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