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Module 2 Kozier

Critical Thinking and ADPIE

QuestionAnswer
Creativity is thinking that results in the development of new ideas and products. Creativity in problem solving and decision making is the ability to develop and implement new and better solutions
Critical analysis is the application of a set of questions to a particular situation or idea to determine essential info and ideas and discard superfluous info and ideas
Socratic questioning is a 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 merely believes.
Inductive reasoning when generalizations are formed from a set of facts or observations
Deductive reasoning is reasoning from the general premise to the specific conclusion
Nursing process is a systematic, rational method of planning and providing individualized nursing care. The phases of the nursing process are – assessing, diagnosing, planning, implementing, and evaluating.
Problem Solving when the nurse obtains info that clarifies the nature of the problem and suggests possible solutions. - Trial and Error - Intuition - Research Process and Scientific Method
Assessing the systematic and continuous collection, organization, validation and documentation of data.
Database all the info about the client; includes the nursing health history, physical assessment, pcp H&P exam, lab results and diagnostics test.
Subjective Data aka symptoms or covert data, are apparent only to the person affected and can be described or verified only by that person.
Objective Data aka signs or overt data, are detectable by an observer or can be measured or tested against an acceptable standard
Interview a planned communication or conversation with a purpose
Directive interview is highly structured and elicits specific info.
Nondirective interview rapport-building interview, less structured, the nurse allows the client to control the purpose
Rapport an understanding between people
Closed questions used in the directive interview, are restrictive and generally only require yes/no answers or short factual answers
Open-ended questions associated with the nondirective interview, invite clients to discover and explore, elaborate, clarify and/or illustrate their thoughts/feelings
Neutral questions a question that the client can answers without direction or pressure from the nurse, it is open-ended
Leading questions usually is closed and directs the client’s answer
Cephalocaudal head-to-toe approach
Screening exam a brief review of essential functioning of various body parts or systems
Validation the act of “double-checking” or verifying data to confirm that it is accurate and factual
Cues are subjective or objective data that can be directly observed by the nurse
Inferences are the nurse’s interpretation or conclusion made based on cues
Informal nursing care plan is the strategy for action that exists in the nurse’s mind
Formal nursing care plan is a written or computerized guide that organizes info about the patient’s care
Standardized care plan a formal plan that specifies the nursing care for groups of patients with common needs
Individualized care plan is tailored to meet the unique needs of a specific patient – needs that are not addressed by a standardized plan
Protocols are preprinted to indicate the actions commonly required for a particular group of clients
Policies and Procedures are developed to govern the handling of frequently occurring situations
Standing order a written document about policies, rules, regulations, or orders regarding patient care. They also give nurses the authority to carry out specific actions under certain circumstances, often when a physician is not around
Rationale the scientific principle given as the reason for selecting a particular nursing intervention
Multidisciplinary care plan are standardized plans that outline the care required for clients with common, predictable conditions
Collaborative care plans (critical pathways) sequence the care that must be given on each day during the projected length of stay for the specific type of condition
Goals/desired outcomes what the nurse hopes to achieve to implementing the nursing interventions
The Nursing Outcomes Classification (NOC) a taxonomy for describing patient outcomes that responds to nursing interventions
Indicator “a more concrete individual, family or community state, behavior, or perception that servers as a cue for measuring outcome.”
Independent interventions are those activities that nurses are licensed to initiate on the basis of their knowledge and skills
Dependent interventions are those activities carried out under the physician’s order or supervision, or according to specific routines
Collaborative interventions are actions the nurse carries out in collaboration with other health team members; such as PT, SW, dieticians, physicians
Assignment is a “downward or lateral transfer of both the responsibility and accountability of an activity from one individual to another.”
Nursing Intervention Classification (NIC) a taxonomy consists of 3 levels; level 1 – domains, level 2 – classes, level 3 – interventions
NANDA purpose is to define, refine and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses
NANDA Nursing Diagnoses a clinical judgment about individual, family, or community response to actual and potential health problems/life processes. A nursing diagnosis proves the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable
Diagnosing  Second phase in the nursing process; in this phase, nurses use critical-thinking skills to interpret assessment data and identify client strengths and problems.- refers to the reasoning process
Diagnosis is a statement or conclusion regarding the nature of a phenomenon
Diagnostic labels the standardized NANDA names for diagnoses
Nursing diagnosis the clients problem statement, consisting of the diagnostic label plus etiology
Actual diagnosis is a client problem that is present at the time of the nursing assessment
Risk Nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurse intervene
Wellness diagnosis “describes human responses to levels of wellness in an individual, family, or community that have readiness for enhancement.” NANDA
Possible Nursing diagnosis is one in which evidence about a health problem is incomplete or unclear
Syndrome diagnosis a diagnosis that is associated with a cluster of other diagnoses
Diagnostic label purpose is to direct the formation of client goals and desired outcomes, it may also suggest some nursing interventions
Qualifiers words that have been added to some NANDA labels to give additional meaning to the diagnostic statement
Nursing diagnosis a statement of nursing judgment and refers to a condition that nurses are licensed to treat; describe the human response, a client’s physical, sociocultural, psychological, and spiritual response to an illness or health problem
Medical diagnosis is made by a physician and refers to a condition that only a physician can treat; refers to the disease process – specific pathophysiologic responses that are fairly uniform from client to client
Independent functions areas of health care that are unique to nursing and separate and distinct from medical management
Dependent functions are the physician-prescribed therapies and treatment that nurses are obligated to carry out
Standard (norm) a generally accepted measure, rule, model or pattern
Cue considered significant if it does any of the following; points to a negative/positive change in patients status, varies from norms of the patient pop, indicates a developmental delay
Implementing consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions.
Cognitive skills include problem solving, decision making, critical thinking and creativity
Interpersonal skills are all of the activities, verbal and nonverbal, people use when interacting directly with one another
Technical skills are purposeful “hands-on” skills such as manipulating equip, giving injections, bandaging, moving, lifting and repositioning patients
Evaluating planned, ongoing, purposeful activity in which clients and health care professionals determine the client’s progress and the effectiveness of the plan
Evaluation statement consists of 2 parts: a conclusion and supporting data. The conclusion is a statement that the goal was met, partially met, or not met; the supporting data are lists of client responses that support the conclusion
Quality Assurance an ongoing, systematic process designed to evaluated and promote excellence in the health care provided to patients
Structure evaluation focuses on the setting in which care is given; asks “what effect does the setting have on the quality of care?”
Process evaluation focuses on how the care was given; asks “is the care relevant to the client’s needs? Is the care appropriate, complete, and timely?”
Outcome evaluation focuses on demonstrable changes in the client’s health status as a result of nursing care
Quality Improvement follows client care rather than organizational structure, focuses on process rather than individuals and uses systematic approach with the intention of improving the quality of care rather than ensuring the quality of care.
Sentinel event an unexpected occurrence involving death or serious physical injury or psychological injury, or the risk thereof
Root cause analysis a process of identifying the factors that bring about deviations in practices that lead to the event
Retrospective audit evaluation of client’s records after discharge
Concurrent audit evaluation of a client’s health care while the client is still in the facility
Created by: nymph487