Module 03: Fundamental Nursing Process (Part 01) Flashcards
Who introduced the concept “Thinking like a nurse?”
Dr.Christine Tanner
What does the concept “Thinking like a nurse” include?
(1) Critical Thinking
(2) Clinical Reasoning
Critical Thinking + Clinical Reasoning = Clinical Judgement
This is the process of international higher level of thinking to define a client’s problem, examine evidence-based practice in caring for the patient and making choices in the delivery of care.
Critical Thinking (Something that accrues as you gain more experience)
This is the cognitive process that uses thinking strategies to gather and analyze client information, evaluate its relevance and decide on nursing actions to improve outcomes
Clinical Reasoning (things that you perceive needs to be done and the reason why it should be done)
This is the observed outcome of
critical thinking and decision making
Clinical Judgement
Under the clinical judgement model, what makes a clinical judgement?
(1) Based on the patient’s needs
(2) Clinical Decisions
What is the result of clinical judgement?
Conclusion about a patient’s needs or health problems that leads to taking or avoiding action, using or modifying standard approaches or creating new ones based on patient’s responses.
(Nurses are proactive, hence approaches are always modifiable)
What is the correlation of clinical judgement and the nursing process?
Your clinical judgement is the product of your nursing process.
Under the clinical judgement model, what constitutes critical thinking?
(1) Critical Thinking Competence Knowledge Base
(a) Basic and nursing science
(b) Nursing and health care theory
(c) Patient data
(2) Experience
(a) Personal
(b) Clinical practice
(c) Skill competence
(3) Environment
(a) Time pressure
(b) Setting
(c) Task Complexity
(d) Interruptions
(4) Critical Thinking Attitudes Standards
(a) Intellectual
(b) Professional
What constitutes the nursing process?
(1) Assessment
(2) Analysis or Diagnosis
(3) Evaluation
(4) Planning
(5) Implementation
Critical Thinking is a process that requires the nurse to what?
(1) Think Ahead
(2) Apply Thinking While Acting (thinking on the possible problems and procedures)
(3) Think Back (assessing and modifying interventions)
What constitutes your 4-circle Critical Thinking (CT) model?
(1) Critical Thinking Characteristics (attitudes or behaviors)
(2) Theoretical and experiential knowledge intellectual skills or competencies
(3) Interpersonal and Self-Management Skills (time management and own reflective thinking)
(4) Technical Skills and competencies (practice)
Under the process of critical thinking, this is how the nurse begins to be proactive.
Think Ahead
Under the process of critical thinking, this is how the nurse enacts reflective thinking.
Think Back
This is the application of a set of questions to a particular situation or idea to determine essential information and ideas and discard unimportant ones.
Critical Analysis (Assessment - what are the subjective and objective cues, what are the important ones, eliminate those that entail less attention)
This is the technique one can use to look beneath the surface, recognize and examine assumptions, search for inconsistencies, examine multiple points of view and differentiate what one knows from what one believes
Socratic Questioning (continuous questioning)
These are the generalizations formed from a set of facts or observations (from specific to general)
Inductive Reasoning
This is the reasoning from general premise to specific conclusions
Deductive Reasoning
What are the levels of critical thinking?
(3) Commitment (consider wide array of clinical alternatives, apply all elements of clinical judgment model automatically
(2) Complex (independent decision-making, creativity, with initiative to look beyond expert opinion, consideration of different solutions, options and approaches
(1) Basic (answers are either right or wrong, single solution to a problem
Under the levels of critical thinking, this consider wide array of clinical alternatives, apply all elements of clinical judgment model automatically
Commitment (using different clinical judgements to make a SPECIFC solution to the SPECIFC need of the client)
Under the levels of critical thinking, this is independent decision-making, creativity, with initiative to look beyond expert opinion, consideration of different solutions, options and approaches
Complex (using personal understanding to creating solutions)
Under the levels of critical thinking, the answers are either right or wrong, single solution to a problem
Basic (student nurse, no creativity in answering, basing on textbooks)
What constitutes clinical decision making under the nursing process?
(1) Recognize cues
(2) Analyze cues
(3) Prioritize hypotheses
(4) Generate solutions
(5) Take action
(6) Evaluate Outcomes
What constitutes knowledge base under clinical decision making?
(1) Basic Science: anatomy, physiology, microbiology, underlying disease process
(2) Nursing theory supporting health and wellness
(3) Communication and patient education principles
(4) Normal assessment findings or patient assessment findings
What constitutes environment under clinical decision making?
(1) Time pressure
(2) Setting
(3) Task complexity
(4) Interruptions
What constitutes experience under clinical decision making?
(1) Personal
(2) Clinical experience
(3) Skill competence
What constitutes attitudes under clinical decision making?
(1) Perseverance
(2) Fairness
(3) Confidence
(4) Conciseness
What constitutes standards under clinical decision making?
(1) Intellectual standards in measurement
(2) Evidence-based criteria for evaluation
(3) Professional
(a) Standards of care
(b) Ethical standards
What is the importance of concept mapping in nursing?
This allows the nurse to map words on a page and focus on concepts and relationships
This is a technique that uses a
graphic depiction of nonlinear and linear relationships to represent critical thinking
Concept Mapping
This is a systematic, rational method of planning and providing individualized nursing care.
Nursing Process
What is the purpose of nursing process?
Purposes to identify a client’s health status and actual or potential healthcare problems or needs, establish plans, and to deliver specific nursing interventions
What are the elements under a nursing process?
(1) Assessment - information collection or gathering data
(2) Diagnosis - information interpretation or stating problems and strengths
(3) Outcome or Planning - setting nursing goals desired outcomes and planning interventions
(4) Implementation - performing nursing interventions
(5) Evaluation - patient’s status and effectiveness of nursing interventions
Under the nursing process, this is the act of collecting, organizing, validating, and documenting client data.
Assessment
What is the purpose of assessment?
To establish a database about the client’s response to health concerns or illness and the ability to manage healthcare needs
What are the activities that the nurse should execute under assessment?
(1) Establish a database:
(a) Obtain a nursing health history.
(b) Conduct a physical assessment.
(c) Review client records.
(d) Review nursing literature.
(e) Consult support persons.
(f) Consult health professionals.
(2) Update data as needed.
(3) Organize data.
(4) Validate data.
(5) Communicate and document data.
(6) Interpret and analyze data:
Under the nursing process, this is the act of analyzing and synthesizing data
Diagnosis
What is the purpose of diagnosis?
(1) To identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions
(2) To develop a list of nursing and collaborative problems
What are the activities that the nurse should do under diagnosis?
(1) Interpret and analyze data:
(a) Compare data against standards.
(b) Cluster or group data (generate tentative hypotheses).
(c) Identify gaps and inconsistencies.
(2) Determine client’s strengths, risks, and problems.
(3) Formulate nursing diagnoses and collaborative problem statements.
(4) Document nursing diagnoses on the care plan.
Under the nursing process, this is the act of determining how to prevent, reduce, or resolve the identified priority client problems; how to support client strengths; and how to implement nursing interventions in an organized, individualized, and goal-directed manner
Planning
Under the nursing process, this is the act of carrying out (or delegating) and documenting the planned nursing interventions
Implementing
What is the purpose of planning?
To develop an individualized care plan that specifies client goals or desired outcomes and related nursing interventions
What is the purpose of implementing?
To assist the client to meet desired goals or outcomes; promote wellness; prevent ill- ness and disease; restore health; and facilitate coping with altered functioning
Under planning, what are the activities that the nurse should do?
(1) Set priorities and goals or desired outcomes in collaboration with client. Write goals or desired outcomes.
(2) Select nursing strategies and interventions. Consult other health professionals.
(3) Write nursing interventions and nursing care plan.
(4) Communicate care plan to relevant health- care providers.
Under implementing, what are the activities that the nurse should do?
(1) Reassess the client to update the database. Determine the nurse’s need for assistance. Perform planned nursing interventions. Communicate what nursing actions were implemented:
(a) Document care and client responses to care.
(b) Give verbal reports as necessary.
Under the nursing process, this is the act of measuring the degree to which goals or outcomes have been achieved and identifying factors that positively or negatively influence goal achievement
Evaluating
What is the process of evaluation?
To determine whether to continue, modify, or terminate the plan of care
Which nursing process is used in the statement, “Nurse medina observed reveals that Margaret’s vital signs are: Temperature 39.4 C (103F); pulse 92 beats/min; respirations 28/min; and blood pressure, 122/80 mmHg. Nurse Medina observes that Margaret’s skin is dry, her cheeks are flushed, and she is experiencing chills. Auscultation reveals inspiratory crackles with diminished breath sounds in the right lung.”
Assessment
Which element of the nursing process was used in the statement “After analysis, Nurse Medina formulates a nursing diagnosis: altered respiratory status related to accumulated mucus obstructing airways.”
Diagnosing
Which element of the nursing process was used in the statement “Nurse Medina and Margaret collaborate to establish goals (e.g., restore effective breathing patter and lung ventilation); set outcome criteria (e.g., have a symmetrical respiratory excursion of at least 4 cm, and so on); and develop a care plan that includes, but is not limited to, coughing and deep-breathing exercises q3h, fluid intake of 3000 mL daily, and daily postural drainage.”
Planning
Which element of the nursing process was used in the statement “Margaret agrees to practice the deep-breathing exercises q3h during the day. In addition, she verbalizes awareness of the need to increase her fluid intake and to plan her morning activities to accommodate postural drainage.”
Implementing
Which element of the nursing process was used in the statement “Upon assessment of respiratory excursion, Nurse Medina detects failure of the client to achieve maximum ventilation. She and Margaret re-evaluate the care plan and modify it to increase coughing and deep-breathing exercises.”
Evaluation
What are the characteristics of the nursing process?
(1) Client centered
(2) Adapted from problem solving and systems theory
(3) Decision making is in every phase
(4) Interpersonal and collaborative
(5) Used in all healthcare settings
(6) Utilized critical thinking and clinical reasoning
This nursing process characteristic is when the process is based on the client problems rather than nursing goals
Client centered
This nursing process characteristic is when the medical model focuses on physiologic systems and disease process whereas nursing process is directed towards client’s responses to real or potential disease
Adapted from problem solving and systems theory
This is the systematic and continuous collection, organization, validation and documentation of data
Assessment
This is the process of gathering information about a client’s health status
Data Collection
This contains all the information about a client and includes the ff: 1) physical assessment, 2) primary care provider’s history, 3) laboratory and diagnostic results, 4) materials by other HCP.
Database
What does the database contain?
1) physical assessment,
2) primary care provider’s history,
3) laboratory and diagnostic results,
4) materials by other HCP
This data is referred to as symptoms or covert data, apparent only to the individual and can be verified only by that individual
Subjective Data
This data is referred to as signs or overt data, detectable by an observer or can be measured or tested against an accepted standard
Objective Data
Who are the different sources of data?
(1) Client
(2) Support people
(3) Client Records
(4) Health Care professionals
(5) Literature
This is best source of data, unless too ill, young or confused to communicate clearly
Client
This can supplement or verify information provided by the client, important source for a client who is very young, unconscious, confused
Support People
This is the information documented by various HCP.
Client Records
This is the information from previous contact with the client
Health care professionals
These are the professional journals and reference texts
Literature
What kind of source do support people, client records, health care professionals and literature fall into?
Secondary Data (not too important compared to the client)
What are the three (3) types of data collection methods?
(1) Observing
(2) Interview
(3) Examining
Under the data collection methods, this is gathered by using the senses.
Observing
Under the data collection methods, this is the planned communication with a purpose.
Interview
Under the data collection methods, this is the systematic data collection to detect health problems (IAPP)
Examining
What are the three (3) types of interview?
(1) Focused interview
(2) Directive interview
(3) Nondirective interview
In this type of interview, the nurse asks the client specific questions to collect information.
Focused interview
In this type of interview, it is highly structured and elicits specific information.
Directive interview
This type of interview is concerned with rapport-building
Nondirective interview
What are the different types of interview questions?
(1) Close ended questions
(2) Open ended questions
(3) Neutral Questions
(4) Leading Questions
This type of interview question is used in nondirective interview, invite clients to discover and explore thoughts and feelings.
Open Ended Questions
This type of interview question is used in directive interview, are restrictive and requires yes or no or short factual answers.
Close Ended Questions
This type of interview question is a question that can be answered without direction or pressure.
Neutral Questions
This type of interview questions is usually closed and directs the client’s answers.
Leading Questions
What type of questions should be avoided in an interview?
Why questions because they are perceived as a form of interrogation
What are the advantages of open-ended questions?
(1) They let the interviewee do the talking.
(2) The interviewer is able to listen and observe.
(3) They reveal what the interviewee thinks is important.
(4) They may reveal the interviewee’s lack of information, misunderstanding of words, frame of reference, prejudices, or stereotypes.
(5) They can provide information the interviewer may not ask for.
(6) They can reveal the interviewee’s degree of feeling about an issue.
(7) They can convey interest and trust because of the freedom they provide.
What are the disadvantages of open-ended questions?
(1) They take more time.
(2) Only brief answers may be given.
(3) Valuable information may be withheld.
(4) They often elicit more information than necessary.
(5) Responses are difficult to document and require skill in recording.
(6) The interviewer requires skill in controlling an open-ended interview.
(7) Responses require insight and sensitivity from the interviewer.
What are the advantages of close-ended questions?
(1) Questions and answers can be controlled more effectively.
(2) They require less effort from the interviewee.
(3) They may be less threatening, since they do not require explanations or justifications.
(4) They take less time.
(5) Information can be asked for sooner than it would be volunteered.
(6) Responses are easily documented.
(7) Questions are easy to use and can be handled by unskilled interviewers.
What are the disadvantages of close-ended questions?
(1) They may provide too little information and require follow-up questions.
(2) They may not reveal how the interviewee feels.
(3) They do not allow the interviewee to volunteer possibly valuable information.
(4) They may inhibit communication and convey lack of interest by the interviewer.
(5) The interviewer may dominate the interview with questions.
What are the different factors to be considered under the interview setting?
(1) Time
(2) Place
(3) Seating Arrangement
(4) Distance
(5) Language
What should the nurse consider under time in the interview setting?
(1) When the client is physically comfortable and free of pain
(2) Interruptions are minimal
What should the nurse consider under place in the interview setting?
(1) well-lit, well-ventilated room
(2) free of noise, movements, and distractions
What should the nurse consider under seating arrangement in the interview setting?
(1) If the client s in bed, the nurse sits at a 45 degree angle to the bed
(2) Sits on two chairs placed at right angles to a desk with no table in between
(3) in groups, a horseshoe or circular chair arrangement
What should the nurse consider under distance in the interview setting?
(1) neither too small or too great, usually 2-3 feet
What should the nurse consider under language in the interview setting?
(1) must convert complicated
medical terminology into common English usage
What are the stages of an interview?
(1) Opening (rapport orient)
(2) Body
(3) Closing (plan for next meeting, provide summary)
What are the different types of organization of data?
(1) Gordon’s 11 Functional Health Patterns
(2) Roy’s Adaptation Model
(3) Wellness Models
(4) Body Systems Model
(5) Maslow’s Hierarchy of Needs
(6) Developmental Theories
This is the act of double checking or verifying data to confirm that it is accurate and factual
Validation
What is the purpose of validating data?
(1) Ensure that assessment information is complete
(2) Ensure that objective and related subjective data agree
(3) Obtain additional information that may haven overlooked
(4) Differentiate cues and inferences
(5) Avoid jumping to conclusions
This is the second phase of the nursing process.
Nursing Diagnosis
What does nursing diagnosis use?
Use critical thinking skills to interpret assessment data and identify client strengths and problems
This is the statement or conclusion regarding the nature of a phenomenon
Diagnosis
This contains a diagnostic phrase, followed by an etiology
Nursing Diagnosis
What does nursing diagnosis include?
contains a diagnostic phrase, followed by an etiology
This is the identification of a disease condition based on specific assessment of physical signs and symptoms, a patient’s medical history and the results of diagnostic tests and procedures
Medical Diagnosis
When is medical diagnosis applied?
Used to communicate a patient’s health problems and associated treatments and responses
What are the seven axes under the ICNP (International Classification for Nursing Practice)?
(1) Focus
(2) Judgement
(3) Client
(4) Action
(5) Means
(6) Location
(7) Time
Under the seven axes of the ICNP (International Classification for Nursing Practice), this pertains to the area of attention that is relevant to nursing.
Focus
Under the seven axes of the ICNP (International Classification for Nursing Practice), this pertains to the clinical opinion related to the focus of nursing practice
Judgement
Under the seven axes of the ICNP (International Classification for Nursing Practice), this pertains to the subject to whom a diagnosis refers and who is the recipient of an intervention
Client
Under the seven axes of the ICNP (International Classification for Nursing Practice), this pertains to the intentional process applied to or performed by a client.
Action
Under the seven axes of the ICNP (International Classification for Nursing Practice), this pertains to the manner or method of accomplishing an intervention
Means
Under the seven axes of the ICNP (International Classification for Nursing Practice), this pertains to the anatomical and spatial orientation
Location
Under the seven axes of the ICNP (International Classification for Nursing Practice), this pertains to the point, period, interval or duration of an occurrence
Time
What are the four (4) status of nursing diagnosis?
(1) Actual
(2) Health promotion
(3) risk
(4) Syndrome
This status of nursing diagnosis is a problem-based diagnosis, present at the time of nursing assessment
Actual
This status of nursing diagnosis pertains to the client’s preparedness to implement behaviors to improve health condition
Health promotion
This status of nursing diagnosis pertains to the clinical judgment that a problem does not exist but the presence of risk factors indicates that a problem is likely
to develop
Risk
This status of nursing diagnosis pertains to the clinical nursing judgment when a client has several similar nursing diagnoses.
Syndrome
What are three (3) components of a nursing diagnosis?
(1) Problem Statement
(2) Etiology
(3) Defining Characteristics
This component of nursing diagnosis describes the health problem or response, includes qualifiers (words added to provide additional meaning)
Problem Statement
This component of nursing diagnosis identifies one or more probably causes of health problems, gives directions to the required nursing therapy and enables the nurse to individualize client’s care
Etiology
This component of nursing diagnosis is a cluster of signs and symptoms that indicate the presences of a particular diagnostic label
Defining Characteristics
Enumerate the diagnostic process.
(1) Assess the patient’s health status
(a) Patient, family, health care resources provide information for database
(b) Clarify inconsistent or unclear information
(c) Use critical thinking to guide and direct line of questioning and examination to reveal detailed and relevant database
(2) Validate data with other sources
(3) Reassess if there is any more additional data needed
(4) Analyze and interpret the meaning of data. Look for data clustering patterns
(a) Group signs and symptoms
(b) Classify and organize
(5) Reassess if that was the data expected
(6) Identify related factors from assessment
(7) Formulate nursing diagnosis and collaborative problems
How do you analyze data?
(1) Comparing with standards
(2) Data clustering and finding patterns
(3) Data interpretation
Explain the process of data analysis.
(1) Identification of significant cue cluster (problem)
(2) Can the nurse take the independent action to prevent or treat the problem
(3) Are these the primary interventions needed to achieve the goal (yes = nursing diagnosis)
(4) Are both medical and nursing orders needed to prevent and treat the problem (yes = collaborative problem and medical diagnosis)
Explain diagnosis and related factors.
(1) Related to problem and etiology
(2) Related to: (a) Patient’s health problem - reduced physical activity and stays in tense position and (b) Discomfort along abdominal incision; increases with movement
(3) Nurse uses critical thinking to see clusters of data and consider the context of the health problem
Diagnosis = Impaired mobility
Etiology (reason or rationale) - acute incisional pain
