week 2 - 16, 17 Flashcards
ability to think in logical and systematic manner with openness to question and reflect on the reasoning process
critical thinking
general types of critical thinking
scientific method problem solving decision making diagnostic reasoning clinical decision making
methodical process for problem solving
scientific method
evaluates problem, identifies solutions, and try solution over time to ensure its effective
problem solving
identifies patient’s health problems
diagnostic reasoning
goes beyond a diagnosis and determines a course of action
clinical decision making
what is OPQRSTU
Onset Palliative/Provocative Quality Radiate/Region Severity Time/Treatment Understanding
examples of subjective data
pain scale
branching questions
emotions
health history
observations and measurements of patients health; what the nurse sees, feels, smells, and measures
objective data
examples of objective data
physical assessment
medical records
diagnostic studies
vital signs
three principle depths of assessment
- comprehensive
- focused/periodic
- emergency
depth of assessment performed when patient is presenting for treatment (nursing health history and physical assessment)
comprehensive
depth of assessment performed throughout a shift or at change in shift (objective and subjective, data pertinent in situation)
focused/ periodic
depth of assessment performed during triage
emergency
collecting information from patient and from secondary sources, along with interpreting and validating the info to form a complete database
assessment
what are AIR notes
assessment
intervention
response
three types of nursing diagnoses
problem-focused
risk
health promotion
type of nursing diagnosis: active problem patient is experiencing; describes human response to condition/life event; describes response/deficiency that patient displays at time of diagnosis; reports active problem
problem-focused diagnosis
type of nursing diagnosis: human response to health condition that patient doesn’t currently display but is at risk for developing
risk diagnosis
type of nursing diagnosis: describes client’s desire/need to improve their state of health; can be made when patient is in any state of health
health promotion diagnosis
four steps to formulating a nursing diagnosis
- start with clustering assessment data
- note abnormal findings
- note medical diagnosis
- use your resources (NANDA-I diagnosis)
clinical judgment concerning a human response to health conditions, life processes or vulnerability by an individual, family or community
nursing diagnosis
related/causative factor in a nursing diagnosis
etiology
connects diagnostic label to etiology in a nursing diagnosis
related to (r/t)
assessment data that supports diagnosis in nursing diagnosis
defining characteristics (as evidenced by)
cause of patient’s risk for potential health complication in nursing diagnosis
risk factor
what is PES
problem
etiology
symptoms
three traditional interview phases
- orientation or setting an agenda
- working phase - collecting assessment data
- termination of the interview
