Nursing process

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  1. PES
    • Three Steps of Diagnosing Problem:
    • P- problem (use NANDA label)
    • E- etiology (factors contributing to or probable causes of the response)
    • S- Signs and Symptoms
  2. Critical Thinking Attitude
    • critical thinking is essential component of proffessional accountability
    • independence, fairness, responsibility, discipline integrity, creativity, perseverance, humility, curiosity, and risk-taking
  3. Critical thinking-central ideas
  4. Critical Thinking-description
    • Logic + Reasoning
    • an active, organized, cognitive process used to examine one's thinking and the thinking of others
  5. Intuition in Critical Thinking
    • insightful sense of knowing without conscious use of reason
    • experience is important in improving intuition
  6. Critical Thinking attitude-responsibility
    Responsibility-take responsibility for your actions
  7. Critical Thinking Attitude-perseverance
    pursuit of a course with determination to overcome obstacles
  8. Evaluation Statement
    • for care plan:
    • Achieve what wanted?
    • What interventions worked/what did not?
    • Goal met? (yes/no, partially, not really)
    • Problem of Dx resolved?
    • Problem change?
    • Priorities change?
    • What happens next?
  9. Physician-initiated nursing interventions
    Dr orders
  10. Intellectual standard of Critical Thinking
    • clarity (what is an example of this?)
    • accuracy (how can I find out if that is true?)
    • precision (can I be more specific?)
    • relevance (how does that help me wit the issue?)
    • depth (What makes this a difficult problem?)
    • breadth (do I need to consider another point of view?)
    • logic (does that follow from the evidence?)
    • significance (which of these facts is most important?)
    • fairness (am I considering the thinking of others?)
  11. Basic Critical Thinking Example
    ex- using a performance check list to perform a nursing skill correctly
  12. Critical Thinking Attitudes
    curiosity, fair-mindedness, humility, courage, and perseverance
  13. Goal/Outcome Statement
    • Under planning stage of Nursing Process
    • written in terms of objective, observable patient behaviors (measurable and realistic)
    • goal designed to help resolve problem
  14. Nursing Interventions for the Goal
    • Use Care Plan Book to find
    • adjusted to fit patien/resources
    • directed to help achieve goal
    • includes: frequencies, amounts, time lines, and details
    • need 5 for care plan
    • Cite references
  15. Steps in Decision-Making Process
    • id the purpose (why decision is needed/what needs to be determined)
    • set the criteria (what is the desired outcome, what needs to be reserved, and what needs to be avoided?)
    • weight the criteria (set priorities least to most important)
    • seek alternatives (ids possible ways to meet criteria)
    • examine alternatives (ensure objective rationale)
    • project (apply creative thinking and skepticism to determine what might go wrong)
    • implement (plan placed into action)
    • evaluate the outcome
  16. Client goal/outcome for the problem
    "The Bear will have a BM within 24 hrs"
  17. Assessment Priorities
    • collecting data
    • organize data
    • validate data
    • document data
    • Maslow's Pyramid:
  18. Etiology statement in nursing diagnoses
    • the why of the problem
    • not medical diagnosis
    • ex. at risk for, knowledge deficit...
  19. Critical Thinking Strategies Examples
  20. Collaborative nursing interventions
  21. prioritizing nursing diagnosis
    • Maslow's Hieratchy of Needs:
    • physiologic, safety and security, love and belonging, self-esteem, then self-actualization
  22. Scientific Method Example
    • a formal way to approach a problem, plan a solution, test the solution and rech a conclusion
    • ex problem solving: Nursing Process
  23. Complete Nursing Intervention Statement
  24. Goal/outcome statement that fits the nursing diagnosis
  25. Nursing Process stages examples
    • assessing-collect data
    • diagnosing-id problem
    • planning-create actions to fix problem
    • implementing-implement those actions
    • evaluating-assess if worked and whats next
  26. Negative goal/outcome evaluation
    • re-evaluate and make necessary changes to correct the Dx
    • ex- "goal not met. No BM noted. However, Bear is passing flatus and complying with dietary and activity interventions. No increase in symptoms of discomfort. Plan to continue plan as written and re-evaluate in 12 hrs."
  27. Nursing Intervention-nurse initiated
    must be tailored to client and work toward fixing Dx
  28. Measurable client goal/outcome
    Objective Data
  29. Objective assessment data
    • more measurable/concrete data
    • can see, hear, touch, and prove
  30. Complex Critical Thinking Example
    Nurse is less reliant on authorities: better able to analyze situations independently
  31. When does Re-assessment happen?
    after evaluation when starting nursing process over again
  32. When does Implementation happen?
    • after planning step of nursing process
    • during implementation you carry out the interventions, and assess patients response and productivity of interventions
  33. Priorities for determining order of care
    • Maslow's Priorities
    • actual problems take priority over "risk for"
    • bsic physiologic needs usually tke priority over emotional needs
    • oxygenation need usually take priority over eating and elimination
  34. Responsibility and Accountability attitudes
  35. Nursing approach to evaluation stage
    • collect data related to the disired outcomes
    • comparing data with desired outcomes
    • relating nursing activities to outcomes
    • drawing conclusions about problem stat.
    • continuing, modifying, or terminating plan
  36. Evaluation response to unmet goals or outcomes
    modify or terminate the nursing care plan as needed to obtain desired results
  37. Self-regulation and self-criticism
    • self-regulation: homeostatic machanisms come into play automatically in the healty person
    • self-criticism:
  38. Nursing Diagnosis Statement
    ids patient problem that a nurse can do something about, ids cause, and provides evidience with signs and symptoms
  39. Subjective Assessment Data
    personal veiw points that are not measurable (patient says)
  40. What is the nursing diagnosis statement purpose?
    to provide a clear focus for planning interventions
  41. Components of the nursing diagnosis
    • sort through all the data (Does any of it represent a problem? Do I need to do anything about it?)
    • group problems and abnormal data together
    • sort by subjective symptoms (pain) and objective signs (bone sticking out arm)
    • stick to problems that are within nursing's scope
Card Set
Nursing process
study guide II
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