week 2 - 16, 17 Flashcards

(28 cards)

1
Q

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

A

critical thinking

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2
Q

general types of critical thinking

A
scientific method
problem solving
decision making
diagnostic reasoning
clinical decision making
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3
Q

methodical process for problem solving

A

scientific method

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4
Q

evaluates problem, identifies solutions, and try solution over time to ensure its effective

A

problem solving

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5
Q

identifies patient’s health problems

A

diagnostic reasoning

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6
Q

goes beyond a diagnosis and determines a course of action

A

clinical decision making

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7
Q

what is OPQRSTU

A
Onset
Palliative/Provocative
Quality
Radiate/Region
Severity
Time/Treatment
Understanding
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8
Q

examples of subjective data

A

pain scale
branching questions
emotions
health history

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9
Q

observations and measurements of patients health; what the nurse sees, feels, smells, and measures

A

objective data

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10
Q

examples of objective data

A

physical assessment
medical records
diagnostic studies
vital signs

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11
Q

three principle depths of assessment

A
  1. comprehensive
  2. focused/periodic
  3. emergency
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12
Q

depth of assessment performed when patient is presenting for treatment (nursing health history and physical assessment)

A

comprehensive

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13
Q

depth of assessment performed throughout a shift or at change in shift (objective and subjective, data pertinent in situation)

A

focused/ periodic

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14
Q

depth of assessment performed during triage

A

emergency

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15
Q

collecting information from patient and from secondary sources, along with interpreting and validating the info to form a complete database

A

assessment

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16
Q

what are AIR notes

A

assessment
intervention
response

17
Q

three types of nursing diagnoses

A

problem-focused
risk
health promotion

18
Q

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

A

problem-focused diagnosis

19
Q

type of nursing diagnosis: human response to health condition that patient doesn’t currently display but is at risk for developing

A

risk diagnosis

20
Q

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

A

health promotion diagnosis

21
Q

four steps to formulating a nursing diagnosis

A
  1. start with clustering assessment data
  2. note abnormal findings
  3. note medical diagnosis
  4. use your resources (NANDA-I diagnosis)
22
Q

clinical judgment concerning a human response to health conditions, life processes or vulnerability by an individual, family or community

A

nursing diagnosis

23
Q

related/causative factor in a nursing diagnosis

24
Q

connects diagnostic label to etiology in a nursing diagnosis

A

related to (r/t)

25
assessment data that supports diagnosis in nursing diagnosis
defining characteristics (as evidenced by)
26
cause of patient's risk for potential health complication in nursing diagnosis
risk factor
27
what is PES
problem etiology symptoms
28
three traditional interview phases
1. orientation or setting an agenda 2. working phase - collecting assessment data 3. termination of the interview