Intro Nursing Final Review

systematic phase of the nursing process that involves decision making and problem solving

The end product of the planning phase is a client care plan -

• Planning collumn of Nursing Care Plan includes:
• A. Goals -Client centered
• - Short term & long term
• B. Nursing Interventions - how to achieve goals

"any treatment, based upon clinical judgement and knowledge, that a nurse performs to enhance patient/ client outcomes

• Prioritize problems/ diagnosese
• Formulate goals/ desired outcomes
• Select nursing interventions
• Write nursing interventions

Intial planning - nurse who performs admission assessement usually develops initial comprehensive plan of care

• Ongoing Planning - done by all nurses who work with the client
• 1. Determine wheather health status has changed
• 2. set priorities for care during the shift
• 3. decide what prolems to focus on during the shift
• 4. Coordinate the nurses activities so that more than one problem can be addressed at each client contact

Discharge Planning - the process of anticipating and planning for needs after discharg

informal nursing care plan - strategy fior action that exists in the nurses mind

formal nursing care plan - written or computerized guide that organizes information about the client's care

standardized care plan - formal plan for care for groups of people with common needs

individualized care plan - tailored to meet unique needs of client

• protocols - preprinted - indicate actions commonly required for a particular group of clients
• eg - protocol for admititng patient to ICU

policies or procedures - developed to govern the handling of frequently occuring situations - visiting policy

standing order - give nurses authority to carry out specific actions under certain circumstances - often when a physician is not available

rationale - scientific pricipal given as the reason for selecting a particualr nursing intervention

• 1. Sign and date plan
• 2. Use category headings
• 3. Use standardized medical or english symbols
• 4. Be specific
• 5. Refer to procedure book rather than including steps
• 6. Tailor the plan to the client
• 7. Incorporate prevention and health maintenance
• 8. Include intervetions for ongoing assessment
• 9. Include collaborative and coordination activities
• 10. Include discharge plans and home care

• 1. Clients health values and beliefs
• 2. Clients priorities - family may be more important than health
• 3. Resources available to the nurse and client
• 4. Urgency of the the health problem
• 5. Medical treatment plan - nursing interventions may have to wait when in confict with medical orders

• 1. Provide direction for planning nursing interventions
• 2. Serve as criteria for evaluating client progess
• 3. Enable the client and nurse to determine when the problem has been resolved
• 4. Help motivate the client and nurse by providing a sence of achievement

• 1. Subject - client (not the nurse) eg client, clients arm
• 2. Verb - action client is to perform , walk, learn, drink
• 3. Conditions or modifiers - circumstances under which the behavior is performed eg. walk with the help of a cane
• 4. Cirterion of desired performance - may specifiy time, speed, accuracy, distance, quality
• eg walk with help of cane 30 meters

1. Write goals and outcomes in terms of client responses, not nurse activities - begins statement with "the client will..."

2. Be sure that desired outcomes are realistic for the client's capabilities, linitations, and designated time span (if indicated)

3. Ensure that the goals and desired outcomes are compatible with the therapies of other professions

4. Make sure that each goal is derived from only one nursing diagnosis

5. Use observable, measurable terms for outcomes

6. Make sure client considers the goals/ desired outcomes important and values them

“Critical thinking in nursing practice is a discipline specific, reflective process that guides a nurse in generating, implementing, and evaluating approaches for dealing with client care and professional concerns.”

•Nurses apply knowledge to provide holistic care

•Nurses make important decisions

•Nurses deal with change in stressful environments

•Nurses use knowledge from other subjects and disciplines

• 1. curiosity - why do we do it this way? what causes that? Value tradition but question to see if they are still valid
• 2. fair-mindedness -consider opposing viewpoints & try to understand new ideas before rejecting them
• 3. humility -know limits of your knowledge, admit what they do not know - seek new information
• 4. courage - challenge the status quo
• 5. perserverance - find effective solutions to client & nursing problems - dont be tempted to find quick and easy answet
• 6. self assessment - may help determine what attitudes a nurse already possesses and which need to be cutivated
• 7. Confidence - in the resoning process -comes from cultivating reasoning and examining arugments - not afraid of disagreements
• 8. Independence - The internal converation going on within the mind of the critical thinking is filled with questions - dont just follow orders - examine what you believe in the light of new evidence

A. Critical analysis - uses socratic qustioning to determine essential info and discard superfluous infl

• Socratic Questions:
• 1. Quesiton the quesiton - is clear? imortant?
• 2. Question the assumption - does it hold true? why do you assume this?
• 3. Quesiton the point of view - can you see it any other way? what would someone who disagrees say?
• 4. Question evidence and reasons - what evidence is there? how do you know? what would change your mind?
• 5. Question implications and consequences - what effect would it have? what are alternitives?

B. Inductive reasoning - move from specific to general - generalizations are formed from a set of facts - touch several hot flames and conclude that all flames are hot

C. Deductive reasoning - general premise to specific conclusion

• 1. Facts - can be verified through investigation
• 2. Inferences - conclusions drawn form facts - goes beyond facts to make statements about something not currently known
• 3. Judgements - a type of opinion - evaluation of facts or ideas that reflect values or other criteria
• 4. Opinions - beliefs formed over time and include judgements that may fit facts or be in error

major component of critical thinking

thinking that results in the development of new ideas and products

tge ability to develop and implement new and better solutions

• Unsing creativity, nurses:
• 1. Generate many idea rapidly
• 2. are generally flexible and natural - they are able to change viewpoints ir directions in thinking rapidly and easily
• 3. Create original solutions to problems
• 4. Tend to be independent and self-confidient, even when under pressure
• 5. Demonstrate individuality

eg - blow bubble to get child breathing deeply

• nurses gathere info from various sources
• Analize data by
• 1. reflection - being able to determine what data are relevant and to make connecitons between the data and the decisions reached
• 2. Context - essential considerations in nursing since care must always be individualized, taking knowledge and applying it

• Problem solving - nurse obtains info that clarifies the nature of the problem ans suggests possible solutions
• 1. Trial and error plus common sense – many variables with individual patients – trail and error requires breaking down information and
• recognizing cues and patterns involving patient care –
• patient appears allergic to bandage - try different ones

• 2. Intuition – requires that a nurse has a knowledge base. Clinical experience allows the nurse to
• recognize cues and patterns and formulate conclusion based on rapid judgment of the situation.

• 3. research process
• scientific method - formalized, systematic, and logical approach to solving problems

The nursing process is a systematic, rational method of planning and providing individualized nursing care

• 1. assessment
• 2. diagnosis
• 3. planning - goals and interventions -
• 4. implementations - what you have actually done
• 5. evaluation - goals and outcomes & implementation evaluate if goals are achieved evaluate
• implmentations were effective

• observation - conscious deliberate skill that is developed through effeort and with an organized approach
• -noticing the data and selecting, organizing, and interpreting the data -

• Nursing Observation - Priority order
• 1. Clinical signes of distress - pallor, flushing, breathing
• 2. Threats to clients safety, real or anticipated (lowered side rail)
• 3. Presence and functioning of associated equipment
• 4. Immediate Environment - including people

• Examination - major methos used in physical health assessment
• Interviewing

• 1. initial assessment - performed within specific time after admission to health care agancy - should be within 24 hours (joint commision) to give base line data
• 2. Emergency assessment - performed durning physiologic or phychologic crisis of the client to identify life-threatening problems
• 3. Problem focused assessment ongoing process integrates with nursing care - pain management (check vital signs)
• 4. Time-lapsed assessment
• - follow-up assessment - after a perois of time

indentifying paterns and making inferences (making judgements from facts) included only those health states that nurses are educated and licensed to treat.

A nursing diagnosis is a judgement made only after data collection

• •Problem identification,NANDA
• •Communication tool
• •Provides structure for planning nursing interventions

• 1. data analysis
• 2. identification of chilent health problems
• 3. formulate diagnosis statements

• 1. Existing or Potential Problem - Nursing Diagnosis
• 2. Etiology - probable cause, related factors - R/T
• 3. Defining characteristics - AEB

• Plan nursing care (with the patient)
• •Expected patient outcomes/goals
• –Short term
• –Long term
• •Goals written in measurable behaviors and identify what the patient is “expected to do”

• •Nursing interventions
• Collaboratinve interventions - dependent action - occurs between several health care professionals to treat clients problem
• nurse mediated - nurse can implement independently - independent actions

what is goal? - outline of what you want to accomplish

• characteristic of goals
• 1. Realistic
• 2. Measurable
• 3. Achievable -
• 4. Time Frame -

• 1. congruent with clients values, beliefs, culture
• 2. within established standards of care - you have to practice withing standards of care - withing your scope of practice
• 3. achievable with resources availablein
• 4. dividualized & client centered
• 5. family centered

• •Actual nursing interventions
• •What was done for the patient
• •Documented in flow sheets and nursing notes

• •Patient outcomes
• •Responses to nursing interventions

• Goals (short and long) need to be evaluated
• implemented nursing actions - evaluate if working

Objective data - signs or overt data - can be seen by observer or can be measured and tested against an acceptable standard

Subjective Data - symptoms - covert data - what the patient feels - can only be described or verified by that person

critical- thinking process for choosing the best actions to meed a desired goal

• 1. Identify the purpose - why is decision needed
• 2. Set the criteria -
• - - a. what is the desired outcome?
• - - b. what needs to be preserved?
• - - c. what needs to be avoided?

• 3. Weight the criteria - sets priorites or ranks acivities
• 4. Seek alternatives -
• 5. Examine Alternatives - is there rational for chooseing one over another?
• 6. Project - decision maker (nurse ) identifies possible ways to meed criteria. When nurse applies creative thinking and skepticism to determine what might go wring as a result of a decision and develops plans to prevent, minsimize or ovecome any problems
• 7. Implement
• 8. Evaluate the outcome

• develping rapport
• using translator for accuarate information
• Emphasizing open-ended questions

1. Directive - nurse controls interview - used when information is needed in a short amount of time -asks leading questions

2. Non-directive - client controls interview - repport building - asks open-ended question

• closed questions - require yes, no, or factual answers
• when, where, who, what, do, is - what medicaiton did you take?

open-ended questions - what, how - how are you feeling?

• 1. ABC - airway, breathing, circulation
• 2. Maslow's hierarchy
• Physical
• Safety
• Love and Belonging
• Self-Esteem
• Self-Actualization

• Actual vs potential - priority to actual (unless potential is really life thrensing)
• Potential - at risk recieves lowest priority
• Acitve problems - higher priority for care

care plans incluse the actions nurses nust take to address the client's nursing diagnoses and produce the desired outcomes

Nursing observation can be defined as “regarding the patient attentively” while minimising theextent to which they feel that they are under surveillance.

Whereas most nursing interventions are intendedto help patients achieve their own goals, observation is deliberately designed to frustrate thepatients’ aims.

the transfer of responsibility for the performance of an activity from one person to another while retaining accountability for the outcome

Nurse must match needs of client with skills and knowledge of caregivers

• Responsibilities
• 1. appropriate delegation of duties - given them duties within their scope of practice
• 2. supervision of personnel to whom work is delegated or assigned

doubtfulness or uncertainty of meaning or intention: to speak with ambiguity

• 1. inharmonious or harsh sound; discord; cacophony
• 2. disagreement or incongruity