Critical Thinking and ADPIE
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| 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
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| 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
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| 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.
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| Inductive reasoning | when generalizations are formed from a set of facts or observations
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| Deductive reasoning | is reasoning from the general premise to the specific conclusion
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| 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.
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| 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
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| Assessing | the systematic and continuous collection, organization, validation and documentation of data.
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| Database | all the info about the client; includes the nursing health history, physical assessment, pcp H&P exam, lab results and diagnostics test.
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| Subjective Data | aka symptoms or covert data, are apparent only to the person affected and can be described or verified only by that person.
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| Objective Data | aka signs or overt data, are detectable by an observer or can be measured or tested against an acceptable standard
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| Interview | a planned communication or conversation with a purpose
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| Directive interview | is highly structured and elicits specific info.
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| Nondirective interview | rapport-building interview, less structured, the nurse allows the client to control the purpose
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| Rapport | an understanding between people
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| Closed questions | used in the directive interview, are restrictive and generally only require yes/no answers or short factual answers
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| Open-ended questions | associated with the nondirective interview, invite clients to discover and explore, elaborate, clarify and/or illustrate their thoughts/feelings
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| Neutral questions | a question that the client can answers without direction or pressure from the nurse, it is open-ended
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| Leading questions | usually is closed and directs the client’s answer
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| Cephalocaudal | head-to-toe approach
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| Screening exam | a brief review of essential functioning of various body parts or systems
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| Validation | the act of “double-checking” or verifying data to confirm that it is accurate and factual
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| Cues | are subjective or objective data that can be directly observed by the nurse
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| Inferences | are the nurse’s interpretation or conclusion made based on cues
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| Informal nursing care plan | is the strategy for action that exists in the nurse’s mind
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| Formal nursing care plan | is a written or computerized guide that organizes info about the patient’s care
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| Standardized care plan | a formal plan that specifies the nursing care for groups of patients with common needs
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| Individualized care plan | is tailored to meet the unique needs of a specific patient – needs that are not addressed by a standardized plan
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| Protocols | are preprinted to indicate the actions commonly required for a particular group of clients
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| Policies and Procedures | are developed to govern the handling of frequently occurring situations
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| 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
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| Rationale | the scientific principle given as the reason for selecting a particular nursing intervention
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| Multidisciplinary care plan | are standardized plans that outline the care required for clients with common, predictable conditions
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| 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
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| Goals/desired outcomes | what the nurse hopes to achieve to implementing the nursing interventions
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| The Nursing Outcomes Classification (NOC) | a taxonomy for describing patient outcomes that responds to nursing interventions
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| Indicator | “a more concrete individual, family or community state, behavior, or perception that servers as a cue for measuring outcome.”
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| Independent interventions | are those activities that nurses are licensed to initiate on the basis of their knowledge and skills
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| Dependent interventions | are those activities carried out under the physician’s order or supervision, or according to specific routines
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| Collaborative interventions | are actions the nurse carries out in collaboration with other health team members; such as PT, SW, dieticians, physicians
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| Assignment | is a “downward or lateral transfer of both the responsibility and accountability of an activity from one individual to another.”
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| Nursing Intervention Classification (NIC) | a taxonomy consists of 3 levels; level 1 – domains, level 2 – classes, level 3 – interventions
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| NANDA | purpose is to define, refine and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses
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| 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
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| 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
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| Diagnosis | is a statement or conclusion regarding the nature of a phenomenon
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| Diagnostic labels | the standardized NANDA names for diagnoses
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| Nursing diagnosis | the clients problem statement, consisting of the diagnostic label plus etiology
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| Actual diagnosis | is a client problem that is present at the time of the nursing assessment
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| 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
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| Wellness diagnosis | “describes human responses to levels of wellness in an individual, family, or community that have readiness for enhancement.” NANDA
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| Possible Nursing diagnosis | is one in which evidence about a health problem is incomplete or unclear
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| Syndrome diagnosis | a diagnosis that is associated with a cluster of other diagnoses
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| Diagnostic label | purpose is to direct the formation of client goals and desired outcomes, it may also suggest some nursing interventions
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| Qualifiers | words that have been added to some NANDA labels to give additional meaning to the diagnostic statement
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| 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
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| 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
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| Independent functions | areas of health care that are unique to nursing and separate and distinct from medical management
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| Dependent functions | are the physician-prescribed therapies and treatment that nurses are obligated to carry out
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| Standard (norm) | a generally accepted measure, rule, model or pattern
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| 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
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| Implementing | consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions.
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| Cognitive skills | include problem solving, decision making, critical thinking and creativity
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| Interpersonal skills | are all of the activities, verbal and nonverbal, people use when interacting directly with one another
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| Technical skills | are purposeful “hands-on” skills such as manipulating equip, giving injections, bandaging, moving, lifting and repositioning patients
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| Evaluating | planned, ongoing, purposeful activity in which clients and health care professionals determine the client’s progress and the effectiveness of the plan
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| 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
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| Quality Assurance | an ongoing, systematic process designed to evaluated and promote excellence in the health care provided to patients
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| Structure evaluation | focuses on the setting in which care is given; asks “what effect does the setting have on the quality of care?”
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| 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?”
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| Outcome evaluation | focuses on demonstrable changes in the client’s health status as a result of nursing care
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| 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.
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| Sentinel event | an unexpected occurrence involving death or serious physical injury or psychological injury, or the risk thereof
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| Root cause analysis | a process of identifying the factors that bring about deviations in practices that lead to the event
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| Retrospective audit | evaluation of client’s records after discharge
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| Concurrent audit | evaluation of a client’s health care while the client is still in the facility
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