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Foundations Quiz 2

QuestionAnswer
critical thinking acquired through experience, commitment, and active curiosity; interwoven with the nursing process
clinical decision-making skills separate professional nurses from technical staff
interpretation be orderly in data collection, look for patterns to categorize data, clarify any data you are uncertain about
analysis be open-minded as you look at information about a client, do not make careless assumptions
inference look at the meaning and significance of findings
evaluation look at all situations objectively, use criteria to determine results of nursing actions, reflect on your own behavior
explanation support your findings and conclusions, use knowledge and experience to choose strategies you use in the care of clients
self regulation reflect on your experiences, identify the ways you can improve your own performance
basic critical thinking students think concretely on the basis of a set of rules or principles, following a step-by-step process without deviation form the plan
complex critical thinking analyzes and examines choices independently; students learn to think beyond and synthesize knowledge
committment students anticipate needs and make choices without assistance from others
critical thinking competencies in nursing diagnostic reasoning and inference, clinical decision making, and nursing processes
Kataoka-Yahiro and Saylor (1994) define the outcome of critical thinking as a nursing judgement that is relevant to nursing problems in a variety of settings
critical thinking model serve to explain concepts and help nurses make decisions and judgements about patients
five components of critical thinking knowledge base, experience, nursing process competencies, attitudes, and standards
concept mapping a visual representation that allows nurses to graphically illustrate the connections between a client's health problems
critical thinking synthesis a reasoning process used to reflect on and analyze thoughts, actions, and knowledge
concept mapping a visual representation that allows nurses to graphically illustrate the connections between a client's health problems
critical thinking synthesis a reasoning process used to reflect on and analyze thoughts, actions, and knowledge
nursing assessment helps nurses to form a clear definition of the client's problems, which in turn provides the foundation for planning and implementing nursing interventions and evaluation the outcomes of care
cue information that you collect through the use of your senses
working phase of the interview gather data, using appropriate communication strategies (active listening, paraphrasing, summarizing, open-ended questions)
inference your judgement or interpretation of the cues you just gathered
termination phase of the interview give clients clues that the interview is about to conclude
orientation phase of the interview you first meet the client, introduce yourself, and explain what you are trying to accomplish; it is important to establish trust and confidence with your client at this stage
nursing diagnostic process critical analysis and interpretation of assessment data that reveal a client's response to health problems, identification of client needs, and formulation of nursing diagnoses
working phase of the interview gather data, using appropriate communication strategies (active listening, paraphrasing, summarizing, open-ended questions)
termination phase of the interview give clients clues that the interview is about to conclude
nursing diagnostic process critical analysis and interpretation of assessment data that reveal a client's response to health problems, identification of client needs, and formulation of nursing diagnoses
medical diagnosis the identification of a disease condition based on specific evaluation of signs and symptoms
collaborative problem an actual or potential complications that nurses monitor to detect a change in client status
NANDA (North American Nursing Diagnosis Association) formed in 1982 to develop, refine, and promote a taxonomy of nursing diagnostic terminology for use by all professional nurses
nursing diagnosis a clinical judgement about the client in response to an actual or potential health problem
collaborative problem an actual or potential complications that nurses monitor to detect a change in client status
NANDA (North American Nursing Diagnosis Association) formed in 1982 to develop, refine, and promote a taxonomy of nursing diagnostic terminology for use by all professional nurses
defining characteristics clinical criteria or assessment findings
diagnostic reasoning the process of using assessment data to logically explain a clinical judgement, in this case a nursing diagnosis
defining characteristics clinical criteria or assessment findings
clinical criteria objective or subjective signs and symptoms
actual nursing diagnosis describes human responses to health conditions or life processes
risk nursing diagnosis describes human responses to health conditions/life processes that may develop
wellness nursing diagnosis describes human responses to levels of wellness that have a readiness for enhancement
components of a nursing diagnosis diagnostic label, related factors, etiology, definition, risk factors, and support of the diagnostic statement
diagnostic label the name of the nursing diagnosis
related factors a condition or etiology identified from the client's assessment
etiology the cause of the nursing diagnosis
definition describes the characteristics of the human response
risk factors environmental, physiological, psychosocial, genetic, or chemical elements that increase the vulnerability of an individual, family, or community to an unhealthful event
sources of diagnostic errors data collection, interpretation and analysis of data, data clustering, diagnostic statement, documentation
planning process identify nursing behaviors in which client-centered goals, expected outcomes, and nursing interventions are developed; planning is holistic; prioritizing is necessary for the best client outcomes
establishing priorities helps nurses to anticipate and sequence nursing interventions (high, intermediate, low)
high-priority tasks safety, adequate oxygenation, and circulation
intermediate-priority tasks non-emergent, non-life threatening needs
low-priority tasks not related to a specific illness or prognosis but may call for an intervention that affects the client's future well-being; most deal with client's long-term health care needs
initial planning involves the development of a preliminary care plan following the client's initial assessment and initial selection of nursing diagnoses
ongoing planning involves continuous updating of the client's plan of care; continual assessments are made, and revisions may be necessary
discharge planning involves the important aspects and preparations needed for the client to go home
goal a broad statement that describes the desired change in a client's condition or behavior
expected outcome measurable criteria to evaluate goal achievement (ex. patient will be able to retain 400 cc of liquid by 4:00 pm); provides focus or direction; determines when a specific, client-centered goal has been met
client-centered goal reflects a client's highest possible level of wellness and independence in function; a specific and measurable behavior or response
short-term goal an objective behavior or response expected within hours to a week; what you expect the client to achieve in a short period of time
long-term goal an objective behavior or response expected within days, weeks, or months; expected to be achieved in a longer period of time
combining goals and outcome statements goals and outcomes are presented in the same statement; sometimes they are used interchangeably
client-centered client-centered outcomes and goals reflect the client behavior and responses expected as a result of nursing interventions; the goal must be written to reflect the desires of the client rather than the nurse
singular (specific) goal or outcome must be defined precisely before a client response to a nursing action can be evaluated; each goal and outcome addresses only one behavior or response
observable observable changes occur in physiological findings and the client's knowledge, perceptions, and behavior
measurable measurable outcomes are of paramount importance; do not use the phrase "normal"; time-limited time frames for each goal and expected outcome indicate when nurses expect the identified response to occur
mutual factors combine goals and expected outcomes to ensure that the client and nurse agree on the direction and time limits of care; by setting mutual goals and expected outcomes, nurses can increase a client's motivation and cooperation
realistic for the client to succeed, the goals and outcomes must be attainable; factor in the client's physiological, emotional, cognitive, and sociocultural potential as well as the economic cost and resources available to reach these in a timely manner
choosing interventions must be competent in knowing the scientific rationale for the interventions, possessing the necessary psychomotor and interpersonal skills, and being able to use available health care resources effectively
nurse-initiated interventions independent (elevating bed, assessing patients)
physician-initiated interventions dependent (administer Colace at bedtime)
collaborative interventions interdependent (may include psychosocial and family); team approach
selection of interventions 6 factors include: characteristics of nursing diagnosis, goals and expected outcomes, evidence base for interventions, feasibility of the intervention, acceptability to the client, and nurse's competency
nursing care plan helps to ensure continuity of care by all nurses
student care plan helps you organize your plan for the day; helps you to apply theory you learned
institutional care plan part of the client's legal record
standardized care plan individualized to each client
clinical guidelines and protocols documents that guide decisions and interventions for specific health care problems or conditions; developed on the basis of current scientific evidence and help health care providers make decisions about appropriate health care
standing order reprinted document containing orders for the conduct of routine therapies, monitoring guidelines and/or diagnostic procedures for specific clients with identified clinical problems
NIC interventions offer a level of standardization to enhance communication of nursing care across settings
implementation process reassess the client, review and revise the existing nursing care plan, organize resources and care delivery, anticipate and prevent complications
implementation skills cognitive (critical thinking), interpersonal (communication for a trusting relationship), and psychomotor (integration of cognitive and motor activities)
direct care ADLs, IADLs, physical care techniques, lifesaving measures, counseling, teaching, controlling for adverse reactions, preventative measures
indirect care communicating nursing interventions (written or oral); delegating, supervising, and evaluating the works of other health care team members
client adherence clients and their families invest time in carrying out require treatments
evaluation the last step; you determine if your client's condition or well-being has improved; determine if they have met client outcomes, not if their nursing interventions were complete
the evaluation process identify evaluative criteria and standards, collect data, interpret and summarize findings, document findings and clinical judgements, and terminate, continue, or revise the care plan
quality/performance improvement an approach to the continuous study and improvement of the processes involved in providing health care services to meet the needs of clients and others
culture thoughts, communications, actions, customs, beliefs and institution of racial, ethnic, religious, or social groups
subcultures represent various ethnic, religious, and other groups with distinct characteristics from the dominant culture
ethnicity a shared identity related to social and cultural heritage such as values, language, geographical space, and racial characteristics
emic worldview the insider, or native, perspective
etic worldview an outsider's perspective
enculturation socialization into one's primary culture as a child
acculturation the process of adapting to and adopting a new culture
assimilation results in varying degrees of affiliation with the dominant culture
biculturalism (multiculturalism) occurs when an individual identifies equally with two or more cultures
selected components of cultural assessment ethnic heritage and ethnohistory, biocultural history, social organization, religious and spiritual beliefs, communication patterns, time orientation, caring beliefs and practices, experiences with professional health care
Created by: tdombros