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FUNDAMENTALS OF NURSING PRACTICE > Module 03: Fundamental Nursing Process (Part 01) > Flashcards

Module 03: Fundamental Nursing Process (Part 01) Flashcards

1
Q

Who introduced the concept “Thinking like a nurse?”

A

Dr.Christine Tanner

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2
Q

What does the concept “Thinking like a nurse” include?

A

(1) Critical Thinking
(2) Clinical Reasoning

Critical Thinking + Clinical Reasoning = Clinical Judgement

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3
Q

This is the process of international higher level of thinking to define a client’s problem, examine evidence-based practice in caring for the patient and making choices in the delivery of care.

A

Critical Thinking (Something that accrues as you gain more experience)

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4
Q

This is the cognitive process that uses thinking strategies to gather and analyze client information, evaluate its relevance and decide on nursing actions to improve outcomes

A

Clinical Reasoning (things that you perceive needs to be done and the reason why it should be done)

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5
Q

This is the observed outcome of
critical thinking and decision making

A

Clinical Judgement

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6
Q

Under the clinical judgement model, what makes a clinical judgement?

A

(1) Based on the patient’s needs
(2) Clinical Decisions

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6
Q

What is the result of clinical judgement?

A

Conclusion about a patient’s needs or health problems that leads to taking or avoiding action, using or modifying standard approaches or creating new ones based on patient’s responses.

(Nurses are proactive, hence approaches are always modifiable)

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7
Q

What is the correlation of clinical judgement and the nursing process?

A

Your clinical judgement is the product of your nursing process.

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8
Q

Under the clinical judgement model, what constitutes critical thinking?

A

(1) Critical Thinking Competence Knowledge Base
(a) Basic and nursing science
(b) Nursing and health care theory
(c) Patient data

(2) Experience
(a) Personal
(b) Clinical practice
(c) Skill competence

(3) Environment
(a) Time pressure
(b) Setting
(c) Task Complexity
(d) Interruptions

(4) Critical Thinking Attitudes Standards
(a) Intellectual
(b) Professional

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8
Q

What constitutes the nursing process?

A

(1) Assessment
(2) Analysis or Diagnosis
(3) Evaluation
(4) Planning
(5) Implementation

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9
Q

Critical Thinking is a process that requires the nurse to what?

A

(1) Think Ahead
(2) Apply Thinking While Acting (thinking on the possible problems and procedures)
(3) Think Back (assessing and modifying interventions)

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9
Q

What constitutes your 4-circle Critical Thinking (CT) model?

A

(1) Critical Thinking Characteristics (attitudes or behaviors)
(2) Theoretical and experiential knowledge intellectual skills or competencies
(3) Interpersonal and Self-Management Skills (time management and own reflective thinking)
(4) Technical Skills and competencies (practice)

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10
Q

Under the process of critical thinking, this is how the nurse begins to be proactive.

A

Think Ahead

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11
Q

Under the process of critical thinking, this is how the nurse enacts reflective thinking.

A

Think Back

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12
Q

This is the application of a set of questions to a particular situation or idea to determine essential information and ideas and discard unimportant ones.

A

Critical Analysis (Assessment - what are the subjective and objective cues, what are the important ones, eliminate those that entail less attention)

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13
Q

This is the technique one can use to look beneath the surface, recognize and examine assumptions, search for inconsistencies, examine multiple points of view and differentiate what one knows from what one believes

A

Socratic Questioning (continuous questioning)

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14
Q

These are the generalizations formed from a set of facts or observations (from specific to general)

A

Inductive Reasoning

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15
Q

This is the reasoning from general premise to specific conclusions

A

Deductive Reasoning

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16
Q

What are the levels of critical thinking?

A

(3) Commitment (consider wide array of clinical alternatives, apply all elements of clinical judgment model automatically
(2) Complex (independent decision-making, creativity, with initiative to look beyond expert opinion, consideration of different solutions, options and approaches
(1) Basic (answers are either right or wrong, single solution to a problem

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17
Q

Under the levels of critical thinking, this consider wide array of clinical alternatives, apply all elements of clinical judgment model automatically

A

Commitment (using different clinical judgements to make a SPECIFC solution to the SPECIFC need of the client)

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18
Q

Under the levels of critical thinking, this is independent decision-making, creativity, with initiative to look beyond expert opinion, consideration of different solutions, options and approaches

A

Complex (using personal understanding to creating solutions)

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19
Q

Under the levels of critical thinking, the answers are either right or wrong, single solution to a problem

A

Basic (student nurse, no creativity in answering, basing on textbooks)

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20
Q

What constitutes clinical decision making under the nursing process?

A

(1) Recognize cues
(2) Analyze cues
(3) Prioritize hypotheses
(4) Generate solutions
(5) Take action
(6) Evaluate Outcomes

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21
Q

What constitutes knowledge base under clinical decision making?

A

(1) Basic Science: anatomy, physiology, microbiology, underlying disease process
(2) Nursing theory supporting health and wellness
(3) Communication and patient education principles
(4) Normal assessment findings or patient assessment findings

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22
Q

What constitutes environment under clinical decision making?

A

(1) Time pressure
(2) Setting
(3) Task complexity
(4) Interruptions

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23
Q

What constitutes experience under clinical decision making?

A

(1) Personal
(2) Clinical experience
(3) Skill competence

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24
Q

What constitutes attitudes under clinical decision making?

A

(1) Perseverance
(2) Fairness
(3) Confidence
(4) Conciseness

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25
Q

What constitutes standards under clinical decision making?

A

(1) Intellectual standards in measurement
(2) Evidence-based criteria for evaluation
(3) Professional
(a) Standards of care
(b) Ethical standards

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26
Q

What is the importance of concept mapping in nursing?

A

This allows the nurse to map words on a page and focus on concepts and relationships

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26
Q

This is a technique that uses a
graphic depiction of nonlinear and linear relationships to represent critical thinking

A

Concept Mapping

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27
Q

This is a systematic, rational method of planning and providing individualized nursing care.

A

Nursing Process

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28
Q

What is the purpose of nursing process?

A

Purposes to identify a client’s health status and actual or potential healthcare problems or needs, establish plans, and to deliver specific nursing interventions

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29
Q

What are the elements under a nursing process?

A

(1) Assessment - information collection or gathering data
(2) Diagnosis - information interpretation or stating problems and strengths
(3) Outcome or Planning - setting nursing goals desired outcomes and planning interventions
(4) Implementation - performing nursing interventions
(5) Evaluation - patient’s status and effectiveness of nursing interventions

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30
Q

Under the nursing process, this is the act of collecting, organizing, validating, and documenting client data.

A

Assessment

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31
Q

What is the purpose of assessment?

A

To establish a database about the client’s response to health concerns or illness and the ability to manage healthcare needs

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32
Q

What are the activities that the nurse should execute under assessment?

A

(1) Establish a database:
(a) Obtain a nursing health history.
(b) Conduct a physical assessment.
(c) Review client records.
(d) Review nursing literature.
(e) Consult support persons.
(f) Consult health professionals.

(2) Update data as needed.
(3) Organize data.
(4) Validate data.
(5) Communicate and document data.
(6) Interpret and analyze data:

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33
Q

Under the nursing process, this is the act of analyzing and synthesizing data

A

Diagnosis

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34
Q

What is the purpose of diagnosis?

A

(1) To identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions
(2) To develop a list of nursing and collaborative problems

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35
Q

What are the activities that the nurse should do under diagnosis?

A

(1) Interpret and analyze data:
(a) Compare data against standards.
(b) Cluster or group data (generate tentative hypotheses).
(c) Identify gaps and inconsistencies.

(2) Determine client’s strengths, risks, and problems.
(3) Formulate nursing diagnoses and collaborative problem statements.
(4) Document nursing diagnoses on the care plan.

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36
Q

Under the nursing process, this is the act of determining how to prevent, reduce, or resolve the identified priority client problems; how to support client strengths; and how to implement nursing interventions in an organized, individualized, and goal-directed manner

A

Planning

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37
Q

Under the nursing process, this is the act of carrying out (or delegating) and documenting the planned nursing interventions

A

Implementing

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38
Q

What is the purpose of planning?

A

To develop an individualized care plan that specifies client goals or desired outcomes and related nursing interventions

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39
Q

What is the purpose of implementing?

A

To assist the client to meet desired goals or outcomes; promote wellness; prevent ill- ness and disease; restore health; and facilitate coping with altered functioning

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40
Q

Under planning, what are the activities that the nurse should do?

A

(1) Set priorities and goals or desired outcomes in collaboration with client. Write goals or desired outcomes.
(2) Select nursing strategies and interventions. Consult other health professionals.
(3) Write nursing interventions and nursing care plan.
(4) Communicate care plan to relevant health- care providers.

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41
Q

Under implementing, what are the activities that the nurse should do?

A

(1) Reassess the client to update the database. Determine the nurse’s need for assistance. Perform planned nursing interventions. Communicate what nursing actions were implemented:
(a) Document care and client responses to care.
(b) Give verbal reports as necessary.

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42
Q

Under the nursing process, this is the act of measuring the degree to which goals or outcomes have been achieved and identifying factors that positively or negatively influence goal achievement

A

Evaluating

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42
Q

What is the process of evaluation?

A

To determine whether to continue, modify, or terminate the plan of care

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43
Q

Which nursing process is used in the statement, “Nurse medina observed reveals that Margaret’s vital signs are: Temperature 39.4 C (103F); pulse 92 beats/min; respirations 28/min; and blood pressure, 122/80 mmHg. Nurse Medina observes that Margaret’s skin is dry, her cheeks are flushed, and she is experiencing chills. Auscultation reveals inspiratory crackles with diminished breath sounds in the right lung.”

A

Assessment

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44
Q

Which element of the nursing process was used in the statement “After analysis, Nurse Medina formulates a nursing diagnosis: altered respiratory status related to accumulated mucus obstructing airways.”

A

Diagnosing

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45
Q

Which element of the nursing process was used in the statement “Nurse Medina and Margaret collaborate to establish goals (e.g., restore effective breathing patter and lung ventilation); set outcome criteria (e.g., have a symmetrical respiratory excursion of at least 4 cm, and so on); and develop a care plan that includes, but is not limited to, coughing and deep-breathing exercises q3h, fluid intake of 3000 mL daily, and daily postural drainage.”

A

Planning

46
Q

Which element of the nursing process was used in the statement “Margaret agrees to practice the deep-breathing exercises q3h during the day. In addition, she verbalizes awareness of the need to increase her fluid intake and to plan her morning activities to accommodate postural drainage.”

A

Implementing

46
Q

Which element of the nursing process was used in the statement “Upon assessment of respiratory excursion, Nurse Medina detects failure of the client to achieve maximum ventilation. She and Margaret re-evaluate the care plan and modify it to increase coughing and deep-breathing exercises.”

A

Evaluation

47
Q

What are the characteristics of the nursing process?

A

(1) Client centered
(2) Adapted from problem solving and systems theory
(3) Decision making is in every phase
(4) Interpersonal and collaborative
(5) Used in all healthcare settings
(6) Utilized critical thinking and clinical reasoning

48
Q

This nursing process characteristic is when the process is based on the client problems rather than nursing goals

A

Client centered

49
Q

This nursing process characteristic is when the medical model focuses on physiologic systems and disease process whereas nursing process is directed towards client’s responses to real or potential disease

A

Adapted from problem solving and systems theory

50
Q

This is the systematic and continuous collection, organization, validation and documentation of data

A

Assessment

51
Q

This is the process of gathering information about a client’s health status

A

Data Collection

52
Q

This contains all the information about a client and includes the ff: 1) physical assessment, 2) primary care provider’s history, 3) laboratory and diagnostic results, 4) materials by other HCP.

A

Database

53
Q

What does the database contain?

A

1) physical assessment,
2) primary care provider’s history,
3) laboratory and diagnostic results,
4) materials by other HCP

54
Q

This data is referred to as symptoms or covert data, apparent only to the individual and can be verified only by that individual

A

Subjective Data

55
Q

This data is referred to as signs or overt data, detectable by an observer or can be measured or tested against an accepted standard

A

Objective Data

56
Q

Who are the different sources of data?

A

(1) Client
(2) Support people
(3) Client Records
(4) Health Care professionals
(5) Literature

57
Q

This is best source of data, unless too ill, young or confused to communicate clearly

A

Client

58
Q

This can supplement or verify information provided by the client, important source for a client who is very young, unconscious, confused

A

Support People

59
Q

This is the information documented by various HCP.

A

Client Records

60
Q

This is the information from previous contact with the client

A

Health care professionals

61
Q

These are the professional journals and reference texts

A

Literature

62
Q

What kind of source do support people, client records, health care professionals and literature fall into?

A

Secondary Data (not too important compared to the client)

63
Q

What are the three (3) types of data collection methods?

A

(1) Observing
(2) Interview
(3) Examining

64
Q

Under the data collection methods, this is gathered by using the senses.

A

Observing

65
Q

Under the data collection methods, this is the planned communication with a purpose.

A

Interview

66
Q

Under the data collection methods, this is the systematic data collection to detect health problems (IAPP)

A

Examining

67
Q

What are the three (3) types of interview?

A

(1) Focused interview
(2) Directive interview
(3) Nondirective interview

67
Q

In this type of interview, the nurse asks the client specific questions to collect information.

A

Focused interview

68
Q

In this type of interview, it is highly structured and elicits specific information.

A

Directive interview

69
Q

This type of interview is concerned with rapport-building

A

Nondirective interview

70
Q

What are the different types of interview questions?

A

(1) Close ended questions
(2) Open ended questions
(3) Neutral Questions
(4) Leading Questions

71
Q

This type of interview question is used in nondirective interview, invite clients to discover and explore thoughts and feelings.

A

Open Ended Questions

71
Q

This type of interview question is used in directive interview, are restrictive and requires yes or no or short factual answers.

A

Close Ended Questions

72
Q

This type of interview question is a question that can be answered without direction or pressure.

A

Neutral Questions

73
Q

This type of interview questions is usually closed and directs the client’s answers.

A

Leading Questions

74
Q

What type of questions should be avoided in an interview?

A

Why questions because they are perceived as a form of interrogation

75
Q

What are the advantages of open-ended questions?

A

(1) They let the interviewee do the talking.
(2) The interviewer is able to listen and observe.
(3) They reveal what the interviewee thinks is important.
(4) They may reveal the interviewee’s lack of information, misunderstanding of words, frame of reference, prejudices, or stereotypes.
(5) They can provide information the interviewer may not ask for.
(6) They can reveal the interviewee’s degree of feeling about an issue.
(7) They can convey interest and trust because of the freedom they provide.

76
Q

What are the disadvantages of open-ended questions?

A

(1) They take more time.
(2) Only brief answers may be given.
(3) Valuable information may be withheld.
(4) They often elicit more information than necessary.
(5) Responses are difficult to document and require skill in recording.
(6) The interviewer requires skill in controlling an open-ended interview.
(7) Responses require insight and sensitivity from the interviewer.

76
Q

What are the advantages of close-ended questions?

A

(1) Questions and answers can be controlled more effectively.
(2) They require less effort from the interviewee.
(3) They may be less threatening, since they do not require explanations or justifications.
(4) They take less time.
(5) Information can be asked for sooner than it would be volunteered.
(6) Responses are easily documented.
(7) Questions are easy to use and can be handled by unskilled interviewers.

77
Q

What are the disadvantages of close-ended questions?

A

(1) They may provide too little information and require follow-up questions.
(2) They may not reveal how the interviewee feels.
(3) They do not allow the interviewee to volunteer possibly valuable information.
(4) They may inhibit communication and convey lack of interest by the interviewer.
(5) The interviewer may dominate the interview with questions.

78
Q

What are the different factors to be considered under the interview setting?

A

(1) Time
(2) Place
(3) Seating Arrangement
(4) Distance
(5) Language

79
Q

What should the nurse consider under time in the interview setting?

A

(1) When the client is physically comfortable and free of pain
(2) Interruptions are minimal

80
Q

What should the nurse consider under place in the interview setting?

A

(1) well-lit, well-ventilated room
(2) free of noise, movements, and distractions

81
Q

What should the nurse consider under seating arrangement in the interview setting?

A

(1) If the client s in bed, the nurse sits at a 45 degree angle to the bed
(2) Sits on two chairs placed at right angles to a desk with no table in between
(3) in groups, a horseshoe or circular chair arrangement

82
Q

What should the nurse consider under distance in the interview setting?

A

(1) neither too small or too great, usually 2-3 feet

83
Q

What should the nurse consider under language in the interview setting?

A

(1) must convert complicated
medical terminology into common English usage

84
Q

What are the stages of an interview?

A

(1) Opening (rapport orient)
(2) Body
(3) Closing (plan for next meeting, provide summary)

85
Q

What are the different types of organization of data?

A

(1) Gordon’s 11 Functional Health Patterns
(2) Roy’s Adaptation Model
(3) Wellness Models
(4) Body Systems Model
(5) Maslow’s Hierarchy of Needs
(6) Developmental Theories

85
Q

This is the act of double checking or verifying data to confirm that it is accurate and factual

A

Validation

86
Q

What is the purpose of validating data?

A

(1) Ensure that assessment information is complete
(2) Ensure that objective and related subjective data agree
(3) Obtain additional information that may haven overlooked
(4) Differentiate cues and inferences
(5) Avoid jumping to conclusions

87
Q

This is the second phase of the nursing process.

A

Nursing Diagnosis

88
Q

What does nursing diagnosis use?

A

Use critical thinking skills to interpret assessment data and identify client strengths and problems

89
Q

This is the statement or conclusion regarding the nature of a phenomenon

A

Diagnosis

90
Q

This contains a diagnostic phrase, followed by an etiology

A

Nursing Diagnosis

91
Q

What does nursing diagnosis include?

A

contains a diagnostic phrase, followed by an etiology

92
Q

This is the identification of a disease condition based on specific assessment of physical signs and symptoms, a patient’s medical history and the results of diagnostic tests and procedures

A

Medical Diagnosis

93
Q

When is medical diagnosis applied?

A

Used to communicate a patient’s health problems and associated treatments and responses

94
Q

What are the seven axes under the ICNP (International Classification for Nursing Practice)?

A

(1) Focus
(2) Judgement
(3) Client
(4) Action
(5) Means
(6) Location
(7) Time

95
Q

Under the seven axes of the ICNP (International Classification for Nursing Practice), this pertains to the area of attention that is relevant to nursing.

A

Focus

96
Q

Under the seven axes of the ICNP (International Classification for Nursing Practice), this pertains to the clinical opinion related to the focus of nursing practice

A

Judgement

97
Q

Under the seven axes of the ICNP (International Classification for Nursing Practice), this pertains to the subject to whom a diagnosis refers and who is the recipient of an intervention

A

Client

98
Q

Under the seven axes of the ICNP (International Classification for Nursing Practice), this pertains to the intentional process applied to or performed by a client.

A

Action

99
Q

Under the seven axes of the ICNP (International Classification for Nursing Practice), this pertains to the manner or method of accomplishing an intervention

A

Means

100
Q

Under the seven axes of the ICNP (International Classification for Nursing Practice), this pertains to the anatomical and spatial orientation

A

Location

101
Q

Under the seven axes of the ICNP (International Classification for Nursing Practice), this pertains to the point, period, interval or duration of an occurrence

A

Time

102
Q

What are the four (4) status of nursing diagnosis?

A

(1) Actual
(2) Health promotion
(3) risk
(4) Syndrome

103
Q

This status of nursing diagnosis is a problem-based diagnosis, present at the time of nursing assessment

A

Actual

104
Q

This status of nursing diagnosis pertains to the client’s preparedness to implement behaviors to improve health condition

A

Health promotion

105
Q

This status of nursing diagnosis pertains to the clinical judgment that a problem does not exist but the presence of risk factors indicates that a problem is likely
to develop

A

Risk

106
Q

This status of nursing diagnosis pertains to the clinical nursing judgment when a client has several similar nursing diagnoses.

A

Syndrome

107
Q

What are three (3) components of a nursing diagnosis?

A

(1) Problem Statement
(2) Etiology
(3) Defining Characteristics

108
Q

This component of nursing diagnosis describes the health problem or response, includes qualifiers (words added to provide additional meaning)

A

Problem Statement

109
Q

This component of nursing diagnosis identifies one or more probably causes of health problems, gives directions to the required nursing therapy and enables the nurse to individualize client’s care

A

Etiology

110
Q

This component of nursing diagnosis is a cluster of signs and symptoms that indicate the presences of a particular diagnostic label

A

Defining Characteristics

111
Q

Enumerate the diagnostic process.

A

(1) Assess the patient’s health status
(a) Patient, family, health care resources provide information for database
(b) Clarify inconsistent or unclear information
(c) Use critical thinking to guide and direct line of questioning and examination to reveal detailed and relevant database

(2) Validate data with other sources
(3) Reassess if there is any more additional data needed
(4) Analyze and interpret the meaning of data. Look for data clustering patterns
(a) Group signs and symptoms
(b) Classify and organize

(5) Reassess if that was the data expected
(6) Identify related factors from assessment
(7) Formulate nursing diagnosis and collaborative problems

112
Q

How do you analyze data?

A

(1) Comparing with standards
(2) Data clustering and finding patterns
(3) Data interpretation

113
Q

Explain the process of data analysis.

A

(1) Identification of significant cue cluster (problem)
(2) Can the nurse take the independent action to prevent or treat the problem
(3) Are these the primary interventions needed to achieve the goal (yes = nursing diagnosis)
(4) Are both medical and nursing orders needed to prevent and treat the problem (yes = collaborative problem and medical diagnosis)

114
Q

Explain diagnosis and related factors.

A

(1) Related to problem and etiology
(2) Related to: (a) Patient’s health problem - reduced physical activity and stays in tense position and (b) Discomfort along abdominal incision; increases with movement
(3) Nurse uses critical thinking to see clusters of data and consider the context of the health problem

Diagnosis = Impaired mobility
Etiology (reason or rationale) - acute incisional pain

FUNDAMENTALS OF NURSING PRACTICE (13 decks)

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