Nsg Fundamentals Unit 3 Flashcards
Define the steps and characteristics of the nursing process.
The nursing process is dynamic, continuous, patient centered. DOESN’T revolve around the nurse.
A- What is the purpose? Gather data.
D- Identify patient health needs (problems the nurse needs to take care of)
P- Goal outcome (decide goals patient to achieve) (Choosing interventions to help patient achieve goal)
I-Put interventions into action
E Judge whether actions we took were successful.
What elements define critical thinking?
It is not linear process.
Aquired through hard work, commitment and active curiosity.
It is knowledge based.
What skill separates the RN from other ancillary staff?
DECISION MAKING
What are the KEYS to critical thinking?
Stop and Think. Recognize Assumptions Evaluate Information Draw Conclusions Plan of action. (STOP at the RED light to plan your action)
What is critical thinking
It is a cognitive process to analyze knowledge, and anticipate what may happen. It is based on evidence and science to support action and interventions.
Characteristics of a critical thinker
Fair minded Reasoned thinking open to alternatives flexible able to reflect on behavior done seek the truth Ability to plan for care/anticipate needs
Characteristics and attitude of critical thinkers
Understand logical connection between ideas
Identify, construct, evaluate arguments
detect inconsistencies and mistakes in reasoning
problem solve systematically
ID relevance and importance of ideas
reflect on the justification of one’s values/beliefs
Why is Critical Thinking Important for Nurses?
Nurses apply knowledge to provide holistic care
Nursing is an applied discipline
Nursing uses knowledge from other fields
Nursing is fast-paced
What are the components of critical thinking?
Specific knowledge base Experience Competencies Attitudes Standards
What are the levels of critical thinking?
Level 3 Commitment (to apply)
Level 2 Complex
Level 1 Basic
What is the focus in theoretical classes within nursing program.
Facts, information and principles.
What is the focus in practical/lab classes within nursing program.
Knowing what to do and how to do it as it applies to practice. Hands on.
What is self knowledge?
Your own beliefs, values, culture and religion.
What is ethical knowledge?
What about caring component?
Right from wrong.
Knowing, being with, doing for, believing patient will improve
Looking up a medication a nurse is unfamiliar with prior to administration is demonstrating what component of critical thinking?
?Competence
Knowledge (trying to gain more information)
?Experience
?Independent Thinker
What is the purpose of the Nsg Assessment?
Written, comprehensive and identify priorities of care.
ANA says RN responsibility to do comprehensive assessment.
1. Data collection
2. Organize data
3. Validating data
4. Clustering data to identify patterns
5. Record (documenting what you did) and Report data
What are the different types of nsg assessments?
- Initial/Assessment: establish complete data base on this patient, identifies problems, establishes prioritization and baseline information (get done within certain amount of time, typically 24 hours)
- Focused Assessment: Gather ongoing data about specific problem ALREADY identified. (pt has PNA~ focus on lungs—see if there is progress or changes) *listen to heart and lungs
- Comprehensive Assessment: “shift assessment” establish baseline, prioritization and continuous data collection
- Emergency Assessment: identify life threatening problem.
- Time-Lapsed: compare patient health status to baseline (periodic assessments—i.e. LTC)
- Special Needs: nutritional usually end in referral—ie dietician , WOCN, PT/OT difficulty eating
Objective Data
can be measured, is overt, more reliable (SIGNS!)
Subjective Data
patient reported (SYMPTOMS!) “I cant tell if it is actually there, not measureable”
PRIMARY SOURCE of information
PATIENT (even minors)
SECONDARY SOURCE of information
FAMILY MEMBER
Assessment: Data Collection (methods)
- Observation “hallway observation” .. FOUR SENSES! General appearance- age, presentation, interacting
- Interview- getting information. Establish trust before asking questions, OPEN ENDED QUESTIONS… AVOID WHY.” Tell me..” LISTEN ACTIVELY, REFLECTIVE LISTENING, AVOID IMPULSE TO INTERRUPT
- History Collection- Have they had sx before? Seen physician? What have you done for this before? Recent medication changes?
- Physical Examination- complete head to toe assessment, systematic manner
- Other Sources of Data Collection
What is the difference between medical and nursing assessment?
Medical Assessments focus on disease and pathology.
Nursing assessment focus on patient responses to illness. Treat signs/symptoms of disease/pathology.
What is important to do with assessment data for prioritization and care planning?
Organize, Validate, Cluster
What is timeframe and menas for reporting critical values?
Timing: Data should be reported verbally (phone or in person) immediately when assessment findings are critical.. WITHIN 1 HOUR
General documentation guidelines include
~Charting by exception (only charting the abnormals) otherwise WNL
~Problem oriented medical record- organizes data around the patient problem
vs sources of information
~SOAP **SBAR is tool of communication
What is a nursing diagnosis?
This is NOT a medical diagnosis- statement of a health condition (sign/symptoms) that a RN can identify, prevent or treat independently
What are the three types of nursing diagnoses?
a. Problem-Focused
b. Risk
c. Health Promotion
Problem focused Nursing Diagnosis:
Actual problem
Actual evidence of signs/symptoms of diagnosis exists
EX: fluid volume deficit
RISK NURSING DX (need three signs/sx to prove)
Potential/Risk for a problem
Database contains risk factors of dx but no true evidence
EX: risk for altered skin integrity
Health Promotion Nursing Diagnosis: (i.e. WELLNESS DX)
Describes health status, but not a problem
EX: readiness for enhanced comfort
What is Diagnostic Reasoning?
Clinical Judgement!
Apply critical thinking to problem identification
Requires knowledge, skill and expertise
Steps for diagnostic reasoning?
Analyze/interpret
Draw
Verify
Record
What are the elements of a diagnostic statement?
PES
PROBLEM: impaired skin integrity
ETIOLOGY: R/T immobility
SIGNS and SYMPTOMS: AEB stage III decubitus ulcer, red inflamed skin, purulent (THREE IS STRONG!)
What to consider when prioritizing nursing diagnoses?
- Places problems in order of importance
- Does not mean that you must resolve one problem before attending to another
- Determined by the theoretical framework you use
- Consider patient preference
MASLOW
BASIC NEEDS: physiological needs (food, water, warmth, rest, PAIN), safety needs (security, safety)
PSYCHOLOGICAL NEEDS: Belongingness, love needs (intimate relationships, friends)/Esteem needs (prestige, feeling of accomplishments)
SELF FULFILMENT NEEDS: achieve one’s full potential
ABC
Airway- structure, are they able to take air into their lungs
Breathing- process, can they utilize O2 and rid of CO2 (cant do this if diaphragm ruptured, on +narcotics)
Circulation- blood flowing through body
PROBLEM URGENCY “What will kill them first”
High Priority- life threatening
Medium Priority-not a direct threat to life, but may cause destructive physical or emotional changes
Low Priority- requires minimal supportive nursing
PLANNING: Outcomes/ (Goals and Interventions) “What am I going to do with my patient?
INITIAL Planning:
begins with first patient contact
Written ASAP after initial assessment
Development of the initial comprehensive care plan
ONGOING Planning:
Changes made in the plan as the nurse evaluate the patient’s responses to care
DISCHARGE planning:
STARTS AT ADMISSION (major goal is to return to baseline)
Planning: Identify and writing outcomes GOAL= positive patient response
Goals/Obj/Outcomes: Used to describe what is wanted, an aim, end. Derived from the problem statement of nsg dx
Goals describe the changes in the patient health status you hope to achieve:
Long Term Goal: walk hall by end of two weeks
Short Term Goal: ambulate down hall within two days
Key word: Nursing sensitive outcomes!
Planning: Outcomes
BE realistic
SET goals mutually with client
USE goals should be measurable, use observable goals
IDENTIFY one behavior per outcome
USE when indicated, use short vs long term goals
NIC
INTERVENTIONS
NOC
OUTCOMES
Planning: Components of a Patient Centered Outcomes statement
Subject
Action (Verb) measurable (i.e. demonstrate vs understand.. ambulate, utilize)
Performance criteria (extent you expect to see the action- walk,)
Target time (i.e. daily, by discharge, daily)
Special conditions (i.e. amount of assistance—will amb down hallway with PT, ind, with cane, etc)
What are nursing diagnoses?
Common language for nurses
A clinical judgment
Provides a basis for selection of nursing interventions so that goals and outcomes can be achieved
NANDA list of acceptable diagnoses
What is the purpose of interventions?
To achieve patient outcomes and goals
Interventions could also be called what?
Nursing actions
Nursing measures
Strategies
Activities
What are interventions?
Actions based on clinical judgment and nursing knowledge
Reflect direct and indirect care
How do I choose my interventions?
Professional standards
Theories
Nursing research
Evidence-based guidelines
What is the process for generating and selecting interventions?
Review the nursing diagnosis Review the desired patient outcomes Identify several interventions/actions Choose the best interventions for the patient Individualize standardized interventions
What is a protocol?
Written plan specifying the procedures to be followed during care of a client with a select clinical condition or situation
What is a standing order?
Document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedure for specific condition
What are nursing orders?
are instructions that describe how and when nursing interventions are to be implemented
What are the necessary elements of a nursing order?
Date Subject Action verb Times and limits Signature (written or electronically signed)
What is an intervention?
Describes a category of nursing behaviors in which the actions necessary for achieving the goals and outcomes are initiated and completed
Action by nursing
What is the implementation process of the INTERVENTION phase?
Continue data collection
Reassessing the patient
Reviewing and revising the existing care plan
Organizing resources and care delivery (equipment, personnel, environment)
Document Care
Components of the EVALUATION phase?
Measures the patient’s response to nursing actions (interventions) and progress toward achieving goals
Data collected on an on-going basis
Supports the basis of the usefulness and effectiveness of nursing practice
Involves measurement of Quality of Care
Components of evaluating and revising care plan.
Relate outcome to interventions
Draw conclusions about problem status
Revise the care plan
Why use nursing process for care plans?
Requirement by ANA, TJC
Basis for NCLEX exam
Based on priniciples and ruls that promote critical thinking in nursing
What are the 5 rights of delegation?
Right Task Right Circumstances Right Person Right Directions/Communication Right Supervision/Evaluation
