Unit III Exam 2 Flashcards
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What is a disciplin specific, reflective, reasoning process that guides a nurse in generating, implementing, and evaluating approaches for dealing with client care and professional concerns?
Critical thinking
Critical analysis
Determining essential information
Socratic questioning
Differentiate between truth & assumptions
Inductive reasoning
Specific example to generalized conclusion
Deductive reasoning
From generalized to specific conclusion
What level of anxiety is the best to learn something at?
Mild
Stimulates learning
Relativism
Knowledge is relevant
When you are older
Assumes there is only one right answer
Dualism
Best way is to memorize
When you are young
Collect data, analyze, formulate solutions, implement action & evaluate
Problem solving process
Approach that enables nurses to manage explosion of new literature & knowledge
Allows nurses to search for, assess & apply best practices to care
Evidenced based practice
Three main elements of evidenced based practice
Best evidence from well designed research studies
Clinicians expertise
Pt’s values & preferences
PICO
P- pt
Which is the fastest growing subgroup of the late adulthood population?
85-99 years old
The old old
What is the current % of individuals older than 65 years old?
13%
During as dement you suspect the pt may be depressed, your next action is to?
Administer the geriatric depression scale short form
What is thought to be the primary cause of aging?
Genetic theory
Safety issues with the elderly
Side rails up
Bed lowest position
dangle @ bedside b4 standing
Shoes with non skid soles
When can restraints be used? What do the prevent?
Only as a last resort & by MD order
Helps with preventing falls, pulling out iv’s
Reality orientation
Aware of: Person Place Time Circumstance
Turn non ambulatory pt’s every?
Every 2 hours
Slow insidious progressive loss of cognitive function, chronic state
Dementia
Usually transient condition characterized by difficult concentration, disorganized thinking, sensory misperceptions, acute state
Delirium
Are adult day care centers acceptable?
Yes
What is the purpose of teaching?
Promote health
Prevent illness/injury
Restoration of health
Adapting to altered Heath & function
Process of activities intended to produce learning
Dynamic interaction between teacher & student
Teaching
Manipulated environment for intended response
Pavlov’s dog
Behaviorism
Refers to rational thought
Teach from simple to complex
Cognitive
Difficult to measure learning in this domain
Affective domain
Learn skills that require integration of knowledge with muscular activity
Psychomotor domain
Learning is self motivated, self initiated & evaluated
Humanism
Uses both cognitive & affective domains
Name some factors that effect learning.
Motivation
Active involvement
What domain of learning does learning take place?
Cognitive
Affective
Psychomotor
What are key factors in cognitivism?
Developmental & individual readiness
Geragogy
Teaching older adults
Takes longer to process information
Subjective, non specific feeling of uneasiness, tension, apprehension or impending doom
Anxiety
T/F
Anxiety is not the same as stress
True
Symptoms of anxiety
Increase: B/P, heart rate Palpations Nausea Wringing of hands Confusion Sweating
Nursing process components
A- assess D-diagnosis P-planning I-implement E-evaluate
NANDA
Develop, revise nursing diagnosis terminology
Pt benefits of the nursing process
Helps to provide continuous care, pt centered
Nurse benefits of nursing process
Enhancing professional creative care, helps effectiveness in daily care
Helps collaborate with other team members & pts
Professional benefits of the nursing process
Define scope of nursing practice
Methods of data collection
Observe pt
Interview with pt, family
Physical exam
Chart review
Pt’s perception of his/her health problems
Involves feelings “ my leg hurts”
Pt is only one who can provide this data
Symptoms
Subjective
Observations or measurements made by data collector
Sources include physical exam, diagnostic results, pt records
Signs
Objective
Who is the primary & best source of data
Pt
Data validation
Double check your data
Ensure accuracy of info
Data that is acquired through the 5 senses
Cues
Nurses judgement or interpretation of cues
Inferences
A clinical judgement about individuals, family or community responses to actual or potential health or life processes
Nursing diagnosis
Types of nursing disgnoses
Actual
Risk
Wellness
Steps in developing a nursing diagnosis
Identify problem (NANDA list) Identify etiology (related to factors) Identify the defining characteristics (signs & symptoms)
Actual nursing diagnosis
Statement comes from NANDA list
Risk nursing diagnosis
2 part statement
No signs & symptoms
Ex.
Risk for falls r/t fatigue and altered gait
A clinical judgement about a individual, family or community in transition from a specific level of wellness to a higher level of wellness
Wellness diagnosis
Medical diagnosis
Goal - cure disease
Nursing diagnosis goal
Treat human response not disease
Caring for mind, body, spirit
Physiological problems that nurses monitor & collaborate with medicine for co-treatment
Collaborative problems
Descriptive statements about what the pt’s state will be after the nursing interventions are carried out
Expected outcomes
Criteria for writing expected outcomes
Clear concise Specific (be able to measure) Realistic for pt What the pt will accomplish Includes a time frame
The # 1 intervention is?
Assess
Types of nursing interventions
Independent- things done without MD order
Dependent-require MD order
Interdependent-standing orders, protocols
Cognitive NI
Teach
Education
Interpersonal NI
Use therapeutic communication
Technical NI
Perform routine nursing activities
Monitoring NI
Ongoing assessment of pt
Carrying out the proposed plan of care to resolve the problem
Implementing
Determine the pt’s response to the MI’s & the extent to which the EO’s have been achieved
Evaluating
Metacognition
Thinking about thinking
