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N210 exam 2

MC Prof. Crouch exam 2

Critical Thinking -disciplined thinking that is clear, rational, open-minded, and informed by evidence -disciplined, intellectual process of applying skillful reasoning as a guide to belief or action
Analyzing separating the whole into parts; looking at the nature, function, and relationships of the parts
Application of Standards judging according to established criteria; can be personal, professional, or social rules
Discriminating looking at similarities and differences; categorizing or ranking
Information Seeking looking for evidence, facts, or knowledge; identifying relevant sources; gathering subjective, objective, historical and current data
Logical reasoning drawing inferences or conclusions that are supported by evidence
Predicting envisioning a plan and the consequences associated with it
Transforming knowledge changing or converting the condition, nature, form or function of concepts among contexts
Creativity * Uses problem-solving and decision-making to develop and implement new and better solutions * Is required when nurses encounter new situations or need to develop nontraditional interventions
Creative critical thinkers: * Assess a problem * Be knowledgeable about underlying facts and principles
Using creativity nurses can: * Rapidly generate many ideas * Be flexible * Create original solutions to problems * Be independent and self-confident under pressure * Demonstrate individuality
Techniques of Critical Thinking * Critical analysis * Inductive and deductive reasoning * Making valid inferences * Differentiating facts from opinions * Evaluating credibility of sources * Clarifying concepts * Recognizing assumptions
Attitudes that Foster Critical Thinking Independence Fair-mindedness Insight into Egocentricity Intellectual Humility Courage to Challenge Status Quo Integrity Perseverance Confidence Curiosity
Application of Critical Thinking is done mainly through: Problem solving Decision making The Nursing Process
nursing process is a systematic, rational method of planning and providing individualized nursing care
Problem Solving Obtaining information that clarifies the nature of the problem and suggest possible solutions Methods of Problem-Solving * Trial and Error * Intuition * Research Process
Decision Making Choosing the best action to meet a desired goal Nurses make many decisions in the course of solving problems. Examples include: * Value decisions * Time management decisions * Scheduling decisions * Priority decisions
Critical Thinking Attitudes and Skills Self-Assessment * Do a personal assessment to see what skills you need to cultivate & those in which you already excel * Reflect at every step of nursing care to consider your own beliefs, knowledge, values, & abilities in a particular situation
Critical Thinking Attitudes and Skills other methods Tolerating Dissonance Tolerating Ambiguity Creating an Environment that Supports Critical Thinking
Concept Mapping This technique uses a graphic depiction of nonlinear and linear relationships to represent critical thinking They are context dependent Can be used to develop analytical skills Used to bridge nursing theory and practice Good for complex phenomena
Planning * 3rd phase of nursing process * Deliberate and systematic * Begins with first client contact * Continues until nurse-client relationship ends (discharge) * Multidisciplinary * Uses problem-solving and decision-making to formulate goals and outcomes
Initial Planning * Based on the admission assessment * Results in the initial comprehensive plan of care * Should be started as soon as possible
Ongoing Planning * Done by all nurses who work with the client * Determines if a client’s status has changed * Individualization of initial plan based on client needs/status * Also occurs at the beginning of a shift and sets priorities for that shift
Discharge Planning * Process of anticipating and planning for needs after discharge * Begins at first client contact * Involves comprehensive and ongoing assessment * This is becoming more of a focus with the healthcare reform changes
Activities in the Planning Process * Prioritizing problems/diagnoses * Formulating client goals/desired outcomes * Selecting nursing interventions * Writing individualized nursing interventions
Formats differ in different settings Student vs Clinical * Student – more details; must demonstrate your knowledge * Clinical – the focus is on addressing new and existing problems; multidisciplinary approach
Standardized Plans Standards of care Standardized care plans Protocols Policies and procedures
Standards of Care Describe nursing actions 4 clients w/ similar medical conditions Describe achievable rather than ideal nursing care Define interventions 4 which nurses accountable Written from the perspective of the nurse’s responsibilities No medical interventions
Standardized Care Plans • Formal plan that specifies the nursing care for groups of clients with common needs • Written from the perspective of what care the client can expect • Will have a place to be updated in order to be individualized
Protocols • Indicate the actions commonly required for a particular groups of clients • Predeveloped with common actions in mind • May include both physician’s orders and nursing interventions • Example: protocol for admitting a client to the intensive care unit
Policies and Procedures •Developed to govern the handling of frequently occurring situations •Covers a situation pertinent to client care •Example: policy specifying the # of visitors a client may have or visitation times •Institutional records that are not part of the chart
Individualization of Standardized Care Plans •Must include unique needs of each client •Usually consists of both preprinted and nurse-created sections •Standardized care plans for predictable, commonly occurring problems •Individual plan for unusual problems or problems needing special attention
Standing Orders Written document about policies, rules, regulations, or orders regarding client care Give the nurses authority to carry out specific actions under certain circumstances – typically when a PCP/MD is not readily available
Formats for Nursing Care Plans Concept maps Computerized care plans Student care plans Multidisciplinary (collaborative) care plans -Also called critical pathway
Guidelines for Writing Nursing Care Plans Card 1 Date and sign the plan Use category headings Use standardized/ approved medical or English symbols and key words Be specific Refer to procedure book or other sources rather than including steps
Guidelines for Writing Nursing Care Plans Card 2 Tailor the plan to the client Incorporate prevention and health maintenance Include interventions for ongoing assessment Include collaborative and coordination activities Include discharge plans and home care
The Planning Process Consists of following activities: Setting priorities Establishing client goals/desired outcomes Selecting nursing interventions Writing individualized nursing interventions on care plans
Setting Priorities -The process of establishing a preferential sequence for addressing nursing diagnoses and interventions -Deciding what needs attention first *High priority (life-threatening) *Medium priority (health-threatening) *Low priority (developmental needs)
Factors to Consider When Setting Priorities Client’s health values and beliefs Client’s priorities Resources available to the nurse and client Urgency of the health problem Medical treatment plan
Goals/Desired Outcomes Describe what the nurse wants to achieve Purposes Provides direction for planning nursing interventions Serves as criteria for evaluating client progress Enables determination of problem resolution Helps motivate by providing a sense of achievement
Goal Statements General and Broad Followed by specific outcome criteria Shows resolution of problem Long-term or Short-term
Goals vs Desired Outcomes and Nursing Diagnosis Goals derived from diagnostic label Diagnostic label contains the unhealthy response (problem) Goal/desired outcome demonstrates resolution of the unhealthy response (problem)
Nursing Outcomes Classification (NOC) -Taxonomy for describing client outcomes that respond to nursing interventions -Made more specific by identifying indicators that apply to client -Can be stated in traditional language – which is more commonly used
Components of Desired Outcome Statements Subject Verb Condition/modifier Criterion of desired performance example: Client will ambulate 30 feet with assistance of a walker TID
Guidelines for Writing Goals/Desired Outcomes Write in terms of the client responses Must be realistic Ensure compatibility with the therapies of other professionals Derive from only one nursing diagnosis Use observable, measurable terms
Types of Nursing Interventions -direct: performed through interaction with the client -indirect: performed away from but on behalf of client
Independent interventions – Those activities nurses are licensed to initiate (i.e., physical care, ongoing assessment, teaching)
Dependent interventions – Activities carried out under physician’s orders or supervision, or according to specified routines (i.e., check O2 sat on room air)
Collaborative interventions – Actions nurse carries out in collaboration with other health team members – Reflect overlapping responsibilities of health care team
Nursing Interventions Classification (NIC) Taxonomy of nursing interventions First published in 1992 Updated every 4 years More than 542 interventions developed Linked to NANDA diagnostic labels Select appropriate intervention and customize
Nursing Interventions Should move client toward desired goals/outcomes Each nursing dx contains suggestions for interventions, but these must be individualized based on client needs What interventions work for some clients will not work for others
IMPLEMENTATION Fourth step in Nursing Process Depends on/follows previous 3 steps Action phase where nurse performs the interventions Nursing activities and client responses examined during evaluating phase Nursing activities individualized based on assessment data
To implement care successfully, nurses need: Cognitive skills (Intellectual Skills) Interpersonal skills Technical skills
Technical Skills Purposeful “hands-on” skills Often called tasks, procedures, or psychomotor skills Psychomotor refers to physical actions that are controlled by the mind, not reflexive Require knowledge and frequently manual dexterity
Five Activities of the Implementing Phase Reassessing the client Determining the nurse’s need for assistance Implementing nursing interventions Supervising delegated care Documenting nursing activities
EVALUATION Fifth step in the Nursing Process Planned and organized Determines client’s progress toward goals/outcomes Determines effectiveness of NCP Shows accountability and responsibility
5 Components of Evaluation 1. Collecting Data 2. Comparing Data with Desired Outcomes 3. Relating Nursing Activities to Outcomes 4. Drawing Conclusions About Problem Statements 5. Continuing, Modifying, or Terminating the Nursing Care Plan
Components of the Evaluation Process Collecting data related to the desired outcomes (NOC indicators) Comparing the data with outcomes Relating nursing activities to outcomes Drawing conclusions about problem status Continuing, modifying, or terminating the nursing care plan
Components of an Evaluation Statement Conclusion *met *partially met *not met Supporting data
Quality Assurance Ongoing, systematic process Evaluate and promote excellence provision of health care May evaluate the level of care provided May be evaluation of performance of one nurse or an agency or country
Components of Quality Assurance Structure Evaluation Process Evaluation Outcome Evaluation
Structure Evaluation Focuses on the setting Effect setting has on care Describe desirable environmental and organizational characteristics
Process Evaluation Focuses on how the care was given Relevance of care to client needs How nurse uses the nursing process
Outcome Evaluation Focuses on demonstrable client health changes resulting from nursing care Outcome criteria written in terms of client responses or health status
Components of Quality Improvement Investigating Sentinel events Root Cause Analysis
Investigating Sentinel events Sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof Called “sentinel” because they signal the need for immediate intervention, investigation, and response
Root Cause Analysis Process for identifying the factors that bring about deviations in practice that led to an event Idea is to decrease the likelihood of this event happening again
Nursing Audits types • Retrospectively • Concurrently • Peer Review
Peer Review  Nurses functioning in the same capacity appraise the quality of care or practice performed by other equally qualified nurses
Concurrently Evaluation of a client’s record while they are still receiving care Can use interviewing, direct observation, or chart review
retrospectively Evaluation of a client record after d/c
When to check VS • On admission • Change in client’s health status • Pre and post surgery/invasive procedure • Pre/post medication administration that could affect CV system • Pre/post nursing intervention that could affect VS
VS include Temperature Pulse Respirations Blood Pressure Pain is considered the 5th Vital Sign Oxygen Saturation is also typically assessed
Temperature Reflects the balance between heat produced and heat lost from the body
5 Factors Affecting Heat Production Basal Metabolism (BMR) Muscular Activity (Shivering) Thyroxine Output (↑ cellular metabolism) Epinepherine and Norepinepherine SNS response (↑ in metabolic rate) Fever (further ↑ metabolic rate)
4 Ways Heat Is Lost Radiation Conduction Convection Evaporation
Factors Affecting Body Temperature Age Diurnal variations (circadian rhythms) Exercise Hormones Stress Environment
Normal range temp 96.8°F-99.5°F (36°C-37.5°C)
S/Sx Onset of Fever Increased Heart Rate Increased Resp Rate and Depth Shivering Pallid, cold skin Complaints of Feeling Cold Cyanotic nail bed Goosebumps appearance of the skin Cessation of sweating
S/Sx Course of Fever Absence of chills Photosensitivity Glassy-eyed appearance Increased pulse and resp rate Increased thirst Mild to severe dehydration Herpetic lesions of the mouth Loss of appetite – if prolonged fever Malaise, weakness, and aching muscles
S/Sx Abatement of Fever Skin that appears flushed and feels warm Sweating Decreased shivering Possible dehydration
Temperature: Lifespan Considerations Infants: unstable Children: tympanic/temporal site perferred Elder:Tends to be lower than that of middle-aged adults
Apical pulse aka Point of Maximal Impulse (PMI)
Factors Affecting Pulse Age Gender Exercise Fever Medications Hypovolemia Stress Position changes Pathology
Pulse: Lifespan Considerations Newborns: may have heart murmurs that are not pathological children: apex of the heart is located in the 4th space; 5th for over 7 yrs Elder: decreased peripheral circulation
Respiratory Control Mechanisms Respiratory centers -Medulla oblongata -Pons Chemoreceptors -Medulla -Carotid and aortic bodies Both respond to O2, CO2, H+ in arterial blood
Factors Affecting Respirations Exercise – increases metabolism Stress – fight or flight Environmental temperature Medications
Respirations: Lifespan Considerations Infants: some display periodic breathing children: diaphragmatic breathers elders: anatomic & physiologic changes cause system to be less effiecient
Factors Affecting Blood Pressure Age Exercise Stress Race Gender Medications Obesity Diurnal variations Disease process
Classifications of BP Systolic Diastolic Normal <120 <80 Prehyp 120-139 80-89 HTN stage 1 140-159 90-99 HTN stage 2 >160 >100
Measuring Blood Pressure Direct (Invasive Monitoring) Indirect *Auscultatory *Palpatory
Korotkoff’s Sounds 1: faint, clear tapping or thumping sounds 2: Muffled, whooshing, or swishing sound 3: Blood flows freely , Crisper and more intense sound, Thumping quality 4: Muffled & have a soft, blowing sound 5: Period of silence
Blood Pressure: Lifespan Considerations Infants: arm & thigh pressure under 1 yr children: thigh pressure is 10mmHg higher than arm Elder: medication may affect how taken
Oxygen Saturation (SaO2) percent of all hemoglobin binding sites that are occupied by oxygen
Pulse Ox levels Normal 95-100% < 70% life threatening
Factors that affect pulse ox accuracy include: Hemoglobin level – anemia Circulation Activity Carbon monoxide poisoning
Sensory perception Conscious organization and translation of data into meaningful information
Somnolent Extreme drowsiness, but responds to stimuli
Semicomatose Can be aroused by extreme, painful, or repeated stimuli
Risk Factors: Sensory Deprivation • Nonstimulating or monotonous environment • Impaired vision or hearing • Mobility restrictions • Inability to process stimuli • Emotional disorders • Limited social contact
Risk Factors: Sensory Overload Pain or discomfort Admission to an acute care facility Monitoring in intensive care units Invasive tubes Decreased cognitive ability
Nursing Interventions to Promote/Maintain Sensory Function Promote healthy sensory function Adjust environmental stimuli Manage acute sensory deficits *Use of sensory aids *Use of other senses *Effective communication
Promoting Structured Sensory Stimulation for Unconscious Client Auditory: Introduce yourself to the client Orient the client to time, month, year, location Inform client beforehand the care to be provided Read literature to client Play a tape recording of familiar voice Converse directly to client
Promoting Structured Sensory Stimulation for Unconscious Client:Tactile Incorporate during bath activities
Promoting Structured Sensory Stimulation for Unconscious Client:Kinesthetic Perform range-of-motion exercises & Change client’s position
Promoting Structured Sensory Stimulation for Unconscious Client:Visual: Sit client upright in a chair or bed
Promoting Structured Sensory Stimulation for Unconscious Client:Olfactory Provide aromatic stimuli that may include client’s favorites
Promoting Structured Sensory Stimulation for Unconscious Client:Gustatory Provide mouth care, Place different tastes on tongue
Created by: midnight1854