ch. 4 The Nursing Process: Critical Thinking and Decision Making

What are the three components to the assessment of patients when gathering information about their problems and needs?

1. Interviewing: which involves asking questions, listening, and using both verbal and non verbal communication skills. 2. Performing a focused body system assessment: to determine deviations from normal in the patient's physical condition. 3. Reviewing: the results of laboratory and diagnostic tests to determine problems and needs caused by abnormal findings.

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 the difference between the role of the RN and the role of the LPN/LVN in the nursing process? What does ADPIE stand for?

According to the American Nurses Association (ANA) Standards of Practice for registered nurses (RN's), all the steps of the nursing process, from assessment through evaluation, are the responsibility of the RN. This includes outcome identification in addition to planning. The National Federation of Licensed Practical Nurses (NFLPN) Nursing Practice Standards for the licensed practical/vocational nurse (LPN/LVN) identify assessment and nursing diagnoses as the responsibilities of the RN, while the LPN/LVN participates directly in the remaining steps of planning,intervention, and evaluation. This does not mean that the LPN/LVN cannot perform assessment skills, but it does mean that the findings of the LPN/LVN are shared with and sometimes confirmed by the RN. The LPN/LVN contributes greatly to the development of the nursing diagnoses. ADPIE stands for assessment,diagnose,planning, implementation and evaluation.

Give an example of an independent nursing intervention. Give an example of a dependent nursing intervention.

An example of independent nursing interventions is when a the nurse assesses a patient's urine and notices that it is dark yellow and concentrated and that the amount is lower than normal. The nurse decides to put the patient on intake and output measurement because the patient has a risk from imbalanced fluid volume. An example of a dependent nursing interventions is if a patient was complaining of constipation, the nurse would assess the date of the last bowel movement and assess the abdomen. The nurse would use independent interventions to help promote peristalsis, such as increasing fluid intake, encouraging high fiber foods, and assisting with ambulation, if allowed.

expected outcomes

Are statements of measurable actions for the patient within a specific time frame & in response to nursing interventions

Number in order the steps of the nursing process.

Assessment,diagnosis, planning, implementation and evaluation

What types of care plans are available?

Computerized care plans, standardized care plans, multidisciplinary care plans, critical pathways and student care plans.

Subjective data

Information that is known only to the patient and family members. Examples; of subjective data include nausea, pain, anxiety, fear, depression, and discouragement

dependent interventions

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

List three ways to obtain assessment data. How do nurses decide which nursing diagnoses have the highest priority?

Interviewing, which involves asking questions, listening, and using both verbal and nonverbal communication skills. Performing a focused body system assessment to determine deviations from normal in the patient's physical condition gives you a complete guide to performing a physical assessment. Reviewing the results of laboratory and diagnostic tests to determine problems and needs caused by abnormal findings. Nurses uses Maslow's Hierarchy of Human Needs to determine the highest priority of diagnoses.

Direct patient care

Is performed when the nurse interacts directly with the patient. Examples; includes activities such as bathing, teaching, listening, and administering medications

What needs must be met before other needs that are of concern to the patient

Nursing diagnoses are prioritized using Maslow's hierarchy of human needs. Physiological or survival needs must be met before other needs that are of concern to the patient

Which are examples of independent nursing interventions?

Placing a patient on intake and output measurement, assessing the abdomen when a patient is constipated, and encouraging high-fiber foods for a patient who is constipated

Which of the following are examples of activities in which a nurse would need to use critical thinking?

Prioritizing patient care, administering medications, writing nursing orders, questioning the appropriateness of an order, and starting an IV infusion

Which of these nursing diagnoses is correctly written?

Risk for injury related to poor balance when walking

Given that all the following are appropriate nursing diagnoses for your patient, which would be the priority?

Self-care deficit: bathing

what is the difference between short-term goals and expected outcomes?

Short term goals are expected to be met by the time of discharge or transfer to another level of care. Expected outcomes are statements of measurable action for the patient within a specific time frame and in response to nursing interventions.

Why do students write care plans?

Student care plans have been used to help students make connections between the patient's medical diagnoses, medications, laboratory and diagnostic tests, assessment data, nursing diagnoses, nursing orders or interventions, and evaluations.

What list contains nursing diagnoses?

The NANDA-I list contains nursing diagnoses developed and approved by the North American Nursing Diagnoses Association-Interventional. The list is arranged with the primary topic first,followed by modifiers

Nursing Goal

The overall direction in which one must progress to improve a problem

Which of these is considered subjective data?

The patient complains of a headache, and the Patient's mother states that he does not eat well

What are the steps in the nursing process? What does RN's participate in? And what does LPN's/LVN's contribute to in the nursing process?

The steps of the nursing process are assessment, diagnosis, planning, intervention, and evaluation.RN's participate in all aspects of the nursing process. LPN's/LVN's contribute to assessment and diagnosis and participate in planning, intervention, and evaluation.

concept maps

also known as "mind maps," can be used to diagram and connect data about any subject. They also can be used to organize and plan nursing care, in effect making them a care plan as well.

nursing diagnoses

are related to the needs or problems a patient is experiencing

collaborative interventions

are those that involve working with other health care professionals in the hospital setting, such as therapists, social services workers, and dietitians

objective data

are those things that you can observe through your senses of hearing,sight,smell, and touch. Examples; of objective data include "pale, cool, moist skin" and "dark brown, formed bowel movement

Which steps of the nursing process does the LPN/LVN directly participate in?

assessment, implementation and evaluation

Nurses make decisions using blank and the blank.

critical thinking and the nursing process

What are some decisions making in nursing?

critical thinking, validating obtained information, thinking purposefully, and avoiding jumping to conclusions

Assessment

includes collecting objective and subjective data through interviewing, physical assessment, and review of laboratory and diagnostic tests

secondary data

information obtain from family members, friends, and the patient's chart

stent

is a device inserted into a blood vessel to keep it open, allowing blood to flow evenly through it

Care plan

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

Indirect patient care

is performed when the nurse provides assistance in a setting other than with the patient. Examples; of indirect care include documenting care, participating in care conferences, talking with the health care provider, and receiving new health care provider's orders

Evaluation

is 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

Diagnosis

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

Assessment

is the gathering of information through signs and symptoms, patient history, and both subjective and objective findings

Planning

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

Implementation

is the process of taking actions to resolve the patient's problems (the nursing diagnosis) called interventions; when the nurses performs theses interventions, it is called implementation

critical thinking

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

nursing orders

nursing actions,or interventions, are sometimes referred to as

Independent interventions

nursing intervention that are provided without consultation with anyone else; a physician's order is not required to perform them

validate

or ensure the correctness of, the information they obtain

defining characteristics

signs and symptoms, exhibited by the patient

Nursing Diagnosis

the formulation of a patient assessment through analysis of the information gathered. The nursing diagnosis is related to the needs or problems the patient is experiencing and is completely different than medical diagnoses

primary data

when the patient provides information