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AHII > Nursing Process: A tool for Critical thinking > Flashcards

Nursing Process: A tool for Critical thinking Flashcards

1
Q

Student care plans - allows student process to understand how think like a nurse - framework for CT and clin judgement; take content learned and apply it to specific pat situations
Nursing student learns to to write and use nursing care plans to learn to “think like a nurse” (clinical reasoning and critical thinking)
Students learn to apply knowledge gained in classes to create plan of care for patients in clinical setting
Student learns scientific rationales for each intervention chosen because nurses are legally accountable for responses to interventions performed
As students build on knowledge and critical thinking, NP becomes second nature to provide quality care for each patient

A

Why do I need to know nursing process

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2
Q

Purposeful, goal-directed thinking based on scientific knowledge - knowledge extract from lectures
Involves viewing all the facts, seeking and weighing the alternatives, and selecting the best one to meet the desired outcome

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Defining critical thinking

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3
Q

reflection/eval
language/communication
Thinking and learning
Intuition

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Aspects of critical thinking (CT)

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4
Q

Review successes/opportunities for improvement/revision
Eval imp how intervention applied help/not help certain pt situation

A

reflection/eval

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5
Q

Be clear and accurate (verbal and written)
Esp N diagnosis allow for specific language can all use to understand what is happening with certain client

A

language/communication

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6
Q

Info mor powerful and able apply it
Interrelated and lifelong process
As knowledge base and experience grow, so does CT

A

Thinking and learning

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7
Q

Cognitive and emotional cues: “something is not right”
What info relevant and not

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Intuition

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8
Q

Interpretation
Analysis
Inference
Eval
Explanation
Self-regulation

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Critical thinking skills

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9
Q

Look for patterns to categorize data-clarify uncertain info

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Interpretation

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10
Q

Make no assumptions
Be open to what data reveals - look heavily at data; fill in gaps

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Analysis

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11
Q

Look at significance of findings; what probs exist

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Inference

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12
Q

Use criteria to determine results - intervention successful or not

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Eval

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13
Q

Support your findings and use knowledge to select strategies

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Explanation

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14
Q

self-awareness of need to improve

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Self-regulation

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15
Q

Decision making criteria
Answers assist nurse to:

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Clinical decision making:

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16
Q

What needs to be achieved? - make progress
What info needs to be preserved?
What needs to be avoided? - want to prevent
What need do for pat

A

Decision making criteria

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17
Q

Make decisions and set priorities - help nurse
Select activities/interventions
Anticipates what may go wrong
Consider alternatives

A

Answers assist nurse to:

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18
Q

Lexicon - standard nursing language
North American Nursing Diagnosis Association (NANDA)
Nursing Intervention Classification (NIC)
Nursing Outcomes Classification (NOC)

A

Nursing process: standard nursing language

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19
Q

Diagnosis labels, definitions and defining characteristics

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North American Nursing Diagnosis Association (NANDA)

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20
Q

Interventions/activities linked to NANDA

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Nursing Intervention Classification (NIC)

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21
Q

Behaviors measured along a continuum in response to nursing interventions

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Nursing Outcomes Classification (NOC)

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22
Q

A systematic, problem-solving process that is used to identify, diagnose, and treat human responses to health and illness

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Nursing process defined

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23
Q

Nurse focus
Nurse wants to act upon manifestions (s&s)
Physician focus

A

A systematic, problem-solving process that is used to identify, diagnose, and treat human responses to health and illness

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24
Q

Patient’s responses to symptoms
Patient’s ability to care for self

A

Nurse focus

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25
Q

Disease process/pathology
Treatment of disease

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Physician focus

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26
Q

Five inter-related steps (ADPIE)
Assessment:
Diagnosis;
Planning
Implementation:
Evaluation:
Not linear - more spiral

A

Steps of the NP

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27
Q

collect data; organize data

A

Assessment:

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28
Q

analyze data; identify nursing diagnoses and collaborative probs

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Diagnosis;

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29
Q

(Outcome and Interventions/Activities): proriotize probs; identify measurable outcomes (goals); select nursing interventions; doc plan of care

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Planning

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30
Q

carry out nursing orders; doc nursing care and client responses

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Implementation:

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31
Q

monitor client outcomes; resolve, cont, revise current plan of care

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Evaluation:

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32
Q

Accurate and comprehensive assessment leads to accurate nursing diagnosis
ASSESSMENT
Data collection

A

Nursing assessment

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33
Q
  1. Collect data - ongoing: come from pt; assessment; H&P
  2. Identify cues & make inferences: cues: pieces actually stick out that interesting to know
  3. Validate info: check info a diff way
  4. Organize (cluster data)
  5. Identify patterns
  6. Report and record
    Lead to Nursing diagnosis
A

ASSESSMENT

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34
Q

Data sources
Methods
Subjective (aka symptoms)
Objective (are signs)

A

Data collection

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35
Q

Patient/Family - listen to pts since know their body
Health care team
Medical record - read H&P before meet pt so have good understanding what’s going on
Diagnostic and Lab data

A

Data sources

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36
Q

Interviews/History
Observations
Physical Assessment
Medical Record review

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Methods

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37
Q

One type data
What a person states or communicates in writing

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Subjective (aka symptoms)

38
Q

One type data
Observations or measurements of a patient’s health status

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Objective (are signs)

39
Q

Cues
Inference

A

Identifying data

40
Q

Identifying data which includes Information the nurse obtains through the use of the senses (S & O data)
Relevant data- decide what info. is meaningful/important

A

Cues

41
Q

Process of deriving logical conclusions from multiple observations (inductive reasoning)
May be correct or incorrect, or correct to within a certain degree of accuracy; requires more data - find extra data that supports/not support inference making

A

Inference

42
Q

complement and clarify the other

A

Subjective and objective may

43
Q

objective - cues differ from subjective and objective; need have good look at pt

A

Subjective may differ from

44
Q

Rule: Review your data and reflect. Be sure information is accurate, factual and complete.
Ask questions: What may be missing? abnormals? potential risks? Immediate needs?
Based on data make inferences
Data measured accurately can be accepted as factual (ht, wt, lab results, etc.)
Data that some one else observes may or may not be true. - make sure you believe data is true
Critical info should be checked

A

Validate data

45
Q

Look for factors that may alter data - EX: renal pt elevated d-dimer/looking for clots (not looking at if pt has a clot but may be altering data r/t lab
Recheck your own data for accuracy
Ask someone else to collect same data/validate data
Double check that equipment is working appropriately - pts with afib do manual BP
Double check abnormal or inconsistent info.
Clarify statements and verify your inferences with pt - repeat what hear
Compare your impressions with other team members
Compare what patient states with observations for congruency

A

Guidelines to validating data

46
Q

Identify patterns by organizing the cues into meaningful usable clusters
Data clusters

A

Organize data

47
Q

set of signs and symptoms that are grouped together in a logical way; cluster relevant data

A

Data clusters

48
Q

Analysis
Select a Nursing Diagnosis

A

Identify patterns/interpreting data

49
Q

Recognize patterns/trends in clustered data - imp for AEB portion of N diagnosis statement; pop all inform together that proves what occurring to pt; look at clustered data
Compare to standards and textbook knowledge
Draw conclusions about the real problem

A

Analysis

50
Q

Based on the defining characteristics of the prob

A

Select a Nursing Diagnosis

51
Q

To clarify the exact nature of the problem
Potential risk factors
To achieve the overall expected outcome
Assessment - diagnosis - planning - intervention - evaluation: all connect together and spiral back on each other; need ensure have stuff can predict and prevent probs or promote wellness

A

Nursing diagnosis: Purpose

52
Q

Clusters and patterns of data contain defining characteristics (manifestations: signs and symptoms) that support the Nursing Diagnosis
Nanda N. diagnosis also identifies potential Related Factors

A

Identifying nursing diagnosis

53
Q

Functional, psychological, pharmacological, mechanical, physiological

A

Nanda N. diagnosis also identifies potential Related Factors

54
Q

Actual
Potential (Risk for)
Wellness
Collaborative

A

Types of nursing diagnosis labels

55
Q

A problem that has been validated by the presence of major defining characteristics

A

Actual

56
Q

Individual is vulnerable to development of problem(s)

A

Potential (Risk for)

57
Q

Assist individual to pursue optimal health

A

Wellness

58
Q

Interdisciplinary plans of care
Hospitals use - holistic plans of care use all HCPs

A

Collaborative

59
Q

*PES= problem etiology symptoms
Contains the Nursing problem/diagnosis (diagnostic label), etiology (contributing factors or cause: r/t), and manifestations: signs & symptoms (pt’s defining characteristics) of the diagnosis
Start with ABCs then work way down to other issues

A

Writing three part (actual) nursing diagnosis sentence

60
Q

Risk for:
Two Part contain the label and a list of the individual risk factors
Risk for falls: lack of awareness of hazards; use of walker; narcotic pain medications
Problem not occurred: no signs/symptoms
Preventing potential for injury by controlling the risk factors

A

Writing two part: nursing diagnosis sentence

61
Q

One part contain the label
More home based
Wellness nursing diagnosis
Patient has desire for higher level of wellness
Example: Patient who desires to improve nutrition habits to lose weight
Readiness for enhanced nutrition

A

Writing one part: nursing diagnosis sentence

62
Q

Potential complications of medical conditions/prbs nurse cannot treat independently
Nurses manage collaborative problems using physician-prescribed intervention
Nurses monitor for risk, to detect onset of problems, or evaluate change in status/to see anything may go wrong/see pt is improving
Nurse having call physician to get order for pain med even if PRN; if was already on the MAR - independent and decision to give it
All collaborative problems begin with the diagnostic label “potential complication” (PC) Monitoring one problem
Potential Complication: hyperglycemia R/T long-term corticosteroid therapy

A

Collaborative probs

63
Q

Problems will exist or progress without detection
Omitting interventions that are essential
Choose inappropriate interventions that may:
Waste time
Cause harm
Aggravate the real problem
Place yourself in legal jeopardy
Need do appropriate N diagnosis and prob

A

Risks of nursing diagnostic errors

64
Q

Don’t make a medical diagnosis a nursing diagnosis: focus on person’s response to the medical problem; medical diagnosis cannot be beginning but can relate it to medical issue
Incorrect: Mastectomy r/t cancer
Correct: Risk for self-concept disturbance r/t effects of mastectomy

A

Errors in writing nursing diagnosis: making a nursing diagnosis from a medical

65
Q

Don’t rename a medical problem to make it sound like a nursing diagnosis
Incorrect: Imbalanced Hemodynamics related to hypovolemia
Correct: Fluid volume deficit r/t hypovolemia

A

Errors in writing nursing diagnosis: renaming a medical prob

66
Q

Incorrect: Risk for injury r/t lack of side rails on the bed
Correct: Risk of injury r/t disorientation and attempts to get out of bed

A

Errors in writing nursing diagnosis: legally incriminating

67
Q

Don’t state two problems at the same time - can be related to 2+ issues and needs to be evidence of more than one issue but first part needs be one nursing issue; separate out
Incorrect: Pain and fear r/t diagnostic procedure
Correct: Fear related to unfamiliarity with diagnostic procedures; Pain r/t movement in during radiology exam

A

Errors in writing nursing diagnosis: two probs in one diagnostic statement

68
Q

Don’t make a nursing diagnosis out of a physician’s order or a collaborative problem; monitor for potential complications; r/t can be medical diagnosis but not a physician’s order
Incorrect: Imbalanced nutrition related to being NPO (NPO is a physician’s order. Monitor potential complications)
Correct: Risk for dehydration r/t fluid imbalance

A

Errors in writing nursing diagnosis: creating a nursing diagnosis from a physician’s order

69
Q

Don’t write a nursing diagnosis based on value judgments; r/t something happen not to beliefs
Incorrect: Spiritual Distress r/t atheism as evidenced by statements that she has never believed in God.
There may be no diagnosis in this situation. This person may be at peace with her beliefs (not with yours!)

A

Errors in writing nursing diagnosis: value judgements

70
Q

The Plan of Care should be individualized to pat; may mean talk with pt to make mutually acceptable goals: ST and LT goals for pt
Consider age, health, culture, capabilities, human and financial resources
Partner with patient
Standards of care
Diagnosis - planning: priorities, outcome, interventions, activities

A

Planning

71
Q

Chosen Goals/Outcomes guide the POC (plan of care) and choices for nursing interventions
Goals
Outcomes
Measuring stick for the Plan of Care
Use objective criterion for measuring goals

A

Goals and outcomes

72
Q

Describe early expected benefits of nursing interventions

A

Goals

73
Q

Standardized outcomes developed by nursing experts; describe benefits expected at a certain point in time

A

Outcomes

74
Q

Describe something you can hear, see, feel, or smell in the person to demonstrate the outcome

A

Use objective criterion for measuring goals

75
Q

SMART GOALS
Specific (individualize to patient)
Measurable (correct verb and indicators)
Attainable - can get it
Realistic oriented
Timed (expected completion)

A

Developing goals/outcomes

76
Q

Identify
Describe
State
Verbalize
Demonstrate
Communicate
List
Hold
Exercise
Perform
Express
Relate
Walk
Cough
Share
Will lose
Will gain
Has an absence of

A

Measurable verbs for goals and outcome statements - help with SMART goal: things need to be able to see, smell, feel, hear

77
Q

Actions performed by the nurse to:
Can be Independent (already on MAR) and Collaborative (call and get med)
Choices listed under each Nursing Diagnosis - look at handbook

A

interventions/activities

78
Q

Reduce risks
Monitor health status
Resolve, prevent, or manage problems
Facilitate independence or assist with ADLs
Promote optimum sense of physical, psychological, and spiritual well being

A

Actions performed by the nurse to:

79
Q

Factors to Consider
Priorities of care - ABCs; what effect pt most; damage
Acceptability (patient) of goal or end of interventions
Feasibility
Fit the Chosen Nursing Diagnosis
Expected goals/outcomes
Evidence-based nursing knowledge

A

Selecting interventions

80
Q
  1. Take care of immediate life-threatening issues (ABC)
  2. Safety issues
  3. Patient-identified issues
  4. Nurse-identified priorities
A

Priotizing interventions

81
Q

Based on the overall picture, the patient as a whole person, and availability of time and resources

A
  1. Nurse-identified priorities
82
Q

Research evidence that supports successful intervention
Valid sources-textbooks, scientific websites, nursing journals, research studies, policy & procedures (in hospital - back up for safety), interdisciplinary journals, etc.

A

Scientific rationale: EBP

83
Q

Helps nurse weigh risks and benefits of performing intervention
You are legally accountable for responses to interventions performed!

A

Research evidence that supports successful intervention

84
Q

4 key questions need to be answered
Perform the chosen prioritized, evidence-based interventions in a …
Throughout entire plan of care all pieces must link together and be related to each other and must always be evaluated

A

Implementation: Putting the Plan into Action

85
Q

Can be done to prevent/minimize risk/causes of prob
Can be done to manage prob
How tailor interventions to meet EO
How likely are we to get desired versus adverse responses to the intervention

A

4 key questions need to be answered

86
Q

Safe, effective, organized way to get the results needed while preventing errors
To meet the goals and outcomes of the plan
Continually evaluate the effectiveness of each intervention and make revisions

A

Perform the chosen prioritized, evidence-based interventions in a …

87
Q

Rule: Assuming your diagnoses are accurate and your outcomes and interventions are appropriate, the ultimate question to be answered during evaluation is:
Implementation - evaluation: Goals met? Partially met? Unmet? Continue the plan? Revise the plan?
If goal met: goes back into assessment phase where keep making sure not fall below line
Partially met: decide if continue/revise plan or may need more time which would be a revision and goes back to assessment
Unmet - revision of plan
Are the goals/outcomes criteria ….
Reflect on why goal/outcome was not met.
Review all the steps of the nursing process
Update the care plan
Always assess and evaluate

A

Evaluation

88
Q

“Has the patient achieved the determined goals/outcomes?”

A

Rule: Assuming your diagnoses are accurate and your outcomes and interventions are appropriate, the ultimate question to be answered during evaluation is:

89
Q

Completely met? How do you know?
Partially met? Can you revise the plan?
Not met at all? Why not?

A

Are the goals/outcomes criteria ….

90
Q

What must be changed/revised in the POC to move the patient towards the intended outcome?

A

Reflect on why goal/outcome was not met.

91
Q

Evaluation happens in every step of the nursing process - make sure what doing is appropriate and working for specific pat
Assessment: Perform assessment to detect changes in pt. health; confirm data
Diagnosis: Determine if all diagnoses that must be managed are listed in plan of care
Planning: Check that goals/outcomes and interventions are appropriate, prioritized, realistic, and measurable
Implementation: Determine if plan is being followed as prescribed and the factors that help or hinder the progress

A

Good evaluation examines all steps

92
Q

Nursing Assessment data must support the diagnostic label and the related factors must support the etiology
The outcome and goals flow from the diagnosis
Specific interventions must be prioritized and move the patient towards achieving the goals/outcomes.
The evaluation restates the goals/outcome including the indicators of success or failure of the plan

A

Nursing care plan summary

AHII (47 decks)

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