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NSG 300 7-9 EXAM 11/9 > TOPIC 5 > Flashcards

TOPIC 5 Flashcards

1
Q

critical thinking is:

A

The ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process

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2
Q

critical thinking is more than just problem solving…

A

It is a continuous attempt to improve how to apply yourself when faced with problems in patient care.

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3
Q

What are the levels of critical thinking

A
  1. Basic
  2. Complex
  3. Commitment
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4
Q

what are the components of critical thinking

A

specific knowledge base
experience
competencies
attitudes
standards

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5
Q

basic level of critical thinking

A

a learner trusts that experts have the right answers for every problem. Thinking is concrete and based on a set of rules or principles.

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6
Q

complex critical thinkers

A

begin to separate themselves from experts and analyze the clinical situation and examine choices more independently. In complex critical thinking, each solution has benefits and risks that you weigh before making a final decision

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7
Q

commitment level of critical thinking

A

nurses anticipate when to make choices without assistance from others and accept accountability for decisions made.

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8
Q

scientific method

A

a systematic, ordered approach to gathering data and solving problems.

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9
Q

five steps of the scientific method

A

identify the problem
collect data
formulate a question or hypothesis
test the question or hypothesis
evaluate results of the test or study

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10
Q

what are the two components of clinical decision making?

A

-a nurse’s understanding of a specific patient
-a nurse’s subsequent selection of interventions.

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11
Q

what are some important aspects of knowing your patient

A

-spend more time during initial patient assessment (determine what is important to them)
-PERSONAL CONVO rather than task-oriented convo
-listen to patients experience with illness
-check on patients consistently
-ask for the same patient over consecutive days

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12
Q

reflective journaling

A

o Define and express clinical experiences in your own words

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13
Q

meeting with colleagues

A

o Discuss and examine work experiences and validate decisions

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14
Q

concept mapping

A

o Visual representation of patient problems and interventions that shows their relationships to one another

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15
Q

assess

A

Gather information about the patient’s condition

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16
Q

diagnosis

A

identify the patients problem

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17
Q

plan

A

set goals of care and desires outcomes and identify appropriate nursing actions

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18
Q

implement

A

perform the nursing actions identified in planning

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19
Q

evaluate

A

determine if goals and expected outcomes are achieved and were effective

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20
Q

Assessment involves collecting information from…

A

the patient
secondary sources
interpreting and validating information to form a complete database

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21
Q

when is a Patient-centered interview conducted

A

during a nursing history

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22
Q

when are periodic assessments conducted

A

during ongoing contact with patients

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23
Q

when are physical examinations conducted

A

during a nursing history and at any time a patient presents a symptom

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24
Q

cue

A

is information that you obtain through use of the senses

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25
Q

inference

A

is your judgment or interpretation of these cues

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26
Q

comprehensive assessment

A

moves from the general to the specific
-Typically certain aspects of a situation stand out as most important. You then ask more focused questions on the basis of the patient’s responses and physical signs.

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27
Q

problem oriented

A

You focus on a patient’s presenting situation and begin with problematic areas. You ask the patient follow-up questions to clarify and expand your assessment so you can understand the full nature of the problem.

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28
Q

what are the assessment data resources

A

-Patient
-Family caregivers and significant others
-Health care team
-Medical records
-Other records and the scientific literature
-Nurse’s experience

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29
Q

foundation for creating nurse-patient relationships

A

tricot building
presence
rounding

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30
Q

patient centered interview

A

relationship based and is an organized conversation focused on learning about the well and the sick as they seek care.

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31
Q

motivational interviewing

A

a collaborative, person-centered form of guiding to elicit and strengthen motivation for change

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32
Q

what are the phases of an interview

A

-orientation and setting an agenda
-working phase
-terminating the interview

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33
Q

Orientation and setting an agenda

A

-Begin by introducing yourself, your position, explaining the purpose of the interview.
-Explain why you are collecting data and assure patients that all of the information will be confidential.
-Ask the patient for his or her list of concerns or problems.

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34
Q

working phase

A

-ask open-ended questions.
-Use attentive listening and other therapeutic communication techniques that encourage a patient to tell his or her story.
-Gather information about a patient’s concerns and then complete all relevant sections of the nursing history.

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35
Q

termination phase

A

-Summarize your discussion with a patient and check for accuracy of the information collected.
-Give your patient a clue that the interview is coming to an end.
-End the interview in a friendly manner, telling the patient when you will return to provide care.

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36
Q

cultural consideration is important to consider during an assessment so…

A

avoid making stereotypes and don’t make assumptions

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37
Q

nursing health history

A

Data collected about a patient’s level of wellness

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38
Q

biographical information

A

o age, address, occupations, marital status, health care insurance.

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39
Q

components of the nursing health history

A

biographic data
chief complaint/reason for seeking health care
patient expectation
history of present illness
health history
family history
environmental history
psychosocial history
spiritual health
ROS (review of systems)

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40
Q

Present illness or heath concerns

A

Determine when the problems began, how severe, intensity, quality, what makes them worse, and what makes them better

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41
Q

Concomitant symptoms

A

o Does the patient experience other symptoms along with the primary symptom?

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42
Q

data documentation

A

Use clear, concise appropriate terminology
Becomes baseline for care
record subjective data in quotes

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43
Q

what are 3 elements of the assessment process

A

data collection
interpretation
validation

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44
Q

data collection

A

capturing and gathering all data necessary for the patient

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45
Q

interpretation

A

o Critically interpret assessment data to determine whether abnormal findings are present.
o Cues and inferences

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46
Q

validation

A

o Comparison of data with another source to determine data accuracy

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47
Q

problem-focused nursing diagnosis

A

o Identify an undesirable human response to existing problems or concerns of a patient

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48
Q

defining characteristics

A

Related signs and symptoms or clusters of data that support the problem-focused diagnosis.

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49
Q

related factor

A

an etiological or causative factor for the diagnosis, and allows you to individualize a problem-focused nursing diagnosis for a specific patient need.

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50
Q

risk diagnosis

A

o Diagnoses that apply when there is an increased potential or vulnerability for a patient to develop a problem or complication
-Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem.

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51
Q

health promotion

A

the process of enabling people to increase control over, and to improve, their health

52
Q

data cluster

A

is a set of cues, the signs or symptoms gathered during assessment

53
Q

clinical criterion

A

an objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a diagnostic conclusion

54
Q

NANDA-I classification of nursing

A

Þ provides the standards for the patterns of data for each nursing diagnosis. These standards are the defining characteristics or risk factors

55
Q

diagnostic label

A

the name of the nursing diagnosis as approved by NANDA International
-It describes the essence of a patient’s response to health conditions in as few words as possible.

56
Q

related factor

A

is identified from the patient’s assessment data and is the REASON the patient is displaying the nursing diagnosis. (indicated the etiology)

57
Q

what are the 4 categories of related factors for the NANDA-I?

A

-pathophysiological (biological or psychological)
-treatment-related
-situational (environmental or personal)
-maturational.

58
Q

nursing diagnosis label includes..

A

o P (problem)
o E (etiology or related factor)
o S (symptoms or defining characteristics)

59
Q

what should you do once you identify a patients nursing diagnosis

A

enter them either on the written plan of care or in the electronic health information record (EHR)

60
Q

When initiating an original care plan, place the _____________ nursing diagnosis first.

A

highest-priority

61
Q

what is one way to consider nursing diagnosis of high priority

A

with maslow’s hierarchy of needs (ABCs always first)

62
Q

highest priority nursing diagnoses

A

if untreated, result in harm to a patient or others (e.g., those related to airway status, circulation, safety, and pain) (maslow’s)

63
Q

intermediate priority nursing diagnoses

A

involve nonemergent, non-life-threatening needs of patients.

64
Q

low-priority nursing diagnoses

A

not always directly related to a specific illness or prognosis but affect a patient’s future well-being.

65
Q

when does priority setting begin?

A

when you identify and prioritize a patient’s main diagnoses or problems

66
Q

what do you do after priority setting?

A

to prioritize the specific nursing interventions that you plan to use to help a patient achieve desired goals and outcomes.

67
Q

goal

A

o A broad statement that describes the desired change in a patient’s condition, perceptions, or behavior (Short-term & Long-term)

68
Q

A patient-centered goal

A

reflects a patient’s specific behavior, not your own goals or interventions. It is important to select and measure patient outcomes that are influenced by nursing care.

69
Q

when writing goals and expected outcomes what should be..

A

specific
measurable
attainable
realistic
time

70
Q

short term goal

A

an objective behavior or response that you expect a patient to achieve in a short time, usually less than a week. In an acute care setting, you often set goals for over a course of just a few hours.

71
Q

long term goal

A

an objective behavior or response that you expect a patient to achieve over a longer period, usually over several days, weeks, or months.

72
Q

nurse-initiated intervention

A

Require no order and no supervision or direction from others. Nurse initiated interventions are autonomous actions based on scientific rationale.
o Independent—Actions that a nurse initiates

73
Q

Health care provider initiated interventions

A

based on the health care provider’s response to treat or manage a medical diagnosis.
-Dependent—Require an order from a physician or other health care professional

74
Q

collaborative interventions

A

o Interdependent—Require combined knowledge, skill, and expertise of multiple health care professionals

75
Q

consultation

A

a process by which you seek the expertise of a specialist such as your nursing instructor, a physician, or a clinical nurse educator to identify ways to handle problems in patient management or in planning and implementation of therapies.
-Consultation occurs at any step in the nursing process, most often during planning and implementation.

76
Q

when and how to consult

A

HOW: begin with your understanding of the patients clinical problem.
-direct the consultation to the right professional.
-Provide the consultant with relevant information about the problem area: Summary, methods used to date and outcomes
-Do not influence consultants.
-Be available to discuss the consultants findings.
-Incorporate the suggestions.

77
Q

Direct care interventions

A

o Treatments nurses provide through interactions with patients or a group of patients

78
Q

Indirect care interventions

A

o Treatments performed away from a patient but on behalf of the patient or group of patients
o Documentation
o Interprofessional collaboration

79
Q

what does the American Nurses Association (ANA) do?

A

defines standards of professional nursing practice.

80
Q

what are the Quality and Safety Education for Nurses (QSEN) skill competencies

A

authoritative statements of the duties that all registered nurses (RNs) are expected to perform competently, regardless of role, patient population they serve, or specialty. (Established standard competencies in knowledge, skills, and attitudes (KSAs) for the preparation of future nurses.)

81
Q

Clinical practice guidelines and protocols

A

o A systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations

82
Q

Standing orders

A

document that details the nursing care to be implemented in specific nursing situations, frequently when a physician is not present; may expand scope of nursing responsibilities, (give nurses legal protection to intervene appropriately in the best interests of patients with rapidly changing needs)

83
Q

Preparing for implementation

A

Time management
Equipment
Personnel
Environment
Patient

84
Q

what are the five preparatory activities

A

-reassessing the patient
-reviewing and revising the existing nursing care plan
-organizing resources and care delivery
-anticipating and preventing complications
-implementing nursing interventions.

85
Q

Reassessment is not the ______ of care or determination of a patient’s response to an intervention, but it is the gathering of additional information to ensure that the plan of care is still appropriate.

A

evaluation of care

86
Q

if a patients status has changed and the nursing interventions are no longer appropriate, what should be done?

A

modify the nursing care plan

87
Q

what are the steps to modify and existing written care plan?

A
  1. Revise data in the assessment column to reflect the patient’s current status.
  2. Revise the nursing diagnoses and delete the old nursing diagnosis
  3. Revise specific interventions that correspond to the new nursing diagnoses and goals.
  4. Choose the method of evaluation for determining whether you achieved patient outcomes.
88
Q

cognitive skills

A

Grasp each clinical situation at hand, interpret the information you observe, and anticipate a patient’s response so you individualize patient care appropriately.

89
Q

interpersonal skills

A

Interpersonal communication is essential for effective nursing action. Develop a trusting relationship, express a level of caring, and communicate clearly with patients and their families. Good interpersonal communication keeps patients informed and engaged in decision making, provides individualized instruction, and supports patients who have challenging emotional needs.

90
Q

psychomotor skills

A

require the integration of cognitive and motor activities.

91
Q

what are the first steps in promoting a smooth transition for a patient from health care setting to home?

A

Adequate and timely discharge planning and education of the patient and family (patient adherence)

92
Q

evaluation measures

A

are the same as assessment measures, but you perform them at the point of care when you make decisions about a patient’s status and progress.

93
Q

what is the intent of evaluation

A

to determine if the known problems have remained the same, improved, worsened, or otherwise changed.
- Collect evaluative measures over a period of time; look for trends.

94
Q

What is the aim of self-management?

A

to minimize the impact of chronic disease or sudden acute illness on physical health status and functioning and to enable people to cope with the psychological effects of an illness.

95
Q

what are the purposes of the Nursing Outcome Classification (NOC)?

A
  • to identify, label, validate, and classify nurse-sensitive patient outcomes;
  • to field test and validate the classification; and
  • to define and test measurement procedures for the outcomes and indicators using clinical data.
96
Q

what are the steps to evaluate the degree of success in achieving outcomes of care?

A
  1. Examine the outcome criteria to identify the exact desired patient behavior or response.
  2. Evaluate a patient’s actual behavior or response.
  3. Compare the established outcome criteria with the actual behavior or response.
  4. Judge the degree of agreement between outcome criteria and the actual behavior or response.
  5. If there is no agreement (or only partial agreement) between the outcome criteria and the actual behavior or response, what is/are the barrier(s)? Why did they not agree?
97
Q

when do you discontinue a care plan

A

if the patient has met all goals and outcomes

98
Q

when goals and outcomes of a patient are not met, what needs to be done?

A

identify the factors that interfere with their achievement. Usually a change in a patient’s condition, needs, or abilities makes alteration of the care plan necessary.

99
Q

what is a nurse executive

A

a clinical and business leader who is concerned with maximizing quality of care and cost-effectiveness while maintaining relationships and professional satisfaction of the staff.

100
Q

what is a nurse manager

A

uses transformational leadership is focused on change and innovation through team development, motivates and empowers staff to function at a high level of performance, and serves as a role model for the nurses on the unit.

101
Q

TEEAMS

A

Time, Empowerment, Enthusiasm, Appreciation, Management, and Support

102
Q

TEEAMS (Time, Empowerment, Enthusiasm, Appreciation, Management, and Support) approach

A

the nurse manager spends TIME on the unit with the staff sharing ideas, EMPOWERS the staff, is ENTHUSIASTIC about seeking opportunities to enhance the team, shows APPRECIATION and recognizes team members for a job well done, MANAGES the team and holds team members accountable, and provides SUPPORT in the stressful health care environment.

103
Q

What is the Magnet Recognition Program?

A

A hospital that is Magnet certified has a transformed culture with a practice environment that is dynamic, autonomous, collaborative, and positive for nurses.

104
Q

team nursing

A

the registered nurse (RN) is the leader who leads a team of other RNs, practical nurses, and nursing assistive personnel (NAP) who provide direct patient care.

105
Q

primary nursing

A

supports a philosophy regarding nurse and patient relationships.

106
Q

Patient- and family-centered care

A

a model of nursing care in which mutual partnerships among the patient, family, and health care team are formed to plan, implement, and evaluate the nursing and health care delivered.

107
Q

Respect and dignity

A

Ensuring that the care provided is given on the basis of the patient’s and family’s knowledge, values, beliefs, and cultural backgrounds.

108
Q

Information sharing

A

Meaning that health care providers communicate and share information so patients and families receive timely, complete, and accurate information to effectively participate in care and decision making.

109
Q

Participation

A

Whereby the patients and families are encouraged and supported in participating in care and decision making.

110
Q

Collaboration

A

Demonstrated by the health care leaders collaborating with patients and families in policy and program development, implementation, and evaluation, and patients who are fully engaged in their health care.

111
Q

Total patient care

A

Emphasizes a high degree of collaboration with other health care professionals.

112
Q

Case management

A

Approach that coordinates and links health care services to patients and their families while streamlining costs and maintaining quality.

113
Q

Decentralized management

A

decision making occurs at the level of the staff creating an environment in which managers and staff become more actively involved in shaping the identity and determining the success of a health care organization

114
Q

responsibility

A

duties and activities an individual is employed to perform

115
Q

autonomy

A

independent decisions about patient care

116
Q

authority

A

legitimate power to give commands and make final decisions specific to a given position

117
Q

accountability

A

answerable for the actions

118
Q

Competencies needed for effective interpersonal collaboration include…

A

· Work with individuals of other professions to maintain a climate of mutual respect and shared values.
· Use the knowledge of one’s own role and those of other professions to appropriately assess and address the health care needs of patients and populations served.
· Communicate with patients, families, communities, and other health care professionals in a responsive and responsible manner that supports patient-centered care and a team approach to the maintenance of health and treatment of disease.

119
Q

Interprofessional rounding

A

members of the team meet and share patient information, answer questions asked by other team members, discuss patients’ clinical progress and plans for discharge, and focus all team members on the same patient goals

120
Q

delegation

A

transfers responsibility while remaining accountable for outcomes, requires nurses to know the Nurse Practice Act for their state to know what skills are transferrable

121
Q

what are the 5 rights of delegation?

A

Right Task
Right Circumstances
Right Person
Right Direction/communication
Right Supervision/Evaluation

122
Q

right task

A

one that can be delegated for a specific patient, such as tasks that are repetitive, require little supervision, are relatively noninvasive, have results that are predictable, and have potential minimal risk.

123
Q

right circumstance

A

Appropriate patient setting, available resources, and other relevant factors are considered in determining the right circumstance.

124
Q

right person

A

delegating the right tasks to the right person to be performed on the right person.

125
Q

right direction/communication

A

indicates that a clear, concise description of the task, including its objective, limits, and expectations, is given.

126
Q

right supervision/evaluation

A

appropriate monitoring, evaluation, intervention as needed, and feedback are provided.

127
Q

Steps to Effective Delegation

A

o Assess the knowledge and skills of the delegatee.
o Match tasks to the delegatee’s skills.
o Communicate clearly:
-Task, outcome, time
o Listen attentively.
o Provide feedback.

NSG 300 7-9 EXAM 11/9 (10 decks)

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