Chapter 4 (The nursing process: critical thinking and decision making)

know critical care plan

-Based on progression expected each day the patient is hospitalized -Uses average length of stay for particular medical diagnosis as basis for progression of care

What is subjective data?

-Data that only the subject or "patient" can feel and will tell you. Usually in a statement.

know multidisciplinary care plan

-Frequently used in hospitals -Contains areas for other disciplines -this type of care plan includes choices of different nursing diagnoses with options the nurse may select in order to individualize the patients care

know student care plan

-Help make connections b/w patient's medical diagnoses, medications, laboratory & diagnostic tests, assessment data, nursing diagnoses, nursing orders or interventions and evaluations -this care plan are excellent tools for sharpening your critical thinking skills and your nursing decision making

know standardized care plan

-Preprinted documents w/typical nursing diagnoses & corresponding intervention pertaining to a particular medical diagnosis -Many give opportunity to individualize

know computerized care plan

-Standard for most hospitals -RN chooses appropriate nursing diagnoses & then selects corresponding goals & interventions

What is objective data?

-What you observe and can measure -can observe through the senses of hearing, sight, smell, and touch

outcomes statements should include the following information?

-a realistic, specific action to be taken by the patient (not the nurse) -an action that the patient is willing and able to perform -an action that is measurable -a definite time frame for the action to have been accomplished

name the types of nursing care plans

-computerized -standardized -multidisciplinary -critical -student

name types of nursing interventions

-direct or indirect patient care -independent, dependent, or collaborative -individualized

nurses gather data about how the patient's body is functioning using what techniques

-inspection -palpation -auscultation -percussion

what are the four nursing diagnosis

-prioritizing diagnoses -selecting nursing diagnoses -determining nursing diagnoses -writing nursing diagnoses

Steps of the Nursing Process

1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation

Preparing to Care for Patients Prior to Clinical Experience (steps)

1.reasearch 2. possible nursing diagnoses 3.expected outcomes 4. develop your interventions 5.meet and assess the patient 6.evaluate your nursing diagnosis 7. implement your interventions 8.evaluate your care plan

What is a head to toe assessment?

A complete health assessment starting at the head and proceeding in a systematic manner downward

acronym used for nursing process

ADPIE

what does the American Nurses Association (ANA) Standards of Practice?

All the steps of the nursing process are the responsibility of the RN

what is done in the diagnosis phase in the nursing process?

Analysis of the assessment information gathered is the formulation of nursing diagnoses through an analysis of the assessment information that you have gathered

the three part statements are often called

PES

What is the nursing process?

a decision making framework used by all nurses to determine the needs of their patients and to decide how to care for them

what is a care plane?

a document plan for giving patient care and includes the health-care provider's orders, nursing diagnoses, and nursing orders

what is independent interventions

a physician order is not required to perform them

what is aesthetic

concerned with beauty or the appreciation of beauty

what is rapport

creating a relationship of mutual trust and understanding

what is north American nursing diagnosis association international (NANDA) responsible for

creating and maintaining an approved list of nursing diagnoses to be used throughout most countries

what steps do the LPN participate in

directly in the remaining steps of planning, intervention, and evaluation

the ______ refers to the causative to the causative factors and is connected to the diagnostic label by the words "related to"

etiology

when you complete a procedure, you need to _____________ the patients response and the effectiveness of the procedure

evaluate

what is palpation

examination of the body using touch

_______ ________are statement of measurable action for the patient within a specific time frame and in response to nursing interventions

expected outcomes

What is love and belonging?

friendship, family, intimacy, sense of connection giving and receiving affection, meaningful relationships, belonging to groups

What is done in the assessment phase in the nursing process?

gathering information through signs and symptoms, patient history, and both subjective and objective findings (Interviewing Physical assessment Reviewing laboratory and diagnostic tests)

most facilities use an admission form that requires a nursing history to be performed as well as a what

head-to-toe assessment

What is self-esteem?

how much you value, respect, and feel confident about yourself pride sense of accomplishment, recognition by others

what is cognitive

how we encode, process, store, and retrieve information

nursing interventions can also be classified as _________ dependent, or collaborative

independent interventions

_____________ __________ _____________ is performed when the nurse provides assistance in a setting other than with the patient

indirect patient care

what is collaborative interventions

involve working with other health-care professionals in the hospital setting

what is physiological need

it is the most basic needs; required to sustain biological life. These needs are dominant when they are chronically unsatisfied example is food water, air, ect.

What is auscultation?

listening to the sounds produced by the body using a stethoscope

________ _____ goals are not expected to be met before the patient is discharged from the hospital

long term

what is done in Prioritizing Diagnoses

nurses use the Maslow's hierarchy of human needs to determine diagnosis

____________ _________________ are related to the needs or problems a patient is experiencing

nursing diagnoses

a _________ _______ is the overall direction in which one must progress to improve a problem

nursing goal

what is direct patient care

performed when the nurse interacts directly with the patient

what is done in the evaluation phase in the nursing process?

performed when the nurse reflects on the interventions he or she has performed and decides if they have brought the patient closer to achieving the goals and outcomes set in the planning step

when the patient provides information, it is considered

primary data

the _______ is the diagnostic concept for label based on the patients needs

problem

What does PES stand for?

problem, etiology, signs and symptoms

what is safety and security need?

protection, emotional and physical safety and security order, law stability , shelter

when you enter a patients room or area to perform a nursing interview, it is important to first establish what?

rapport

what is a dependent interventions

require a health-care provider's order before they can be performed

when you obtain information from family members, friends, and the patients chart, it is considered

secondary data

the planning step of the nursing process involves several areas and they are

setting long-term and short-term goals, planning outcomes for each nursing diagnosis, and planning the interventions you will use in the implementation step

______ _______ goals are expected be met by the time of discharge or transfer to another level of care

short term

the ______ ________ _________ include the data collected and the evidence used to support the diagnostic label

sign and symptoms

when assessing a patient what two categories are used?

subjective and objective data

what is percussion

tapping the person's skin with short, sharp strokes to assess underlying structures

what is self actualization

the process by which people achieve their full potential

what is done in planning phase in the nursing process

the process of determining priorities and what nursing actions should be performed to help resolve or manage each patient problem

what is done in the implementation phase in the nursing process?

the process of taking actions to resolve the patients problem; actions are also called interventions

Transcendence needs

to help others achieve self-actualization

what is critical thinking

using skillful reasoning and logical thought to determine the merits of a belief or action

what is validating in critical thinking skills

verifying patients information

What is inspection?

visual examination of the patient's body for rashes; breaks in the skin, and normal appearance of the eyes, ears, mouth, limbs, and genitals