CH 4: Nursing Process: Critical thinking, Decision making and Clinical Judgment Flashcards
objective data
data that can be assessed through senses
primary data
data provided by the patient
secondary data
data obtained from a source than the patient
subjective data
symptoms knowable only by the patient
care plan
a documented strategy that includes the health-care provider’s orders, nursing diagnosis, and nursing order
critical thinking
skillful reasoning and logic thought to determine the merits of a belief or action
to avoid making decisions based on assumptions, nurses must do what to the information they obtain?
validate
nursing process
overlapping, 5 step method for decision making
rapport
creating a relationship of mutual trust
Assessment
gathering information through signs & symptoms, patient history, & subjective objective findings
- interview (asking questions)
- performing a focused body system assessment to determine deviations from normal
- reviewing laboratory and diagnostic tests
techniques nurses use to gather data about patient’s body
- inspection: visual examination of the patient’s body for rashes; breaks in the skin
- palpation: touching or feeling the torso & limbs for pulses, abnormal lumps; temp
- auscultation: listening for abnormal sounds in the lungs, heart, or bowels
- percussion: using tapping movements to detect abnormalities of the internal organs
Diagnosis
formulation of nursing diagnoses through an analysis of the assessment information you have gathered.
nursing diagnosis
concise statement of a problem that the patient is experiencing as a result of the patient’s medical diagnoses
- are selected based on definitions and defining characteristics
- FOCUS ON PATIENT’S NEEDS
defining characteristics
signs & symptoms experienced by the patient that directly influence the nursing diagnosis
Planning
process of determining priorities and what nursing actions should be performed to help resolve or manage each patient problem
- nurse determines expected outcomes for patient to meet for the nursing diagnosis to be resolved
Implementation (interventions)
process of taking actions to resolve the patient’s problem
Evaluation
performed when the nurse reflects on the interventions performed and decides whether the patient is now closer to achieving goals and outcomes set in the planning step
What are the LPN/LVN responsibilities mostly in the nursing process?
participates mostly in the remaining steps of planning, intervention, and evaluation
- does not mean that LVN cannot perform assessment skills, but shared and sometimes confirmed with RN
What are the responsibilities of the RN in the nursing process?
from assessment through evaluation and includes outcome identification
What can LVNs not delegate?
nursing decisions & care planning
Can nurses examine laboratory and diagnostic tests?
yes, although health-care providers will review the results, the nurses are able to examine them as well
Physicians, physician assistants and nurse practitioners all focus on medical diagnoses based on what?
signs, symptoms, laboratory findings, and test results
Maslow’s Hierarchy: physiological needs
food, air, water, temperature regulation, elimination, rest, sex, and physical activity
Maslow’s Hierarchy: safety and security
protection, emotional and physical safety and security, order, law, stability, shelter
