Exam 1 Flashcards by Alayna Johnson

What are the 5 steps of the nursing process?

Assess:
* Gather information about condition

Diagnose:
* Identify problems

Planning:
* Set goals of care, desired outcomes, & identify appropriate nursing actions

Implement:
* Preform nursing actions

Evaluation:
* Determine if goals / outcomes where achieved

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What is the difference between a cue & an inference?

Cues: Info obtained through senses - Signs & symptoms
* Swollen finger
* Red
* Painful
* What patient is doing (Action wise - Facial grimace, grabbing chest)

Inference: What you think ; judgement about cues
* Broken finger

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What are the CJMM cognitive skills of clinical judgement?

Recognizing cues: Identify significant data ; data can be from any source
* What matters most?
* Assessment
* Relevant vs irrelevant

Analyzing cues: Connecting data to clients clinical presentation-determining if data is expected
* What could it mean?
* Analysis

Prioritizing cues: Ranking hypothesis ; what are the concerns/client needs/problems & their priority
* Where do I start?
* Analysis

Generate solutions: Using hypothesis or client needs to determine interventions for an expected outcome
* What can I do?
* Planning

Take action: Implementing generated solutions addressing highest priorities/hypotheses
* What will I do?
* Implementation

Evaluate outcomes: Comparing observed outcomes w/ expected ones
* Did it help?
* Evaluation

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What are the classic rights of clinical reasoning?

Right client

Right time

Right reason

Right cues

Right actions

extra info: Rights help guide ability to notice & recognize relevent data to direct nursing action

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What is difference between nursing process & NCSBN clinical judgement?

Nursing process:
* Scientific method of what a nurse does
* Step by step approach directed at planning & providing pt care

NCSBN clinical judgement:
* Measures nurse’s ability to use clinical reasoning skills
* Demonstrates how nurses think
* Incorperates nursing process, Tanners clinical judgement, & NCSBN CJMM cognitive skills

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Match each part of the nursing process w/ the appropriate Tanner model & NCJMM:

ADPIE/AAPIE - Nursing process

Noticing, interpreting, responding, reflecting - Tanner model

Recognizing cues, analyze cues, prioritize hypothese, generate solutions, take action, evaluate outcomes - NCJMM

Assessment (NP), Noticing (T), Recognizing cues (NCJMM)
Diagnosis/Analysis (NP), interpreting (T), Analyze cues & Prioritize hypotheses (NCJMM)
Planning (NP), Responding (T), Generate solutions (NCJMM)
Implementation (NP), Responding (T), Take action (NCJMM)
Evaluation (NP), Reflecting (T), Evaluate (NCJMM)

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Part of Tanner’s Model that involves:
* Identifying s/s (subjective/objective)
* Gathering complete & accurate data
* Assessing systematically & comprehensively
* Predicting potential complications
* Identifying assumptions

Noticing
(Tanner’s Model)

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Part of Tanner’s Model that involves:
* Comparing & contrasting
* Clustering related information
* Recognizing inconsistencies, Checking accuracy & reliability
* Distinguishing related from irrelevant
* Determining importance of information
* Judging how much ambiguity is acceptable
* Managing complications
* Using legal, ehtical, & professional guidlines

Interpreting
(Tanner’s Model)

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Part of Tanner’s Model that involves:
* Setting priorities
* Delegating

Responding
(Tanner’s Model)

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Part of Tanner’s Model that involves:
* Evaluating data (Relection-IN-action)
* Evaluating & correcting thinking (Relection-ON-action)

Reflection
(Tanner’s Model)

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What are examples of a Nursing Diagnosis?

Pain

Ineffective breathing pattern

Risk for infection

Knowledge deficit

Fluid & electrolyte imbalance

Mobility deficiet

Risk for falls

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What are examples of a Medical Diagnosis?

Cholecystitis

COPD

Lupus

Diabetes

Hyper/Hypovolemia

Knee replacement

UTI

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What are 4 types of nursing Dx errors?

Data collection errors

Data clustering incorrectly

Analysis & interpreting of data

Diagnostic statments

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Juan just completed his first year as a RN working on the meg surg unit. He feels more confident in skills & experience that he has gained. What stage of Benner’s is Juan in?

A) Advanced Beginner
B) Novice
C) Competent
D) Proficient

A) Advanced Beginner

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Professional definition of what a nurse is licensed to perform

Scope of practice

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Professional guidlines for ethical behavior

Sets expectations for professional to achieve

Code of ethics

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Minimum level of care accepted to ensure high-quality care to pts

Standards of care

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John Wu notices a rash on his pt that he has not seen before. He reports the rash to the nurse & asks her to assess it w/ him. What type of critical thinking attitude is John demonstrating?

A) Humility
B) Thinking independently
C) Curiosity
D) Responsiblity & authority

D) Responsiblity & authority

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During clinical last week, Sarah’s pts IV had infiltrated. Why is Sarah now more aware of noticing S/s of an infiltrated IV?

A) Reflection
B) Curiosity
C) Experience
D) Knowledge

C) Experience

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What are some questions to ask yourself when identifying S/s? (Noticing - Tanner’s model)

What findings are most significant?

What data are relevant/ not relevant?

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What are some questions to ask yourself when gathering complete & accurate data? (Noticing - Tanner’s model)

What additional information is needed to decide what is wrong w/ this pt?

What questions should the nurse ask (pt, family, others) in the assesment?

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What are examples of gathering complete & accurate data? (Noticing - Tanner’s model)

Patient: Interview, assessment
Medical/records: Health Hx / Dx
Medication: Administration record
Spouse / caregiver
Lab values, diagnostic reports

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What is the differrence between Reflecting-ON- Action & Reflecting-IN- Action

Reflecting-ON- Action: Correcting while in action
* Ex: Med follow up

Reflecting-IN- Action: Reflect on what happened / what was done
* Ex: Intervention / education follow up

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List some sources of data:

Patient (Subjective / objective / Primary)

Family, Significant other, neighbor (secondary)

Healthcare team (SW, PT/OT,Dr, etc)

Medical records, other records

Scientific lierature (Research)

Nurse’s experience

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Process of developing & evaluating nursing solution or approaches to client problems

Problem solving

Requires use of logic & clinical reasoning to identify strengths/weaknesses of nursing solutions to client problems

Critical thinking

How would you describe of each letter of ADPIE?

**Assessment**: Interpreting & validating information to form a complete database (*Holistic care - Whole person*) * Investigate / collect data * Primary (Pt) or secondary (Family, neighbor, spouse, et.) **Diagnosis**: Problem/ potential problem based on assessment data & goal for pt **Planning**: Plan created to resolve problem or prevent problems based on evidence-based care * Determines what is most important **Implementation**: Carry out plan in safe manner **Evaluation**: Outcome of plan * Determine if it was effective in acheiving goal

What are 3 types of assessments?

Pt centered interview Physical assessment (Head-to-toe, focused assessment, pain assessment) Periodic assessment (Rounding)

What other sources are appropriate for data collection?

Patient (Primary - Subjective) Family / sig. other Heathcare team (SW, PT/OT, Dr, ect) Medical records Other records Scientific literature (Research studies to keep up to date) Nurse's experience

What is the difference between subjective & objective data?

**Subjective**: Subject verbalizes problem * Ex: Pain 10/10, "My head hurts" **Objective**: Data observed * Ex: Facial grimacing, BP, ect

Tanners Assessing systemically & comprehensively

Noticing

S/s noticed when using sences (touch, taste, smell, hear, see) Carefully review assessment data to determine relevant / immediate concern (Subjective / objective) * Comes first Ex: * Lumps * Temp * Shuffling gate * Warm skin * Odor

Cues

CJMM Identify relevant from irrelevant * Can use assessments, medical Hx, vitals, labs What is more important / a main concern? Tools used: * Maslows * ABCs * CAB (if CPR)

Recognizing cues

Noticing normal / abnormal data or data has changed Objective / subjective cues

Identifying S/s

Noticing data from reliable availible source * No cues involved Ex: * MAR, medical records * H & P * Pt / family/ Sig. other * HCT * Dx tests, labs * Past Dx

Gathering complete & accurate data

What are 4 things pt centered interviews consist of?

Courtisy Comfort Connect Conformation (Clarification - Like debrifing)

What is the inital interview goal?

To find the complaint * What brought them in to be seen

What are 3 phases associated w/ gathering complete & accurate data?

**Orientation & setting agenda:** * Begin by introducing self * Explain the procedure & why you are collecting data * Focus on pt goals, preferences, & concerns, not your personal agenda * Ensure pt comfort **Working phase (Open-ended):** * Involves gathering ongoing assessment information * Begin w/ open-ended questions * Have pts explain reasons for seeking health care or describe symptoms * Use active listening * Organize time & focus on changes **Termination (Summarise, Teach back):** * Summarize discussions w/ pt & check for accuracy * Let pt know when interview is almost over * End interview in friendly manner

What are some interview techniques?

Leading questions (Can be conflicting) Verbal / nonverbal communication Back channeling (Active listening / "Uh huh, go on...") Probing

What are some ways to help improve communication w/ older adults?

Direct eye contact Head nodding Smiling Leaning forward

What does each letter stand for in SPICES?

**S**: Sleep disorder **P**: Problms w/ eating **I**: Incontinence **C**: Confusion **E**: Evidence of falls **S**: Skin breakdown

Noticing data using systematic methods or assessment tools Types of systems: * ACE.S * Sleep scale * SPICES * Braden scale * Head-To-Toe * Morris fall scale * Focused assessment, ect When in distress, used focused assessment

Assessing systematically & comprehensively

Being proactive by settig up interventions to prevent further complications Noticing a situation has a high risk for complications * Nurses should be alert

Predicting potential complications

Another name for Hospital Aquired Infection

Nosocomial

Made w/o proof Noticing risks of arriving at a conclusion w/o supporting evidence

Identifying assumptions

**Develops, revises, & maintains scope of practice** statements & standards that apply to the practice of all professional nurses Guide nurses to make significant & visible contributions that improve the health & well-being of all individuals, communities, & population ADPIE *Standards* describe a competent level of behavior in the nursing roles * *Standards* set a level of performance to assure patients that they are receiving high quality of care

ANA scope & standards

List and describe the levels of nursing from Novice to Expert

**Novice:** Beginning nursing student or any nurse in a situation in which there is no previous level of experience **Advanced beginner:** A nurse who has had some level of experience w/ the situation **Competent:** A nurse who has been in the same clinical position for 2 - 3 years **Proficient:** A nurse who has more than 2 - 3 years of experience **Expert:** A nurse w/ diverse experience

What are 5 critical thinking competencies?

**Knowledge based:** * Basic & nursing science * Nursing & health care theory * Pt data **Experience:** * Personal * Clincail practice * Skill competence **Enviornmet:** * Time pressure * Setting * Task complexity * Interruptions **Critical thinking attitudes** **Standards:** * Intellectual * Professional

What are some enviornmental factors that affect the adequacy of an assessment?

Setting Time pressure Task complexity Inturruptions

What are the 3 priority levels that can be use to help set priorities?

1. ABCs, CAB, vital sign concerns, life threatening labs 2. Changes in mental status, untreated medical issue, acute pain, acute elimination problems, abnormal labs, & risks 3. Long term issues, long term issues in health management, rest, family coping

A nurse received change-of-shift reports on these 4 patients & start rounding. Which pt does the nurse need to focus on as priority? A) A pt who had abdominal surgery 2 days ago & is requesting pain meds B) A pt admitted yesterday w/ afib who now had a decreased level of consciousness C) A pt w/ a wound drain who needs teaching before discharge in the early afternoon D) A pt going into surgery for a mastectomy in 3hrs who has a question about the surgery

B) A pt admitted yesterday w/ afib who now had a decreased level of consciousness

While administering meds, a nurse realizes that a prescribed dose of medication was not given. The nurse acts by completing an incident report & notifying the patients HCP. Which of the following is the nurse exercising? A) Authority B) Responsibility C) Accountability D) Decision making

C) Accountability

Which task is appropriate for a RN to delegate to an UAP? A) Determining whether the pt understands the preoperative preparation required before the surgery in the morning B) Administering the ordered antibiotics to the pt before surgery C) Obtaining pt's signature on surgical informed consent D) Helping pt to the bathroom before leaving for OR

D) Helping pt to the bathroom before leaving for OR

What are 8 different sources of law w/in the legal limits of nursing?

**Constitutional law:** Derived from federal & state constitutions **Statutory law:** Laws that are civil orcriminal **Civil law:** Rights of individuals & provide fair / equitable tx when civil wrongs or violations occur **Nurse practice act:** Civil state laws that define nursing & the standards nurses must meet w/in individual states **Criminal law:** Protect society & provide punishment for crimes **Administrative law / Regulatory law:** Degree of offense often distinguishes whether the person intentionally commited the mistreatment, knew or should have known harm would result, or did not consider harm **Common law:** Originates from decisions that were made in absence of law **Case law:** Describes decisions made in legal cases that were resolved in courts * Presented to judge / jury

Consensus or sociological perspective, incorporates the societal & professional codes & standards that are part of the nursing discipline Skill orientation Part of professional identity

Doing

Personal or psychological view of the nurse professional explains what it means to do the right thing Attribute is about professional & adopting attitudes & behaviors that reflect the value of how a preofessional thinks, feels, & acts May incorporate rules & principles, but it is beyond the laws, codes, & standards w/in the discipline or society

Being

Being attentive to what is considered right & good for both a societal & professional perspective

Acting ethically

The final attribute of professional identity & the process of professional identity formation

Changing identities

Refers to nurse's understanding of pt response to nursing actions while care is occuring Observations & interactions w/ the pt by the nurse determins pt status & adjusts care accordingly Critical step in evaluating pt's reaction to interventions Nurse is continuously assessing & reflecting on pt's response to meds, such as changes in facial expression, muscle relaxation, or verbal indications of relief

Reflection-in-Action

Consideration of the situation after the pt care occurs Nurse contemplates a situation & considers what was successful / unsuccessful Critical for development of knowledge & improvement in reasoning How learning from practice is incorporated into personal experience for consideration in future care situations Significant learning ffrom practice occurs & is critical to the development of increasing skillfulness as a nurse May use verbal narratives to engage in making sense of their own experiences, & process to thinking

Reflection-on-Action

What does each letter stand for in ACE.S?

**A**: Assess Function and Expectations **C**: Coordinate and Manage Care **E**: Evolving Knowledge **S**: Situational Decisions

*1st Part of ACE.S* Assess, respond to, and respect an older adult’s functional status and strengths, wishes, and expectations. **Determine the older adult’s function and expectations, along with cognition, mood, culture, physiologic status, and comfort to obtain a comprehensive assessment of health care needs** Use standardized assessment tools to assess the older adult’s individual aging pattern

Assess Function and Expectations

*2nd Part of ACE.S* **Manage chronic conditions, including atypical presentations, in daily life and during life transitions to maximize function and maintain independence.** Assist older adults and families/caregivers to access knowledge and evaluate resources. Advocate during acute exacerbations of chronic conditions to prevent complications.

Coordinate and Manage Care

*3rd Part of ACE.S* Understand geriatric syndromes and unique presentations of common diseases in older adults. **Access and use emerging information and research evidence about the special care needs of older adults and appropriate treatment option**s. Interpret findings and evaluate clinical situations in order to provide high quality nursing care based on current knowledge and best practices

Evolving Knowledge

*4th Part of ACE.S* **Analyze risks and benefits of care decisions** in collaboration with the interdisciplinary team and the older adult, family, and caregivers. **Evaluate situations where standard treatment recommendations need to be modified** to manage care in the context of the older adult’s needs and life transitions. **Consider the older adult’s wishes**, expectations, resources, lived experiences, culture, and strengths when modifying care approaches.

Situational Decisions

Exam 1 Flashcards

(65 cards)