Think Like a Nurse 1 Flashcards
What does it mean to use a trauma-informed and inclusive lens?
- Reframe perspective
- Reduce retraumatization
- Value lived experiences
- See the whole person
Critical thinking
A combination of reasoned thinking, openness to alternatives, an ability to reflect, and a desire to see truth
An active, organized cognitive process used to carefully examine ones thinking and the thinking of others
Nursing Process
A systematic problem-solving process that is foundational in all nursing actions
Situational factors that influence critical thinking ability
- Anxiety, stress fatigue
- Awareness of risks involved
- Knowledge of related factors
- Awareness of related factors
- Positive reinforcement
-Evaluative or judgmental styles - Presence of motivating factors
- Time limitations
- Environmental distractions
Nursing Process
Assessment, Diagnosis & analysis, Planning, Implementation, Evaluation
What does ADPIE stand for?
A= Assessment
D= Diagnosis
P= Planning
I= Implementation
E=Evaluation
What is the critical thinking process for assessment?
- Consider the situation
- Collect information
- Process that information
What is the critical thinking process for diagnosis?
Identify Issues
What is the critical thinking process for planning?
Establish Goals
What is the critical thinking process for implementation?
Take action
What is the critical thinking process for evaluation?
- Evaluate the outcomes
- Adjust goals and actions according to outcomes
What does an assessment mean?
Systematic and continuous collection, validation, and communication (i.e. documentation) of patient data - utilizes knowledge, critical thinking skills, noticing skills, and reflection skills
Which part of the nursing process involves these skills?
- Identifying assumptions
- Identifying an organized approach to assessment
- Checking accuracy and reliability
- Distinguishing relevant from irrelevant
- Distinguishing normal from abnormal and identifying signs and symptoms
- Clustering related information
- Recognizing inconsistencies
- Identifying patterns
- Identifying missing information
- Drawing valid conclusions based on evidence
Assessment
What are some types of assessment data?
- Pain 6/10
- Red, raised papules on the lower right leg
- Vital signs at 0800 noted on patient chart
- Bilateral lower lungs clear to auscultation
- Stomach pain
- Stomach tenderness
- Periorbital bruising bilaterally
- Caregiver states patient is anxious
What are some data collection methods?
- Observation
- Interview
- Physical examination
- Inspection
- Auscultation
- Palpation
- Percussion
What is the purpose of an interview during an assessment?
- Purposeful structured communication
- Components of health history
What does it mean to get ready for an interview?
Prepare yourself, the space and the patient
What is the orientation phase of an interview?
Introductions, the purpose of the interview, establish trust and confidence, establish role you will play, take note of cultural, spiritual, and comfort needs and how they may influence patient participation
What is the working phase of an interview?
- Asking pertinent questions and gathering information, using observation skills
- Closed (closed-ended) questions
- Open-ended questions
What is the termination phase of an interview?
- Ending the interview process
- What will happen next for the patient
- Thank the patient for participating
What is the purpose of a physical examination during an assessment?
Data gathered regarding the patient’s health status
- Comprehensive
- Focused
- Shift
- Etc
How do you make sense of the data collected from an assessment?
- Comparing findings with expected norms
- Validating data findings
- Reassessing data that does not make sense
- Clustering sets of data that support a particular judgment
- Recognizing trends and patterns
- Documentation
What are nursing diagnoses focused on?
Patient needs and responses
What does nursing diagnosis mean as a NOUN?
- A word or phrase identifying specific patient problems, needs, or risks
- The means of describing health problems that can be improved, prevented, or resolved by independent nursing interventions
What does nursing diagnosis mean as a VERB?
The process of identifying a specific patient problem/need
What are the three types of nursing diagnoses?
- Problem-focused
- Risk
- Health promotion
What is a collaborative nursing diagnosis?
a health issue that requires both nursing and medical intervention
What is a problem-focused nursing diagnosis?
a nursing diagnosis that focuses on a current issue or condition that’s present in a patient at the time of assessment
What is a collaborative nursing diagnosis also known as?
A collaborative problem
What is a problem-focused nursing diagnosis also known as?
An actual diagnosis
What is a risk nursing diagnosis?
a clinical judgment that identifies a patient’s vulnerability to developing a health issue in the future
What is a health promotion nursing diagnosis?
a clinical judgment about a person’s motivation and desire to improve their health and well-being
What is a health promotion nursing diagnosis also known as?
A wellness diagnosis
What does NANDA stand for?
North American Nursing Diagnosis Association
What is the purpose of the North American Nursing Diagnosis Association (NANDA)?
Provides a basis of selecting nursing interventions to address a patient’s needs - a common language for identifying problems, providing a basis for evidence-based nursing practice
What does NIC stand for?
Nursing Intervention Classification
What is the purpose of Nursing Intervention Classification (NIC)?
Describes the nursing treatments that nurses perform to improve patient outcomes
What does NOC stand for?
Nursing Outcome Classification
What is the purpose of Nursing Outcome Classification (NOC)?
Describes the changes in a patient’s health status based on the nursing interventions performed
True or False: Significant data should begin to raise red flags
True
How do you analyze data to identify a nursing diagnosis?
- Compare data to standards (normal vs. abnormal)
- Patterns or clusters of data
- Patient strengths or problem areas
- Potential problems (problems the patient is likely to encounter)
What does the PES in nursing diagnosis PES statement mean?
- Problem
- Etiology
- Signs & Symptoms
What does problem mean in a nursing diagnostic PES statement?
Describes the actual or possible health and problem
What always comes first in a nursing diagnosis PES statement?
Problem
What does etiology mean in a nursing diagnostic PES statement?
Describes the factors believed to be causing or contributing to the problem
What do signs & symptoms mean in a nursing diagnostic PES statement?
Supportive data (for actual problems only)
What always follows the problem in a nursing diagnostic PES statement?
Etiology
What is always last in a nursing diagnostic PES statement?
Signs and Symptoms
How would you quote signs & symptoms on a nursing diagnostic PES statement?
“As evidenced by”
“As manifested by (AEB/AMB)
True or False: “At risk” diagnoses are always two-part statements
True
Why are “at risk” diagnoses always two-part statements?
Because the problems do not actually exist, or there is not enough data to support the problem
True or False: You use PES when writing an “at risk” diagnosis statement
False
We use only the P and the E:
(P) “Risk for ____”
(E) “…R/T _____ “ (associated risk factors)
What questions should you ask yourself when the diagnosis is unclear?
- What are my concerns about the patient?
- Can I/am I doing something about it?
- Can the overall risk be reduced, or problem solved by a nursing intervention?
- Am I sure I have the right problem identified?
True or False: You should use a medical diagnosis when writing a nursing diagnosis (“pneumonia”, “fracture”)
False
True or False: You should relate the problem to an unchangeable situation when writing a nursing diagnosis (“quadriplegia”, “houselessness”)
False
True or False: You should not confuse the etiology or signs/symptoms for the problem (“limping” vs “impaired mobility”)
True
True or False: Specificity does not matter when writing a nursing diagnosis (“as evidenced by medication intolerance”)
False
True or False: It is okay to combine two nursing diagnoses when writing a nursing diagnosis
False
True or False: Using judgmental/value-laden language is not allowed when writing a nursing diagnosis (“will not comply with…” , “bad hygiene”)
True
True or False: It is okay to make assumptions when writing a nursing diagnosis (“will not be able to step up three stairs…” , “will become hostile if…”
False
True or False: You can write a legally inadvisable statement when writing a nursing diagnosis (“AEB night shift nurse’s assessment”)
False
True or False: Anything outside your nursing scope such as identifying a new medical diagnosis based on lab interpretation, etc is prohibited when writing a nursing diagnosis
True
True or False: It is okay to copy and paste another nurse’s statement when writing a nursing diagnosis
False
What does a chief complaint mean?
a brief statement that describes the main reason a patient is seeking medical care
What are close-ended questions?
questions that limit the possible answers that respondents can choose from
What is a comprehensive assessment?
a variety of systems and tools that evaluate a person or a student’s understanding
What does diagnostic reasoning mean?
a cognitive process that involves interpreting patient data, forming a hypothesis, and narrowing down a list of diagnoses to determine a treatment plan
What does evidence-based knowledge mean?
information or advice that is supported by scientific research
What is the purpose of evidence-based knowledge?
to make informed decisions in healthcare
What are open-ended questions?
questions that allow patients to discuss their concerns freely
What is an ongoing assessment?
a head-to-toe evaluation of a patient’s physical and mental status that’s performed at least once per shift in acute care settings like hospitals
What is the purpose of an ongoing assessment?
to verify that treatment is working and to monitor changes in a patient’s condition
What does ROS stand for?
Review of systems
What is a review of systems (ROS)?
a list of questions used in nursing to identify a patient’s symptoms
