Think Like a Nurse 2 Flashcards
What does AACT stand for?
- Assessment
- Actions
- Collaboration
- Teaching
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 part of the nursing process is a formal or informal process, addresses unique needs and goals of individual patients, requires communication regarding the plan to all parties, and selection of appropriate nursing interventions to achieve desired outcomes?
Planning
What are the three types of planning?
- Initial planning
- Ongoing planning
- Discharge planning
What is the first step of planning patient care?
Prioritizing the nursing diagnosis
What is the second step of planning patient care?
Identifying the patient goals/expected outcomes
What is the third step of planning patient care?
Identifying appropriate nursing interventions
What is the fourth step of planning patient care?
Communicating the care plan to all involved in its implementation
What are the greatest threats to the patient’s well-being?
- ABCs
- Maslow’s hierarchy
- Patient preference
- Anticipation of future problems
What is the fifth level of Maslow’s hierarchy and what does it mean?
Self-actualization
Morality, creativity, spontaneity, problem-solving, lack of prejudice, acceptance of facts
What is the fourth level of Maslow’s hierarchy and what does it mean?
Esteem
Self-esteem, confidence, achievement, respect of others, respect by others
What is the third level of Maslow’s hierarchy and what does it mean?
Love/belonging
friendship, family, sexual intimacy
What is the second level of Maslow’s hierarchy and what does it mean?
Safety
security of body, of employment, of resources, of morality, of the family, of health, of property
What is the first level of Maslow’s hierarchy and what does it mean?
Physiological
Breathing, food, water, sex, sleep, homeostasis, excretion
What does outcome mean?
any patient response to an intervention (positive or negative)
What does “expected” or “desired” outcome mean?
the positive patient response that we hope will occur as a result of an intervention
Outcome statements must be ______
S.M.A.R.T
Goals can be ______
General or specific
True or False: A broad, or general, goal must be accompanied by specific expected outcome statements
True
What does the S in S.M.A.R.T stand for?
Specific
What does the M in S.M.A.R.T stand for?
Measurable
What does the A in S.M.A.R.T stand for?
Achievable
What does the R in S.M.A.R.T stand for?
Relevant
What does the T in S.M.A.R.T stand for?
Timed
What are four types of goals?
- Cognitive
- Psychomotor
- Affective
- Physical
What is a cognitive goal?
objectives that focus on developing intellectual skills, knowledge, and critical thinking abilities
What is a psychomotor goal?
a learning objective that focuses on how a person controls or moves their body
What is an affective goal?
an objective that focuses on a person’s attitude, emotions, values, and beliefs
What is a physical goal?
a specific training objective or challenge you set for yourself to improve your physical health
True or false: The goal is not always related to the problem
False
The problem identifies what needs to change and suggests patient goals and outcomes that demonstrate change has occurred
What are nursing interventions?
Actions based on clinical judgement and nursing knowledge that nurses perform to achieve client outcomes
What are the three types of interventions?
- Independent (nurse-initiated)
- Dependent (provider-initiated)
-Collaborative (Interdependent)
True or false: The “related” to part of the nursing diagnosis helps guide interventions
True
“related to” helps identify factors causing the problem, prevents change - which suggests possible intervention
What is the purpose of AACT?
A guideline in clinical to help you identify a comprehensive set of interventions in your nursing care plan
True or False: A well-written intervention identifies a WHO, What, WHEN, and sometimes HOW
True
True or False: The “AMB/AEB” part of the nursing diagnosis does not suggest interventions
False
The evidence describes how we know there is a problem which suggest assessments or actions to be taken, this helps us identify additional interventions
You should select interventions that are ____
Effective, cost-efficient, and supported by scientific data
Evidence-based practice in nursing combines _____
Nursing knowledge, clinical judgment, and expertise, evidence from research, and patient preferences
What are three things to remember with implementation?
Do, delegate, and document
What is the “doing” part of implementation?
- Prepare to act
- Get organized
What is the purpose of nurse protocols and standing orders?
They expand the scope of nursing practice within clearly defined parameters
What is the purpose of nurse protocols and standing orders?
They expand the scope of nursing practice within clearly defined parameters
What are protocols?
Written plans that detail nursing actions that are to be executed in specific situations
What do protocols allow nurses and other members of the healthcare team to do?
Start, modify, or stop an order based on certain criteria
What are standing orders?
Actions that ordinarily require the order or supervision of a physician or other provider
What is a written agreement between a physician or other prescribing provider that allows the nurse or other member of the healthcare team tp provide specific care or treatment in emergent situations?
Standing orders
What does delegation mean according to the OSBN?
The RN may delegate, to other than licensed nursing personnel, tasks relating to the administration of medication and patient care tasks that are ordered or prescribed by a physician-licensed
What does it mean to assign according to the OSBN?
The Rn may assign to a practice team member work, the team member is authorized by license or certification and organizational position description to perform in the practice setting
What are the five rights of delegation/assignment?
- Right task
- Right circumstance
- Right person
- Right communication
- Right supervision
What is documentation?
- A record of care provided to the patient
- A legal document
- Can be used to demonstrate compliance with standards/regulations governing care
What is evaluation?
An onging systematic process with the purpose of ensuring positive patient outcomes
What are adverse reactions?
an undesirable effect on health caused by a drug, medical device, or natural health product