Exam 1 Study Guide Chapters 1-9 IPN

Simulation

A part of care coordination that enables the student to apply previously learned content in a safe and realistic environment that allows time for questioning, clarifying, and feedback; students develop confidence in providing direct nursing care.

Collaborative

A type of nursing intervention that require cooperation among health care professionals and unlicensed assisted personnel.

Cultural Care Theory

Madeleine Leininger theory that explicitly focused on the close relationships of culture and care on well-being, health, illness, and death; based on the belief that nursing is a trans-cultural care profession and that the concept of care is at its center.

Problem Solving

Part of clinical thinking/clinical judgement that involves a systematic and analytic approach to finding a solution to a problem.

Decision Making

Part of clinical thinking/clinical judgement that involves choosing a solution or answer from among different options; often considered a step in the problem solving process.

Reasoning

Part of clinical thinking/clinical judgement that involves logical thinking that links thoughts, ideas, and facts together in a meaningful way; used in scientific inquiry and problem solving.

Judgement

Part of clinical thinking/clinical judgement that involves the results or decision related to the processes of thinking and reasoning.

Advocacy

Part of the nurse-patient relationship, involves defending the rights of others, especially those who are vulnerable or unable to make decisions independently, the nurse must be knowledgeable, organized, and able to communicate in a caring manner.

Termination

The fourth phase of patient nurse communication, includes alerting patient of closure, evaluating outcomes and interactions, and concluding the relationship with discharge.

Implementation

The fourth step of the nursing process; initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes.

Auscultation

The fourth technique of assessment; a technique of listening with the assistance of a stethoscope to sounds made by organs or systems such as the heart, blood vessels, lungs, and abdominal cavity.

Orientation

The second phase of patient nurse communication, includes introductions, establishing professional or personal relationship boundaries, observing interviewing and assessing the patient followed by validation, and identifying the patient needs.

Nursing Diagnosis

The second step of the nursing process; patient data are analyzed, validated, and clustered to identify patient problems; each problem is then stated in standardized language as a specific nursing diagnosis to provide greater clarity and universal understanding by all care providers.

Palpation

The second technique of assessment; uses touch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness.

The Nursing Process

The systematic method of critical thinking used by professionals nurses to develop individualized plans of care and provide care for patients.

Assessment

The third component of SBAR communication- What is the identified problem, concern, or need?

Working

The third phase of patient nurse communication, includes the development of the care plan, implementation of the care plan, collaborative work among the health care team, the use of therapeutic communication to keep patient the main focus, reflection of the patients emotional aspect of illness.

Planning

The third step of the nursing process; the nurse prioritize the nursing diagnoses and identifiers short and long term goals that are realistic, measurable, and patient focused, with specific outcome identification for evaluation purposes.

Percussion

The third technique of assessment; involves tapping the patient's skin with short, sharp strokes that cause a vibration to travel through the skin and to the upper layers of the underlying structures.

Before Assessment

The time when the formulation of nursing diagnoses follows patient data collection and involves the analysis and clustering of related assessment information.

Self-Actualization

The top of Maslow's Hierarchy, the need to fulfill maximum potential; need for growth and change; ex,(goal attainment, autonomy, motivation, problem-solving abilities).

Delegation

The transfer of responsibility for performing a task to another person while the nurse who delegated the task still remain accountable.

Non-English Speaking Patient

The type of patient where a nurse would use a professional interpreter for over-the-phone or face-to-face interpretation to help communicate.

Recommendation

The fourth component of SBAR communication- What actions or interventions should be initiated to alleviate the problem.

Situation

The first component of SBAR communication- What is happening right now?

Dependent

A type of nursing intervention where the nurse incorporates orders into the patient's overall care plan by associating each with the appropriate nursing diagnosis.

Blind Patient

A type of patient where a nurse would use the position of an analog clock as a reference when communicating about their meal.

Marjory Gordon's Functional Health Patterns

Developed functional health patterns to help nurses focus on patient strengths and related but sometimes overlooked data relationships.

Focused Assessment

A brief individualized physical examination conducted at the beginning of an acute care-setting work shift to establish current patient status or during ongoing patient encounters in response to a specific patient concern.

Curiosity

A clinical thinking trait that; being motivated to achieve and asking why.

Risk Taking

A clinical thinking trait that; being willing to try new ideas.

Confidence

A clinical thinking trait that; feeling certain about one's ability to accomplish a goal.

Perseverance

A clinical thinking trait that; staying determined to work until the goal is achieved.

Evaluation

A critical thinking skill; information, including the reliability, credibility, and bias of the source, is assessed.

Analysis

A critical thinking skill; investigating plans of action on the basis of examination of subjective and objective data; considering the advantages, disadvantages and consequences of all possibilities.

Deductive Reasoning

A critical thinking skill; involves generating facts or details from a major theory, or premise.

Inference

A critical thinking skill; nurses gather relevant baseline data and compare them with other information, such as diagnosis, medical history, and knowledge of disease processes, to make inferences.

Interpretation

A critical thinking skill; nurses use this skill to understand and explain the meaning of data and drawing on knowledge of application.

Intuition

A critical thinking skill; the feeling that you know something without specific evidence; this problem-solving approach relies on an inner sense.

Inductive Reasoning

A critical thinking skill; uses specific facts or details to make conclusions and generalizations it proceeds from specific to general.

Concept Mapping

A part of care coordination that involves a teaching-learning strategy that has been linked with a improved critical-thinking skills in nurses, a way to organize and visualize data to identify relationships and solve problems.

Role Playing

A part of care coordination that involves assigning learners to different roles based on expected outcomes in a particular setting, it allows learners to interact in a safe, controlled environment.

Literature Review

A part of care coordination that involves more accurate, clear, and precise the reviewer can be in approaching the literature, the greater the like-hood that the information discovered addresses the original issue question or problem.

Emergent Assessment

A physical examination done when time is a factor, treatment must begin immediately, or priorities for care need to be established in a few seconds or minutes; patient treatment is based on a quick survey of accident or illness onset, followed by a narrowly focused physical examination of critical injuries or symptoms and signs.

Blood Transfusions

A procedure that may be declined by Jehovah Witness'.

Pork-Based Insulin

A procedure that may be declined by Muslims.

Value System

A set of somewhat consistent values and measures that are organized hierarchically into a belief system on a continuum of relative importance.

Complete Physical Examination

A type of assessment, may be conducted on admission to a hospital, during an annual physical at the office of a physician or nurse practitioner, or on initial interaction wit a specialist.

Independent

A type of nursing intervention allowing nurses to initiate care that they recognize as essential in meeting patient needs or preventing complications; tasks within the nursing scope of practice that the nurse may undertake without a physician's or PCP order.

Risks Diagnosis

Diagnosis applied when there is an increased potential or vulnerability for a patient to develop a problem or complication.

Actual Diagnosis

Diagnosis identifying existing problems or concerns of a patient

Health Promotion Diagnosis

Diagnosis used in situations in which patients express interest in improving their health status through a positive change in behavior.

Personal Space

Approximately 18 to 48 inches, an acceptable communication distance for most English Speaking patients.

Professional Competence Attire

Best expressed through voice inflection; no dramatic make up, and with minimal jewelry while performing patient care.

Physiological Needs

Bottom level of Maslow's hierarchy, the most basic survival needs; includes shelter, food, sleep, breaks, and compensation.

Defining Characteristics

Cues or clusters of related assessment data that are signs, symptoms, or indications of an actual or health-promotion nursing diagnosis.

Related Factors

Cues, conditions or circumstances that contribute to the health problem or have cased a health problem; the underlying cause or etiology of a patient's problem.

Values

Enduring ideas about what a person consider is the good, the best, and the right thing to do and their opposites - the bad, worst and wrong things to do - and what is desirable or has worth in life.

SBAR Communication

Framework for communication between members of the healthcare team about a patient's condition.

Proper Documentation

Important for intervention because it facilitates communication with all members of the health care team and provides an essential legal record; accurate charting help to alleviate omissions and repetition of care.

Self-Esteem

In Maslow's Hierarchy, the need to feel good about oneself, ex,(changes in body image, changes in self-concept, pride in abilities).

Love and Belonging

In Maslow's hierarchy, the need for love and affection, ex,(compassion of care provider, information from family and significant others).

Safety and Security

In Maslow's hierarchy, the need to be safe and comfortable, ex,(physical safety, psychological security).

Comprehensive Assessment

Includes a through interview, health history, review of systems, and extensive physical head-to-toe assessment, including evaluation of cranial nerves and sensory organs, such as with sight and hearing testing(complete assessment).

Objective Data

Information referred to as signs, can be measured or observed; the nurse's sense of sight, hearing, touch, and smell are used to collect this data,

Secondary Data

Information shared by family members, friends, or other members of the health care team.

Primary Data

Information that comes directly from the patient.

Referral

Involve sending a patient to another member of the interdisciplinary health care team or agency for a consultation or other services.

Clustering

Involves organizing patient assessment data into groupings with similar underlying causes.

"Related-To"

Needs to address the underlying etiology of the patient's problem expressed by the nursing diagnostic label rather than listing data that are defining characteristics; the nurse articulates an understanding of the pathophysiology or situation with which the patient is faced.

NANDA

North American Nursing Diagnosis Association, purpose is to define, refine, and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses.

Benner's Novice to Expert

Provides framework to facilitate professional development, takes approximately two to three year to achieve last stage as a nurse.

Nursing Practice Act

Provides the scope of practice defined by each state or jurisdiction and set forth the legal limits of nursing practice.

RN Responsibilities

Retains ultimate responsibility for patient care and delegates task to LPN's.

Maslow's Hierarchy of Needs

Specifies the psychological and physiologic factors that and physiologic factors that affect each person's physical and mental health. Needs at the lower-level must be met first before higher-level needs.

Subjective Data

Spoken information or symptoms that cannot be authenticated; usually gathered during the interview process if the patient is well enough to describe symptoms.

Etiology

The cause or origin of a disease.

Evaluation

The fifth step of the nursing process; the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.

Evaluation

The final phase of the nursing process, focuses on the patient's response to nursing interventions and outcome attainments.

Pre-Interaction

The first phase of patient nurse communication, includes gathering assessment and diagnosis data, organizing the data, identifying the concerns, and planning the interaction which prepare the nurse for initial contact with the patient.

Assessment

The first step of the nursing process; patient care data are gathered through observation, interviews, and physical assessment.

Inspection

The first technique of assessment; involves the use of vision, hearing, and smell to closely scrutinize physical characteristics of a whole person and individual body system.

Diagnostic Label

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; a concise term or phrase that represents a pattern of related, clustered data.

QSEN

The professional organization that has added safety to their core competencies, funded by the Robert Wood Johnson Foundation, adapted by the IM competencies for nursing.

Outcome Orientation

The patient-centered process is designed to achieve specific results; developed to meet patient's goals, decision regarding which nursing interventions and medical treatments to implement are made on the basis and after and their effectiveness in meeting a patient's identified needs and desired outcomes.

Background

The second component of SBAR communication- What led up to the current situation?

Direct Care

Treatments performed through interactions with patients, carried out by having personal contact with patients.

Indirect Care

Treatments that are performed to benefit patients but do not involve face to face contact with patients.