Foundation/Patient Interview..Chap 1&2 Flashcards
Critical Thinking
purposeful, goal-directed thinking process that strives to problem solve patient care issues through the use of clinical reasoning.
Clinical Reasoning
disciplined, creative, and reflective approach used together with critical thinking.
purpose is to establish potential strategies to assist patients in reaching their desired health goals
7 Universal Intellectual Standards (w/ explanations)
- Clarity
- Could you elaborate further? give me an example?
- type of substance abuse..
- Accuracy
- Is that really true? How could I check that?
- Thinking an alcoholic drinks daily may be inaccurate.. May binge drink
- Precision
- Could you give me more detail? Could you be more specific?
- How many??
- Relevance
- How is that connected?
- If alcoholic presents in withdrawal, grandfathers health hx is NOT relevant
- Depth
- Have I dealt w/ the most significant factors?
- binge drinking after recent death of a child
- Breadth
- Do I need to consider another point of view?
- Is there another way to look at this?
- Logic
- Does this make sense?
Key Elements of Clinical Reasoning
- Reasoning has PURPOSE
- Reasoning Settles a QUESTION/solves a problem
- Based on ASSUMPTIONS
- Done with some POINT OF VIEW
- Based on DATA, INFO, EVIDENCE
- Expressed and shaped by CONCEPTS AND IDEAS
- Contains INFERENCES that help draw CONCLUSIONS
- Leads somewhere and has IMPLICATIONS & CONSEQUENCES
**Nursing Process: 6 phases ** test
- Assessment
- Nursing Diagnosis
- Outcomes Identification
- Planning
- Implementation
- Evaluation
Nursing Process: Assessment
nurse collects comprehensive data pertinent to the patient's health or the situation -current health status -Actual & Potential health problems -Areas for health promotion \_\_\_\_ Sources of Info: -Health History -- chart -physical assessment -Diagnostic and lab data
Nursing process: Diagnosis
RN analyzes the assessment data to determine the diagnoses or issues
Nursing process: Outcomes identification
RN identifies expected outcomes for a plan individualized to the patient or the situation
Nursing process: Planning
RN develops a plan that prescribes strategies and alternatives to attain expected outcomes
Nursing process: Implementation
RN implements the identified plan
Nursing process: Implementation
-Coordination of Care
RN coordinates care delivery
Nursing process: Implementation
-Health Teaching and Health Promotion
The RN employs strategies to promote health and a safe environment
Nursing process: Implementation
-Consultation
Advanced practice RN and the nursing role specialist provide consultation to influence the identified plan, enhance the ability of others, and effect change
Nursing process: Implementation
-Prescriptive authority and treatment
Advanced practice RN uses prescriptive authority, procedures, referrals, treatments, and therapies in accordance with state and federal laws and regulations
Nursing Process: Evaluation
RN evaluates progress toward attainment of outcomes
NANDA
North American Nursing Diagnosis Association
Nursing Diagnosis (NANDA-I (2009, p. 419)
A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.
Body System Assessment
- General survey, vital signs, and pain
- Skin, hair, and nails
- Head, neck, and regional lymphatics
- Eyes
- Ears, nose, mouth, and throat
- Breasts and regional nodes
- Thorax and lungs
- Heart and peripheral vasculature
- Abdomen
- Musculoskeletal system
- Mental status and neurological techniques
- Female or male genitalia
- Anus, rectum, and prostate
Nursing Diagnosis Formulation: 4 steps
- Collecting Info
- Interpreting info
- Clustering Info
- Naming a cluster or problem formulation
3 Types of Nursing Diagnoses
- Actual
- Risk
- Wellness
Actual Nursing Diagnoses
typically problem oriented and describe human responses that have been validated by the nurse.
Ex. disturbed sleep pattern and impaired memory
Risk Nursing Diagnosis
Human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community.
Ex. Risk of suicide // risk of falls // risk of infection
Wellness Nursing Diagnosis
represents the patient’s striving for a higher level of health and wellness
Ex. Readiness for enhanced spiritual well-being and Readiness for enhanced family processes
4 Components of writing a nursing Diagnosis
- Descriptor
- Label or Human Response
- Related factors
- Defining characteristics or Risk Factors
PES method of nursing Diagnosis
P-problem
E-Etiology
S-signs and symptoms
Components of Critical Thinking
- Interpretation
- Analysis
- Inference
- Explanation
- Evaluation
- Self-regulation
Descriptor
Ineffective, Impaired, Deficient, readiness for…
Evidence Based Practice
Well designed and executed scientific studies to guide clinical decision making and clinical care
Interpretation
- Nurse must decode hidden messages
- Clarify the meaning of the info
- Categorize it
SOAPIER
S-Subjective data - pain level O-Objective Data - X rays / BP A-Analysis of Data P-Plan I- Intervention E- Evaluation R- Revision
Analysis
- Examines ideas and data
- identifies discrepancies
- reflects on reasons for discrepancies
Inference
- Speculates, derives, or reasons to a specific premis based on info and assumptions obtained from patient
- Skill develops w/ experience
Draw conclusions & provide alternatives Ex. asthma every morning -ask if HX of heartburn or GERD -Gerd is contributing factor of asthma
Explanation
- Requires that conclusions drawn from inferences be correct and justifiable
- Scientific nursing literature serve as bases for clinical justification
Evaluation
Examines the validity of the info and hypothesis
Critical thinking (summed up)
- Thinking about your thinking
- purposeful
- goal-directed
Clinical Reasoning (summed up)
- Thought process that guides practice
- Procedural interactive, conditional
7 Universal Intellectual Standards for Critical Thinking
- Clarity
- Accuracy
- Precision
- Relevance
- Depth
- Breadth
- Logic
Writing the Nursing Diagnosis
DESCRIPTOR
-Ineffective, impaired, deficient, readiness for …
LABEL
-Actual of potential health problems or wellness factor that the nurse has synthesized from the cluster
-Ex. Ineffective breathing pattern
RELATED FACTORS
-“related to…”
-Ineffective breathing pattern RELATED TO pain
-Fatigue RELATED TO anemia
DEFINING CHARACTERISTICS
-“As evidenced by”
