephalocaudal

head to toe

Proximodistal

near/far

Freud's 5 stages

Oral, anal, phallic or Oedipal, latency, genital/pubic

Id

contains a reservoir of unconscious psychic energy that, according to Freud, strives to satisfy basic sexual and aggressive drives. The id operates on the pleasure principle, demanding immediate gratification

Ego

the largely conscious, "executive" part of personality that, according to Freud, mediates among the demands of the id, superego, and reality. The ego operates on the reality principle, satisfying the id's desires in ways that will realistically bring pleasure rather than pain.

Superego

the part of personality that, according to Freud, represents internalized ideals and provides standards for judgment (the conscience) and for future aspirations

Eirkson's stage 8

Integrity vs despair

Erikson's stage 7

Generative vs stagnation and self-absorption

Problem focused nursing diagnosis

describes a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community.

Related factor

Any condition or event that accompanies or is linked with the patient's health care problem.

Risk nursing diagnosis

describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community

Health promotion nursing diagnosis

a clinical judgement of motivation, desire, and readiness to enhance well-being and actualize human health potential

data cluster

grouping of patient data or cues that points to the existence of a patient health problem

Diagnostic label

the name of the nursing diagnosis as approved by NANDA International

Nursing diagnosis errors occur

By errors in data collection, interpretation/analyzation, clustering of data, or the diagnostic statement

Patient centered goal

A specific and measurable behavior or response that reflects a patient's highest possible level of wellness and independence in function

SMART goals

Specific, Measurable, Attainable, Realistic, Timely

Three types of interventions

independent, dependent, collaborative

Independent intervention

those that nurses are licensed to prescribe, perfrom or delegate based on their knowledge and skills

Dependent intervention

One that is prescribed by a physician or advanced practice nurse but carried out by the bedside nurse

Collaborative intervention

Interdependent—Require combined knowledge, skill, and expertise of multiple health care professionals

Nursing care plan

includes nursing diagnoses, goals and/or expected outcomes, specific nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patient's clinical needs and situation.

Standing order

written in advance of a situation that is to be carried out under specific circumstances

Preparing for implementation

Time management

Equipment

Personnel

Environment

Patient

Implementation skills

Cognitive skills

Interpersonal skills

Psychomotor skills

ADL

activities of daily living

IADL

instrumental activities of daily living

Evaluation (nursing process)

Figuring out if you met your goals

Standards for evaluation

Nursing care helps patients

Resolve actual health problems

Prevent potential problems

Maintain a healthy state