Ch 16

Question 1

What is clinical judgement?

Answer 1

A conclusion drawn about pt needs and appropriate actions to take.
Helps:
Make informed and timely decisions
Deliver holistic, patient centered care

Question 2

What is Nursing process?

Answer 2

•5 step process
• applies critical thinking skills
•application of evidence- based practice

Question 3

What are the 5 steps I. The nursing process?

Answer 3

A-assessment
D-diagnosis
P-planning
I-implementation
E-evaluation

Question 4

Clinical judgement steps

Answer 4

6 steps
•recognizing cues
•analyze cues
•prioritize hypotheses
•generate solutions
•take action
•evaluate outcomes

Question 5

Recognize cues

Answer 5

Identifying relevant & important info from different sources(medical history, vital signs)

Question 6

Analyze cues

Answer 6

Organizing & linking the recognized cues to the clients clinical presentation
-what client conditions are consistent w/the cues?

Question 7

Prioritize hypotheses

Answer 7

Evaluating & ranking hypotheses according to priority(urgency, likelihood, risk, difficulty, time, etc)

Question 8

Generate solutions

Answer 8

Identifying expected outcomes and using hypotheses to define a set of interventions for the expected outcomes.
-what are the desirable outcomes

Question 9

Take action

Answer 9

Implementing the solutions that address the highest priorities

Question 10

Evaluate outcomes

Answer 10

Comparing observed outcomes against expected outcomes.
-what signs point to improving/decking/unchanged status?
-were the interventions effective

Question 11

What is assessment?

Answer 11

Gathering of information

Question 12

Assessment steps

Answer 12

-collect data
-interpret information

Question 13

What helps you identify meaningful patterns

Answer 13

Cues you see

Question 14

Applications of critical thinking

Answer 14

5— knowledge base
Environment
Experience
Standards
Attitudes

Question 15

Types of assessment

Answer 15

There are 2
-patient centered interview:
•patient history-acute or chronic issue
• main complaint
•review medication
-periodic assessments
•conducted ongoing
• assessing each time you enter the room

Question 16

Subjective data

Answer 16

What the patient tells you

Question 17

Objective data

Answer 17

What you see; measurable output
- vital signs

Question 18

Primary data

Answer 18

The patient provides

Question 19

Secondary data

Answer 19

Information from family, friends, nurses, or anything in the medical records.

Question 20

Patient centered interview

Answer 20

Orientation: introduction; tells the pt why you are there
Working phase: talking, collecting data, setting a mutual goal
Termination phase: summarizing the data/info to ensure it is accurate

Question 21

Assessment barriers

Answer 21

Setting
Time
Task complexity
Interruptions

Question 22

Examples of cues

Answer 22

-Incision red, draining pus, edges separated
-Tearful. Stated father died of a heart attack.

Question 23

Examples of inferences

Answer 23

•incision is infected
•anxious about scheduled cardiac catherization
•patient is angry and suicidal
(Assuming, trying to diagnose)

Question 24

Obtaining a health history

Answer 24

• biographical data
-name, gender, address
•chief concerns/why they are seeking care:
- how long has this been going on
•patient expectations
•present illness of health concern
(P) provokes
(Q) quality
(R) radiate
(S) severity
(T) time

Question 25

Analyze cues(nursing diagnosis)

Answer 25

-2nd step in nursing process -links assessment to all steps that follow - describes pts PRESENT health status

Question 26

Medical diagnosis

Answer 26

Comes from the physician

Question 27

Nursing diagnosis

Answer 27

Comes from the nurse; is a potential health issue

Question 28

Collabrative problem

Answer 28

Involves nurses and physicians interventions

Question 29

Types of nursing diagnosis

Answer 29

• Problem focused: This is actually going on w/patient. • Risk What could potentially happen.

Question 30

Problem focused

Answer 30

Evidence (cues) proven issues (symptoms)

Question 31

Risk

Answer 31

Possibilities; has not occurred

Question 32

3 part nursing a diagnosis (actual problem)

Answer 32

Problem+etiology+symptoms

Question 33

2part nursing diagnosis(risk or potential problem)

Answer 33

Problem+etiology

Question 34

Maslo es hierarchy of needs

Answer 34

5 levels - physiological needs - safety & security - love&belonging - esteem - self-actualizacion

Question 35

What to put in care plan?

Answer 35

-basic needs & activities of daily living (ADLs) -Medical.multidisciplinary treatment -nursing diagnoses & collaborative problems -special discharge needs or teaching

Question 36

Expected outcome

Answer 36

Willa always be opposite of diagnosis

Question 37

Patient centered goals

Answer 37

Highest level of function goals for patient

Question 38

SMART GOALS

Answer 38

S-specific M-measurable A- achievable R- realistic T- timely

Question 39

Components of a goal statement

Answer 39

Have 3 things -subject -action verb -performance criteria -target time -special conditions Ex: The pt will walk to the doorway w/the help of one person by 11/21/17

Question 40

Take action (implementation)

Answer 40

- 4th step in the nursing process -begins after plan of care is developed -Puts the plan into action to promote positive pt outcome

Question 41

Evaluate outcomes (evaluation)

Answer 41

5th step in the nursing process

Question 42

Nursing interventions

Answer 42

5 nursing interventions Direct care interventions Indirect care interventions Dependent interventions Independent interventions Other provider interventions

Question 43

Direct care interventions

Answer 43

Directly helping patient; bedside (Oral care)

Question 44

Indirect care interventions

Answer 44

What you do on behalf of the patient away from bedside Advocating, giving report

Question 45

Dependent intervention

Answer 45

Waiting on physician to give order (Medication, o2)

Question 46

Independent interventions

Answer 46

You do not need a physicians order (Keeping head of bed elevated)

Question 47

Other provider interventions

Answer 47

Collaborative intervention, giving patient medication, then turning patient

Question 48

Evaluation measures

Answer 48

Physical: listening to lungs, looking for physiological changes Behavioral: going by what the patient tells you; relying on what is told

Question 49

Discontinuing a care plan

Answer 49

A care plan is discontinued once it is effective and has worked

Question 50

Modifying a care plan

Answer 50

A care plan is modified when it has not work and need a reevaluation