Units 1-4 Flashcards
Define Nursing Process
decision making approach that enhances critical thinking.
focus of nursing care
addresses the response of the client to the illness
Primary purpose of nursing care plan is communication so the health care team can see process and address ways to meet goals
Data Collection Sources
Client is the most reliable source usually, but not always
family and significant others
medical records
Process of data analysis
as a student, do analysis at home, as a staff nurse you do it at the hospital.
Planning Phase
develop interventions and outcomes- test interventions and outcomes/ goals.
don’t evaluate interventions- evaluate the goals
Discharge planning begins on admission!
Implementation phase
carry out planned interventions with ongoing assessment
where we do most of our legal charting- what we did with the patient.
Documentation is a legal requirement and is the final stage of the implementation phase.
Evaluation phase
Valuate effectiveness, was the plan effective based on pt and nrsng goals?
Define Critical Thinking
Purposeful- outcome directed thinking that aims to make judgment based on scientific evidence. rather than tradition or guessing
self directed thinking
evidence based practice- based on research and critical thinking.
attitudes and mental habits that effect critical thinking
be able to think independently intellectual courage intellectual empathy intellectual sense of justice intellectually humble be disciplined so you don't stop at easy answers be creative and self confident
divergent thinking
the ability to weigh important info sort out what’s relevant and what isn’t
reasoning
the ability to discriminate between facts and guesses
clarifying
defining terms and noting similarities and differences
reflection
take time to think it all out
learning readiness
define learning readiness- patient has to be ready to learn
requires assessment of client- are they in pain? are they scared? are they elderly? what is their education level?
people who are not ready to listen can not be taught
client must be accepting of diagnosis and need for teaching in order to learn
motivational principles
pt desire to regain control of the situation
assess what patient wants to know and be able to do himself the most.
always start with the MOST important issue to patient
patient goal characteristics
patient goals must be mutually established by client and nurse and client centered, time specific, and measurable.
measurable learning goals are things you can “test on”
teaching techniques and strategies
establish trust and rapport proceed slowly set goals and boundaries set priorities assess when client learns best use demo/ hands on activities involve significant other limit distractions put safety first proceed simple to complex give praise review material give practice time
benefits of standard teaching plans
make sure nothing is missed or forgotten
others can pick up where you left off
Accountability
to be accountable you need to be able to explain your actions
define pain
pain is whatever the patient says it is
pain can be a good thing because it is a protective role and warns us of potentially health threatening conditions
JCAHO
pt has the right to appropriate assessment and management of pain. 0-10 pain scale
Pain
is a subjective response to both physical and psychological stressors
serves as a basis for nursing assessments
nociceptors
nerve receptors for pain located throughout the body but not in the brain.
acute pain
sudden onset, usually temporary
has identifiable cause
lasts less than 6 months
somatic pain
skin, superficial tissue, muscles, bones, joints
sharp, cutting, burning or dull and diffuse. even throbbing, may be accompanied by nausea or vomiting.
visceral pain
associated with organs, cramps, deep dull and poorly localized.
almost always associated with nausea and vomiting
hypotension and restlessness
