Nursing Process & Critical Thinking Flashcards
what are the FIVE STEPS OF THE NURSING PROCESS?
**ADPIE
- ASSESSMENT
- DIAGNOSIS
- PLAN
- IMPLEMENT
- EVALUATE
definition of ASSESSMENT
gathering INFORMATION about the patient’s condition
what do we need to FACTOR IN DURING ASSESSMENT?
- use of CRITICAL THINKING SKILLS
- want to GATHER AS MUCH INFORMATION AS POSSIBLE
- have to COLLECT, REVIEW, & ANALYZE the DATA
what are the TWO STAGES OF ASSESSMENT?
- want to first COLLECT information either from a PRIMARY SOURCE (the patient themselves) or SECONDARY SOURCES (the family, charting)
- want to then INTERPRET & VALIDATE THE DATA
is this data needed?
does the data make sense?
what are our TYPES OF ASSESSMENTS?
- PATIENT CENTERED INTERVIEW
- PERIODIC ASSESSMENTS
- PHYSICAL EXAMINATION
definition of patient-centered interview
conducted during nursing history
definition of PERIODIC ASSESSMENTS
conducted during ONGOING CONTACT WITH PATIENTS
- going throughout the shift
definition of PHYSICAL EXAMINATION
conducted during the NURSING HISTORY or any time the patient presents a SYMPTOM
what are OUR TYPES OF DATA?
- SUBJECTIVE
- OBJECTIVE
definition of SUBJECTIVE DATA
the patient’s own VERBAL DESCRIPTIONS of their health issues
specific feelings or perceptions
definition of OBJECTIVE DATA
findings that come from DIRECT OBSERVATION
what are some important parts of a NURSING HEALTH HISTORY?
- PMH
- FAMILY HISTORY
- PERSONAL & SOCIAL HISTORY
definition of CULTURAL COMPETENCE
having the SELF AWARENESS AND PRACTICE and knowledge of a patient’s core cultural background
definition of CULTURAL HUMILITY
ability to RECOGNIZE UR OWN KNOWLEDGE LIMITATIONS and perspectives
still being open
how should data documentation be like?
should be CLEAR AND CONCISE and using PROPER TERMINOLOGY
- be able to RECORD AND EVALUATE INTERVENTIONS
definition of DATA COLLECTION
use of INFORMATION about a patient’s needs to adapt your data collection
definition of INTERPRETATION
ability to INTERPRET ASSESSMENT DATA TO see if there are ABNORMALITIES
definition of VALIDATION
comparing data with other sources to determine ACCURACY
what is CONCEPT MAPPING?
being able to ORGANIZE YOUR ASSESSMENT DATA
- being able to PLACE ALL THE CUES TOGETHER and look for PATTERNS
definition of DIAGNOSIS
have the IDENTIFICATION OF A HEALTH-RELATED PROBLEM or the POTENTIAL OF A PROBLEM TO DEVELOP based upon patient data
what are the TYPES OF DIAGNOSIS?
- MEDICAL DIAGNOSIS
- NURSING DIAGNOSIS
what is the DIFFERENCE BETWEEN MEDICAL & NURSING DIAGNOSES?
- medical diagnoses are MORE SPECIFIC to the disease a patient has
- NURSING DIAGNOSES are specific to the CLINICAL JUDGEMENT of the patient
ex. med. diagnosis - COPD
ex. nursing diag. - ineffective breathing pattern
how do we WRITE OUT NURSING DIAGNOSES?
through the PES FORMAT
describe the PES FORMAT
- PROBLEM
- ETIOLOGY
- SYMPTOMS
- associated data
- subjective data
- objective data
(1)problem r/t (2)etiology a.e.b/a.m.b. (3) symptoms
definition of COLLOBORATIVE PROBLEMS
problem that REQUIRES BOTH MEDICINE AND NURSING INTERVENTIONS totreat
what is considered a NURSING DIAGNOSIS?
if the nurse can PREVENT THE COMPLICATION or PROVIDE THE PRIMARY TREATMENT for it
definition of PROBLEM FOCUSED DIAGNOSIS
identifying an UNDESIRABLE HUMAN RESPONSE to existing problems or concerns of the patient
definition of a RISK DIAGNOSIS
diagnoses that apply when there is an INCREASED POTENTIAL or VULNERABILITY for a patient to develop a PROBLEM OR COMPLICATION
definition of a HEALTH PROMOTION DIAGNOSIS
identifying the DESIRE OR MOTIVATION to improve health status through a positive behavioral change
definition of DATA CLUSTERING
set of assessment findings and defining specific characteristics
- being able to be MORE SPECIFIC AND COMPARE DATA – focused in specific PATTERSN
definition of DATA INTERPRETATION
putting specific LABELS ON PATTERNS and IDENTIFYING PATIENT RESPONSES
where do DIAGNOSTIC ERRORS OCCUR?
- improper DATA COLLECTION
- CLUSTERING
- wrong ANALYSIS OR INTERPRETATION OF DATA
- improper diagnostic statement
why are DIAGNOSES SO IMPORTANT?
allow for a PROPER SELECTION OF NURSING INTERVENTIONS to achieve DESIRED OUTCOMES for patients
- sets an important start for a ROAD MAP OF DELIVERING CARE
what is within the PROCESS OF PLANNING NURSING CARE?
- being able to SET PRIORITIES
- being able to IDENTIFY PATIENT-CENTERED GOALS
- having the proper PRESCRIPTION OF NURSING INTERVENTIONS
what is the IMPORTANCE SCALE FOR NURSING DIAGNOSES?
HIGH:
- very important if left untreated can cause HARM TO PATIENT
- maslow
INTERMEDIATE:
- nonemergent or non-lifethreatening
LOW:
- not typically directly related to illness specifically–but can affect the patient’s future well-being
what about GOALS, how do they play out during PLANNING?
important to consider because this is the end finish line that we want to achieve!
- is this goal SHORT-TERM or LONG-TERM?
important to be REALISTIC with the goal and priorities that you set
definition of SMART GOALS
SMART - in setting your goals!
S - be SPECIFIC
M - it should be MEASURABLE
A - it should be ATTAINABLE (whether that is during your shift or throughout recovery)
R - be REALISTIC
T - should be TIME FOCUSED
what are the TYPES OF INTERVENTIONS?
- NURSE INITIATED
- HEALTH CARE PROVIDER INITIATED
- OTHER PROVIDER INITIATED
what is the NURSING INTERVENITONS CLASSIFICATION
type of model that is divided into DOMAINS, CLASSES, & INTERVENTIONS
- helps to ENHANCE COMMS between nurses and setting standards for nursing interventions
definition of DIRECT CARE INTERVENTIONS
treatments that nurses PROVIDE through interactions with the patient or group of patients
definition of INDIRECT CARE INTERVENTIONS
treatments that are PERFORMED AWAY from a patient but on the BEHALF OF THE PATIENT or group of patients
- documentation/usage of consultation etc…
definition of STANDARD INTERVENTIONS
- interventions that allow the nurses to ACT QUICKLY & APPROPRIATELY
- captures patient care information that can be shared across disciplines or care settings
what are some interventions?
- care bundles
- PRN orders/standing orders
- standards of practice
definition of CLINICAL PRACTICE GUIDELINES AND PROTOCOLS
systemically developed set of statements that are appropriate health care for specific health care problems
definition of a CARE BUNDLE
group of interventions that are RELATED TO A DISEASE PROCESS OR CONDITION
definition of STANDING ORDERS
- prepreinted document that contains MEDICAL ORDERS
- directs patient care in a specific clinical setting
what are STANDARDS OF PRACTICE?
use of ANA STANDARDS OF PROFESSIONAL NURSING PRACTICE
definition of QSEN
- the QUALITY AND SAFETY EDUCATION FOR NURSES
- gives proper KNOWLEDGE, SKILLS, and attitudes for the prep of future nurses
what to consider BEFORE IMPLEMENTATION?
- what are all POSSIBLE INTERVENTIONS for this patient?
- are there any CONSEQUENCES for this action?
how can we PREVENT COMPLICATIONS?
- identifying RISKS to the patient
- adapting interventions to the situation
- comparing the BENEFIT AND RISK
definiton of EVALUATION
determining if a PATIENTS CONDITION is being IMPROVED AFTER THE NURSING INTERVENTIONS THAT WERE IMPLEMENTED
how do we EVALUATE?
want to look at the OUTCOMES AND DO A BEFORE AND AFTER COMPARISON OF STANDARDS
- examine results from patient, family, and other nurses
- do these results match with the goals set for this patient?
what happens if the OUTCOMES DONT MATCH GOALS?
- either can DISCONTINUE OR MODIFY THE CARE PLAN
- have to REDEFINE OUR DIAGNOSES
- REVISE GOALS AND EXPECTED OUTCOMES
- REVISE INTERVENTIONS
