Module 1 - Clinical Decision Making, Health Assessment, Chronic Illness Flashcards
What are the 5 steps of the Nursing Process?
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
What is critical thinking?
- A nonlinear, deliberate process for collecting, interpreting, analyzing, drawing conclusions about, presenting, and evaluating info that is both factual and belief based
- A skill for processing past learning and newly acquired info about their pt to decide on a course of action
How is critical thinking helpful to nurses?
Enables the nurse to recognize the situation, respond quickly, and adapt interventions to meet specific pt needs in unexpected situations
What are 6 skills needed for critical thinking?
- Intellect
- Creativity
- Inquiry
- Reasoning
- Reflection
- Intuition
_________ is the process of analyzing and synthesizing the patient presentation (objective and subjective data)
Critical thinking
__________ makes use of the knowledge and skills accumulated through experiences
Clinical judgment
__________ involves choosing evidence-based nursing interventions to improve patient outcomes
Clinical decision making
What is involved in the assessment stage of the nursing process?
- Collecting, organizing, validating, and documenting pt data
- Looking for cues or patterns in the data
What is involved in the diagnosis stage of the nursing process?
- Analyzing and synthesizing data
- Identifying health problems, risks, and strengths
- Developing a list of nursing problems
What is involved in the planning stage of the nursing process?
- first step: ABCD
second step: H/T or focused assessment
third step: Maslow’s hierarchy of needs - Based on priority, plan out how to resolve identified patient problems by developing care plan (SMART goals vs desired outcomes)
What is involved in the intervention stage of the nursing process?
Implementing and documenting the intervention
What is involved in the evaluation stage of the nursing process?
- Measure the degree to which the goals/desired outcomes have been achieved
- Decide to continue, change, or stop the current plan of care
The planning step of the nursing process contains which of the following?
A) Assessing + Diagnosis
B) Evaluating goal achievement
C) Performing nursing actions + documenting them
D) Setting goals + selecting intervention
D is correct
A is just the first 2 steps ; B is evaluation ; C is intervention/implementation
The nurse is reviewing the critical paths of the clients on the nursing unit. In performing a variance analysis, which of the following would indicate the need for further action and analysis?
A) Pt family attending diabetes education
B) Attending physio session on the weekend
C) Abnormal VS and presence of wound infection in post-op pt
D) Pt demonstrating accurate medication administration
C is correct
A, B, and D are all relatively normal/good and do not require additional action at the time
A client following a mastectomy: “Incision site approximated; absence of drainage or prolonged erythema at incision site; client remains afebrile.”
These statements are examples of:
A) Assessment data
B) Nursing interventions
C) Nursing goals
D) Evaluation of care plan
A is correct
B/C not correct because there were no interventions or goals planned in these statements.
D not correct because we have not yet performed any interventions - nurses don’t perform mastectomies, doctors do. Evaluating the care plan for a mastectomy would include running tests to see if pt is cancer free
What is a Health Assessment?
A systematic method of collecting data to determine pt ongoing/current health status, predict health risks, and identify health promoting activities. Involves interviewing the pt + physical assessment
What types of data are collected during the health assessment?
- Wellness behaviours
- Illness/injury signs and symptoms
- Patient strengths + weaknesses
- Health history
- Risk factors
What type of assessment would you perform if you had just started your shift and were checking on a patient for the first time?
Head to Toe
What type of assessment would you perform if you had noticed a change in one of the patient’s systems or vital signs?
Focused
What is the purpose of a head-to-toe assessment?
Establish a baseline for problem identification, reference, and future comparisons
What is the purpose of a focused assessment?
Determine the status of a particular identified problem
When would we perform a head-to-toe assessment?
- if it is our first interaction with the patient
- if the patient is returning to the unit following a procedure like surgery
When would we perform a focused assessment?
- if we notice a problem in a system during a head-to-toe
- if an issue arises rapidly
A health history is included in what type of assessment?
Head to toe
Which systems are examined for in a head-to-toe assessment (specifically)
All systems: neuro, respiratory, cardiac, GI, GU, MSK, skin
What are some examples of objective data?
- signs, or things we can measure/test for during physical exam or observation
- vital signs
- cardiac sounds
- respiratory sounds
- skin colour (abnormal vs normal)
- enlarged organs (upon palpation)
What are some examples of subjective data?
- any feelings/perceptions described by the patient
- sensations (pain, nausea, discomfort)
- feelings
- beliefs
- values
- attitudes
How are some ways we can obtain subjective and objective data?
Patient, family/friends/support people, patient records, health care professionals, and literature (research)
What are the 5 main vital signs? What is the 6th vital sign?
- HR
- BP
- RR
- SpO2
- Temp
- Pain
What is the normal range for HR? What is a low HR? What is a high HR?
- 60-100 bpm
- brady: <60 bpm
- tachy: >100 bpm
What is a normal range for BP? What is low BP? What is high BP?
- 90-140 systolic over 70-90 diastolic
- low BP is anything under 90 systolic, under 70 diastolic
- high BP is anything above 140 systolic, above 90 diastolic
What is a normal range for RR? What is low RR? What is high RR?
- 12-20 breaths per min
- <12
- > 20
What is a normal range for SpO2? What is low SpO2, and what is the condition called?
- 95-100%
- below 95% is considered hypoxemia
What is a normal temperature? What is a low temp? What is a high temp?
- 36.5-37.5 C
- <35 = hypothermia
- > 37.5 = hyperthermia
- 38 = fever
Is the rate of aging faster for a 35 year old or an 85 year old?
Neither! They age at the same rate but the 85 year old will have more age-related changes accumulated
What are some age-related neurological changes that can occur, and what diseases are associated with them?
Changes: decreased speed of neural conduction, brain size, and cerebral circulation
Diseases: Alzheimers, dementia, Parkinson’s, stroke, depression
What are some of the clinical manifestations of neuro changes as we age?
Decreased reaction + response time, deterioration of short-term memory, postural hypotension, and impaired balance/vertigo
What are some age-related cardiac changes, and what diseases are associated with them?
Changes: weakened heart muscle, decreased contractility, thickened ventricle walls, decreased blood flow to organs, increased atherosclerotic plaques
Diseases: hypertension, atherosclerosis, heart failure
What are some of the clinical manifestations of cardiac changes as we age?
Increased BP, slower HR, cold hands/feet, coronary artery disease
What are some age-related respiratory changes? What are the clinical manifestations?
Changes: atrophy of resp muscles, reduced ability of chest to expand, decreased # of alveoli, decreased elasticity
CMs: chest becomes rigid/barrel shaped, decreased ability to deep breathe/cough, decreased O2 sat, thicker mucus, increased RR (16-25 per min)
What are some age-related GI changes, and what diseases are associated with them?
Changes: decreased salivary secretions, GI motility, and liver cells/weight/size, loss of teeth, weakened lower esophageal sphincter
Diseases: dyphagia, GERD, GI bleeds
What are some of the clinical manifestations of GI changes as we age?
Dry oral mucosa, constipation, diminished drug metabolism, altered nutrition
What are some age-related GU changes, and what diseases are associated with them?
Changes: decreased blood supply to neurons, bladder capacity, sphincter control, and diluting ability, increased residual volume
Diseases: incontinence, chronic kidney disease, and benign prostatic hypertrophy
What are some of the clinical manifestations of GU changes as we age?
Increased frequency/urgency to urinate, nocturia, incontinence, dehydration, decreased excretion of toxins/drugs
What are some age-related MSK changes, and what diseases are associated with them?
Changes: decreased mineral content in bones, bone density, and muscle mass/strength, degeneration of cartilage, stiffened ligaments
Diseases: arthritis, osteoporosis, fall-injuries
What are some of the clinical manifestations of MSK changes as we age?
Decreased height, flexibility, strength/agility, and mobility, osteoarthritis, restless leg syndrome
What are some age-related skin changes, and what clinical manifestations are associated with them?
Changes: decreased elasticity, # of sweat glands, and blood supply to nail beds, thin skin, slow epidermal takeover
CMs: skin dry, heals slowly, easily tears/bruises, brittle nails, decreased heat regulation, hair quantity
Approximately what percentage of cardiac function do we lose each year (normal, healthy adult)?
1%
When communicating with older adults should we?
A) speak very slowly and loudly
B) ask them as many questions as possible
C) speak clearly, in shorter sentences
D) direct your questions to a younger person in the room
C is correct
What is the most common age-related chronic condition?
Hypertension - present in approx. 25% of adults over 20
What are some lifestyle factors that can contribute to chronic illness?
Smoking, unhealthy diet, physical inactivity, drug use
True or false? The % of adults living with chronic illness has increased over the years, and the % of adults with at least one chronic illness has also increased?
False. The % of adults with chronic illness has remained relatively stable, but the % of adults living with multiple chronic illnesses has increased
Asthma, COPD, and hypertension are examples of ______ disease
Chronic
A fracture, cut, burn, or flu, are examples of ______ disease
Acute
What are the main differences between a chronic and acute condition?
Timing - chronic conditions tend to be persistent/long-lasting, and symptoms come on gradually, while acute conditions typically have a short duration and symptoms come on suddenly
What does it mean to say that chronic condition symptoms are cyclical?
The symptoms are caused by the condition itself AND each symptom can exacerbate the others
What are 8 common symptoms of chronic conditions?
- fatigue
- stress/anxiety
- difficult emotions
- depression
- shortness of breath
- poor sleep
- physical limitations
- pain
How are chronic illnesses typically managed? By the patient + their caregivers, or by physicians and nurses?
Patient and their families/caregivers.
What is the role of management with chronic illnesses?
To improve quality of life, generally, slow progression of the condition, and reduce symptoms
What are some of the roles of nurses in chronic illness management?
(not all, refer to notes for full list)
- help develop strategies
- provide information (about disease, healthcare system, resources etc.)
- advocate for pt, improved access etc.
A characteristic of chronic illness is? (Select all that apply)
A) has reversible pathologic changes
B) has consistent, predictable clinical course
C) results in permanent deviation from normal
D) is associated with many stable and unstable phases
E) always starts with acute illness, then progresses slowly
B, C, D
The nurse’s role to support pt in chronic illness management includes? (Select all that apply)
A) support pt to optimise self-management skills
B) engage pt and family as partners
C) create plan for pt to make lifestyle changes
D) tell pt which lifestyle choice to change
A, B
We want to work WITH pt, not just tell them what to do. Not C because there’s no mention of working with the pt to make the plan
