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Health Assessment > Foundation/Patient Interview..Chap 1&2 > Flashcards

Foundation/Patient Interview..Chap 1&2 Flashcards

1
Q

Critical Thinking

A

purposeful, goal-directed thinking process that strives to problem solve patient care issues through the use of clinical reasoning.

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3
Q

Clinical Reasoning

A

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

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5
Q

7 Universal Intellectual Standards (w/ explanations)

A
  1. Clarity
    • Could you elaborate further? give me an example?
    • type of substance abuse..
  2. Accuracy
    • Is that really true? How could I check that?
    • Thinking an alcoholic drinks daily may be inaccurate.. May binge drink
  3. Precision
    • Could you give me more detail? Could you be more specific?
    • How many??
  4. Relevance
    • How is that connected?
    • If alcoholic presents in withdrawal, grandfathers health hx is NOT relevant
  5. Depth
    • Have I dealt w/ the most significant factors?
    • binge drinking after recent death of a child
  6. Breadth
    • Do I need to consider another point of view?
    • Is there another way to look at this?
  7. Logic
    • Does this make sense?
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6
Q

Key Elements of Clinical Reasoning

A
  1. Reasoning has PURPOSE
  2. Reasoning Settles a QUESTION/solves a problem
  3. Based on ASSUMPTIONS
  4. Done with some POINT OF VIEW
  5. Based on DATA, INFO, EVIDENCE
  6. Expressed and shaped by CONCEPTS AND IDEAS
  7. Contains INFERENCES that help draw CONCLUSIONS
  8. Leads somewhere and has IMPLICATIONS & CONSEQUENCES
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7
Q

**Nursing Process: 6 phases ** test

A
  1. Assessment
  2. Nursing Diagnosis
  3. Outcomes Identification
  4. Planning
  5. Implementation
  6. Evaluation
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8
Q

Nursing Process: Assessment

A 
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
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9
Q

Nursing process: Diagnosis

A

RN analyzes the assessment data to determine the diagnoses or issues

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10
Q

Nursing process: Outcomes identification

A

RN identifies expected outcomes for a plan individualized to the patient or the situation

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11
Q

Nursing process: Planning

A

RN develops a plan that prescribes strategies and alternatives to attain expected outcomes

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12
Q

Nursing process: Implementation

A

RN implements the identified plan

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13
Q

Nursing process: Implementation

-Coordination of Care

A

RN coordinates care delivery

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14
Q

Nursing process: Implementation

-Health Teaching and Health Promotion

A

The RN employs strategies to promote health and a safe environment

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15
Q

Nursing process: Implementation

-Consultation

A

Advanced practice RN and the nursing role specialist provide consultation to influence the identified plan, enhance the ability of others, and effect change

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16
Q

Nursing process: Implementation

-Prescriptive authority and treatment

A

Advanced practice RN uses prescriptive authority, procedures, referrals, treatments, and therapies in accordance with state and federal laws and regulations

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17
Q

Nursing Process: Evaluation

A

RN evaluates progress toward attainment of outcomes

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18
Q

NANDA

A

North American Nursing Diagnosis Association

19
Q

Nursing Diagnosis (NANDA-I (2009, p. 419)

A

A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.

20
Q

Body System Assessment

A
  1. General survey, vital signs, and pain
  2. Skin, hair, and nails
  3. Head, neck, and regional lymphatics
  4. Eyes
  5. Ears, nose, mouth, and throat
  6. Breasts and regional nodes
  7. Thorax and lungs
  8. Heart and peripheral vasculature
  9. Abdomen
  10. Musculoskeletal system
  11. Mental status and neurological techniques
  12. Female or male genitalia
  13. Anus, rectum, and prostate
21
Q

Nursing Diagnosis Formulation: 4 steps

A
  1. Collecting Info
  2. Interpreting info
  3. Clustering Info
  4. Naming a cluster or problem formulation
23
Q

3 Types of Nursing Diagnoses

A
  1. Actual
  2. Risk
  3. Wellness
24
Q

Actual Nursing Diagnoses

A

typically problem oriented and describe human responses that have been validated by the nurse.

Ex. disturbed sleep pattern and impaired memory

25
Q

Risk Nursing Diagnosis

A

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

26
Q

Wellness Nursing Diagnosis

A

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

26
Q

4 Components of writing a nursing Diagnosis

A
  1. Descriptor
  2. Label or Human Response
  3. Related factors
  4. Defining characteristics or Risk Factors
27
Q

PES method of nursing Diagnosis

A

P-problem
E-Etiology
S-signs and symptoms

28
Q

Components of Critical Thinking

A
  • Interpretation
  • Analysis
  • Inference
  • Explanation
  • Evaluation
  • Self-regulation
29
Q

Descriptor

A

Ineffective, Impaired, Deficient, readiness for…

30
Q

Evidence Based Practice

A

Well designed and executed scientific studies to guide clinical decision making and clinical care

30
Q

Interpretation

A
  • Nurse must decode hidden messages
  • Clarify the meaning of the info
  • Categorize it
31
Q

SOAPIER

A 
S-Subjective data - pain level
O-Objective Data - X rays / BP
A-Analysis of Data
P-Plan
I- Intervention
E- Evaluation
R- Revision
31
Q

Analysis

A
  • Examines ideas and data
  • identifies discrepancies
  • reflects on reasons for discrepancies
32
Q

Inference

A
  • 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
33
Q

Explanation

A
  • Requires that conclusions drawn from inferences be correct and justifiable
  • Scientific nursing literature serve as bases for clinical justification
34
Q

Evaluation

A

Examines the validity of the info and hypothesis

35
Q

Critical thinking (summed up)

A
  • Thinking about your thinking
  • purposeful
  • goal-directed
36
Q

Clinical Reasoning (summed up)

A
  • Thought process that guides practice

- Procedural interactive, conditional

37
Q

7 Universal Intellectual Standards for Critical Thinking

A
  1. Clarity
  2. Accuracy
  3. Precision
  4. Relevance
  5. Depth
  6. Breadth
  7. Logic
38
Q

Writing the Nursing Diagnosis

A

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”

Health Assessment (8 decks)

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