3.0 Nursing Judgment Flashcards
Define integrity
Critical thinkers questions and test their own knowledge and beliefs. Your personal integrity as a nurse builds trust from your co-workers. Nurses face many dilemmas or problems in everyday clinical practice, and everyone makes mistakes at times. A person of integrity is honest and willing to admit to mistakes or inconsistences in his/her own behavior, ideas, beliefs.
Define professionalism
Always to strive to follow the highest standards in practice. Best patient care providers. Provide high quality care for our patients. Effective communication: verbal/written.
Evidence Based practice
Stems from knowledge that has been proven by research and/or clinical practice.
Nurses are critical thinkers and problem solvers, and they use evidence to support their actions.
Supports the idea that nurses are required to be life-long learners and function based on a spirit of inquiry.
Allows nurses to think deeply to apply knowledge and understanding of why we do what we do.
Nurses are leaders in healthcare and should never do things because “that’s how it’s always been done”.
ADPIE
Assessment Diagnosis Planning Implementation Evaluation
ADPIE Assessment
Differentiate between subjective & objective data
Only include assessment information on the care plan that is pertinent to the specific problem you are addressing (nursing diagnosis).
It is helpful to write out or document the assessment findings and then highlight the abnormal data.
Once you identify the abnormal assessment data (clusters or cues), think critically about the patient’s systems that are the most problematic, leading to your prioritized nursing diagnoses.
Nursing Diagnosis (NANDA-I)
Clinical judgement is required in order to determine priority nursing diagnoses for patients.
Use clusters or cues from assessment data to lead to appropriate NANDA approved nursing diagnoses.
Formulated based on Maslow’s Hierarchy of Needs:
Basic needs must be addressed first. In 212 we often see complex patients who require complex nursing diagnoses.
ADPIE Nursing Diagnosis
Provide common communication among the nursing team as well as other disciplines.
Demonstrate the critical thinking and problem-solving capabilities among the nursing profession.
Focuses on the care of the patient, which the nurse can provide (different than medical diagnoses).
Change over time with a holistic approach.
Nursing diagnosis provide care and medical diagnosis provide cure.
Nursing Diagnosis Written as a 1, 2 or 3 part statement (PES):
P (problem) = Label taken from the approved NANDA-I list.
E (etiology) = Related to the probable cause of the problem.
This is something the nurse can treat.
It may not be a medical diagnosis.
S (secondary to) = Medical diagnosis
AEB is not needed in 212
Nursing Diagnosis
Type and Defining Characteristics
Problem focused:
Actual problem
3-part statement
Risk for:
Potential problem
2-part statement
Health promotion:
Transition from one level of wellness to a higher level
1-part statement
Syndrome:
Cluster of nursing diagnoses r/t a certain event or situation
1-part statement
Possible:
Suspected problem (not a true diagnosis)
2-part statement
Collaborative problems:
RC (risk for complication)
1-part statement
ADPIE Planning
Patient Outcomes = Goals Short Term (ST) typically by the end of your shift Long Term (LT) typically by time of discharge
SMART goals:
S- Specific M- Measurable A- Attainable R- Realistic T- Timed
Focused on the problem you have identified
The patient will…
ADPIE Implementation
The focus is on altering the etiological (r/t) factors.
Nursing interventions must be based on scientific principles (EBP).
These are specific actions the nurse will do in order to show where and how prioritized plans for the patient will be carried out.
Involve the patient and family in this step, for example, teaching…
Consider collaborative interventions (interprofessional collaboration).
Care plans should include a list of many interventions with a rationale for ONE intervention.
In 212 you are required to cite your rationale by telling where you found that information (textbook, journal, website) along with a page number.
Think critically with your interventions!
The nurse will…
ADPIE Evaluation
Evaluation of Outcomes
Were the patient’s goals met?
If not, what needs to be modified or revised?
The patient may need more time, but they may also need to have new goals created.
It is even possible that the nursing process may need to begin again with the assessment in order to change the plan of care.
This is an essential piece of the process that cannot be forgotten
Concept Mapping
Concept Mapping
A way of placing nursing process (care plan) into a nonlinear format.
Takes complicated and complex patient information and maps the information in a way that promotes critical thinking.
Demonstrates relationships between multiple patient problems.
Allows nurses to see “the big picture” in a way that promotes holistic nursing care.
No right or wrong way for physically mapping, but all nursing process components must be included.
Example of measurable verbs
Identify Describe Perform Explain Give State List Sit Verbalize Perform Demonstrate Share Relate Express Has absence of Exercise Communicate Cough Administer Walk Stand Discuss
