Fundamentals: Nursing Process and Critical Thinking Flashcards
Describe the steps of critical thinking
involves 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.
Define evidence-based knowledge
knowledge based on research or clinical expertise.
Nursing process
Fundamental blueprint for how to care for a patient
Assessment
Collection, verification, and analysis of data
Database
The patient’s perceived needs, health problems, and responses
Cue
Information that was obtained through the use of the senses
Inference
Your judgment or interpretation of cues
Gordon’s 11 functional health patterns
- health perception-health management pattern
- nutritional-metabolic pattern
- elimination pattern
- activity-exercise pattern
- sleep-rest pattern
- cognitive-perceptual pattern
- self perception- self concept pattern
- role- relationship pattern
- sexuality- reproductive pattern
- coping- stress tolerance pattern
- value- belief pattern
subjective data
includes patients’ verbal descriptions of their health problems
objective data
observations or measurements of a patient’s health status
Identify the variety of sources where data can be obtained
- the patient through interviews, observations, and physical exams.
- family members or significant others
- other members of the health team
- medical record information
- scientific and medical literature.
open-ended questions
prompts patients to describe a situation (tell their story) in more than one or two words.
back channeling
active listening prompts
closed ended questions
limits the patients answers to one or two words
biographical information
Factual demographic data about the patient
reasons for seeking health care
Chief concerns or problems
patient expectations
Patient’s understanding of why he or she is seeking health care
present illness/health
Essential or relevant data about the nature and onset of symptoms
health history
Health care experiences and current health habits and lifestyle patterns
family history
To determine whether the patient is at risk for illnesses of a genetic or a familial nature
environmental history
Patient’s home and work, focusing on determining the patient’s safety
psychosocial history
Reveals the patient’s support systems and coping mechanisms
spiritual history
Represents the totality of one’s being
review of systems
Systemic approach for collecting the patient’s self-reported data on all body systems
Medical diagnoses
Identification of a disease condition
Collaborative problem
Actual or potential physiological complication that is monitored in collaboration with others
Defining characteristics
The clinical criteria or assessment findings that support an actual nursing diagnosis
Actual nursing diagnosis
Describe human responses to health conditions or life processes that exist in an individual, family, or community
Risk nursing diagnosis
Human responses to health conditions that may possibly develop in a vulnerable individual, family, or community
Health promotion nursing diagnosis
Desire to increase well-being and actualize human health potential
Data cluster
a set of signs or symptoms gathered during assessment that help you group them together in a logical way.
Defining characteristics
clinical criteria that are observable and verifiable.
Clinical criteria
help
Explain the process of identifying health problems (interpretation)
help
Define wellness nursing diagnosis (health promotion nursing diagnosis)
help
Diagnostic label:
the name of the diagnosis approved by NANDA; it describes the essence of
Related factor:
a condition or etiology identified from the patient’s assessment data, or actual or potential responses to the health problem
Etiology:
the cause of a disease
PES format:
P: problem
E: etiology or related factor
S: symptoms or defining characteristics
planning involves
prioritizing the diagnoses, setting patient-centered goals and expected, prescribed individualization nursing interventions.
High priority
If untreated, result in harm to the patient or others
intermediate priority
Involve nonemergent, nonthreatening needs of the patient.
low priority
are not always directly related to patient illness or prognosis
Goal
A broad statement that describes a desired change in a patient’s condition or behavior
Patient-centered goal
Specific and measurable behavior or response that reflects a patient’s highest possible level of wellness
Short-term goal
Objective behavior that you expect the patient will achieve in a short time
Long-term goal
Objective behavior that is expected over a long period
Expected outcome
A measurable criterion to evaluate goal achievement
Nursing-sensitive outcome
An individual, family, or community state, behavior, or perception that is measurable in response to a nursing intervention.
singular goal or action
is precise in evaluating a patient response to a nursing action; each goal and outcome should address only one behavior, perception of physiologica response
measurable
describes quality, quantity, frequency, length, or weight allow the nurse to evaluate outcomes precisley.
attainable
in order for patients health to improve, he/she must be able to attain those goals set.
realistic
a goal that the patient is able to achieve
timed
is written so nurse knows when a response is expected.
Independent nursing interventions:
nurse initiated interventions that do not require direction or an order from another health care professional.
Dependent nursing interventions:
physician initiated interventions that require an order from another health care professionals.
Collaborative nursing interventions
interdependent nursing interventions that require the combined knowledge, skill, and expertise of multiple care professionals.
direct care
treatments performed through interactions with patients.
indirect care
treatments performed away from the patient but on behalf of the patient.
