HA Flashcards
→ a systematic; rational method of planning and providing
individualized nursing care.
NURSING PROCESS
NURSING PROCESS
→ organized, systematic, goal oriented, humanistic care
(Lydia
Hall)
→ discipline-specific
→ reflective reasoning process
→ PURPOSE:
✔ Guides a nurse in generating, implementing, and
evaluating approaches for dealing with client care and
professional concerns.
CRITICAL THINKING
→ comprehensive assessment of one’s health status
HEALTH ASSESSMENT
HEALTH ASSESSMENT
→ PRIMARY COMPONENTS:
✔ Nursing Health History
✔ Physical Assessment
→ systematic and continuous collection, organization,
validation, and documentation of data
→ a continuous process carried out during all phases of the
nursing process
→ all phases of the nursing process depend on the accurate and
complete collection of data
ASSESSMENT
FACTORS TO BE CONSIDERED DURING
INTERVIEW
Time
Place
seating arrangement
Distance
Language
is a
systematic data collection method that uses observation
→ Physical examination or Physical assessmen
→ nurse uses a written (or computerized) format that organizes
the assessment data systematically in the form of:
nursing health history
nursing assessment
nursing database form
- ORGANIZING DATA
→ act of “double-checking” or verifying data to confirm
that it is accurate andfactual
complete
factual
accurate
- VALIDATION OF DATA
→ must be accurate
→ Factual manner and not as interpreted by the nurse
→ Subjective data - virbatim
DOCUMENTING DATA: RECORDING OF DATA
→ a basic structure underlying a process, system, concept,
or text
FRAMEWORK
TYPES OF FRAMEWORKS
→ a framework that medical practitioners commonly use as
it focuses more on the pathophysiology involved within
specific organ body systems
→ maybe used during the focused assessment of an acutely
or critically ill client
BODY SYSTEM FRAMEWORK
TYPES OF FRAMEWORKS
→ System data in an organized manner: head to toe
→ Used to improve efficiency and expedite the actual
physical examination
CEPHALOCAUDAL FRAMEWORK
TYPES OF FRAMEWORKS
→ Evaluates the effects of mind, body and environment in
relation to a person’s ability to perform the ADLs
→ Data collection in terms of Gordon’s 11 Functional
Health Patterns
GORDON’S 11 Functional Areas:
FUNCTIONAL HEALTH FRAMEWORK
→ a disciplined, creative and reflective approach used
together with critical thinking
CLINICAL REASONING
→ a purposeful, goal-directed thinking process that strives
to problem solve patient care issues through the use of
clinical reasoning
→ It combines logic, intuition, and creativity
CRTICAL THINKING IN HEALTH ASSESSMENT
COMPONENTS OF CRITICAL THINKIN
→ decode hidden messages, clarify the meaning of the
information, categorize the information
→ (categorization, clarifying meaning)
→ Nursing Practice Application:
✔ Be systematic in data collection. Look for patterns to
categorizedata you are uncertain about.
. INTERPRETATION
COMPONENTS OF CRITICAL THINKING’
→ ideas and data presented, identifies any discrepancies,
and reflects on the reason for the discrepancies
→ Nursing Practice Application:
✔ Be open-minded as you look at information about a
client. Do not make careless assumptions. Do the data
reveal what you believe is true, or are there other
options? Look for patterns to categorize data you are
uncertain about.
ANALYSIS
COMPONENTS OF CRITICAL THINKING
→ speculates, derives, or reasons a specific premise based
on information and assumptions obtained from the patient;
can be challenging skill for the novice nurse because a
certain level of knowledge and experience must be
possessed in order to draw conclusions and provide
alternatives in any given scenario (examining evidence,
speculating or conjecturing alternatives, making
conclusions)
INFERENCE
COMPONENTS OF CRITICAL THINKING
→ requires that the conclusions drawn from the inferences
are cored and can be justified.
→ The use of scientific and nursing literature constitutes the
basis for clinical justification
→ (stating results, justifying procedures)
→ Nursing Practice Application:
✔ Support your findings and conclusions. Use
knowledge to select strategies you use in the care of
clients.
EXPLANATION
COMPONENTS OF CRITICAL THINKINGG
→ examines the validity of the information and hypothesis;
this leads to a final conclusion that can be implemented.
→ (assessing results, assessing arguments)
→ Nursing Practice Application:
✔ Look at all situations objectively. Use criteria (e.g.
expected outcomes, pain characteristics, learning
objectives) to determine results of nursing actions.
Reflect on your own behavior.
EVALUATION
COMPONENTS OF CRITICAL THINKING
→ key component to the critical thinking process; the nurse
reflects on the critical thinking skills that were employed
and determines which techniques were effective and which
were problematic.
→ (self-examination, self-correction)
→ Nursing Practice Application:
✔ Reflect on your experience. Identify in what way you
can improve your performance. What will make you
feel that you have been successful?
SELF-REGULATION
→ Delivery of health-care services across a distance utilizing
ICT.
→ Digital transmission of medical imaging, remote medical
diagnosis and evaluation and video consultations with specialist
TELEMEDICINE/ TELEHEALTH
