NURS210 (Unit 2)

Question Answer
The process of intentional, higher-level thinking that is central to the nursing process Critical Thinking
What are the 4 techniques in critical thinking? 1. Deductive Reasoning2. Inductive Reasoning3. Critical Analysis4. Socratic Questioning
The application of a set of questions used to differentiate essential information from nonessential information Critical Analysis
The process of asking questions to determine what information is important or unimportant (a part of critical analysis) Socratic Questioning
Moving from a set of detailed information to a generalized conclusion Inductive Reasoning
Moving from a generalized conclusion to a specific conclusion Deductive Reasoning
The process by which thinking strategies are used to gather and analyze data Clinical Reasoning
What are the 3 common approaches to the problem-solving process? 1. Trial and Error2. Intuition3. Research Process
When working in home health, you must be creative in order to hold up a patient's IV. You use a chair first, but it doesn't work, so you try using a coat rack. What type of problem-solving process is this? Trial and Error
A patient seems fine, but you have a feeling that something's off. Which problem-solving strategy is this? What is another name for it? Intuition, Clinical Judgement
The formal, logical, and systematic approach to the problem-solving process is known as what? Research Process
Which critical thinking attitude includes a nurse thinking for herself? Independence/Autonomy
Which critical thinking attitude includes a nurse not judging a client or coworker based on bias or prejudice? Fair-Mindedness
Which critical thinking attitude includes a nurse being aware of using different methods to reach a desired result? Insight
Which critical thinking attitude includes a nurse being able to say "I don't know, but I'll find out for you," when a patient asks a question? Intellectual Humility
Which critical thinking attitude includes a nurse being willing to look at her own beliefs and view them objectively? Intellectual Courage
Which critical thinking attitude includes a nurse being able to question her own knowledge and beliefs? Integrity
Which critical thinking attitude includes a nurse who continues to address an issue until it is resolved? Perseverance
Which critical thinking attitude includes a nurse being secure in her knowledge and clinical judgement? Confidence
Which critical thinking attitude includes a nurse always looking for new ways to do things? Curiosity
Assessment:
Diagnosis:
4 Steps of Planning: 1. Prioritizing problems,2. Formulating desired outcomes,3. Creating nursing interventions,4. Writing a care plan
Integration:
Evaluation:
When does Planning begin? When does it end? It begins at the first patient contact and continues until the patient is discharges
Planning is multidisciplinary, which means: All providers directly involved in patient care are involved in the planning process
What are the types of planning? 1. Initial Planning2. Ongoing Planning3. Discharge Planning4. Informal Nursing Care Plan5. Formal Nursing Plan
This type of plan is based on the admission assessment and results in the initial comprehensive plan of care: Initial Planning
This type of planning is done by all medical personnel working with the patient and occurs mostly at the beginning of the shift: Ongoing Planning
What are ways that Ongoing Planning involves individualization of the Initial Plan? By asking if the client's health has changed, setting and evaluating client change, and coordinating nurse's activities to focus on more than one problem at once
Which type of planning begins at first client contact, anticipates and plans for needs after patient discharge, and involves comprehensive and ongoing assessment? Discharge Planning
Which type of planning involves a strategy that is only in the nurse's mind? Informal Nursing Care Plan
Which type of planning involves the nurse writing a strategy that provides for a continuum of care? Formal Nursing Care Plan
What are the activities done during Implementation? 1. Reassessment of client2. Determine nurse's need for assistance3. Implement nursing interventions4. Supervise delegated care5. Document
What kind of data is implementation based on? Subjective and objective data gathered in the assessment, diagnosis, and planning phases
What is it called when a patient receives stimuli from the environment, such as a visual, auditory, olfactory, or tactile sense? Sensory Reception
What is it called when the stimuli gained in Sensory Reception are organized and translated? Sensory Perception
What are some clinical manifestations of sensory overload? Fatigue, sleeplessness, irritability, restlessness, anxiety, disorientation, increased muscle tension, reduced physical and cognitive ability, scattered attention
What are some risk factors for sensory overload? Pain, admission to an acute care facility, constant monitoring in ICU, invasive tubes, decreased cognitive ability
Is sensory deprivation more evident in chronic or acute cases? Why? In acute cases, when the body has not had time to adjust
What are some clinical manifestations of sensory deprivation? Drowsiness, decreased attention span, hallucinations, impaired memory, depression, short temper, apathy
What are some risk factors for sensory deprivation? Non-stimulating environment, impaired senses, Inability to process stimuli (brain/spinal injuries), emotional disorders, and limited social contact (esp. elderly)
What are strategies for orienting confused patients? 1. Identify time and place2. Communicate often and effectively3. Encourage family to visit4. Protect against sensory overload and deprivation
What are ways to help a confused client become more oriented in regards to time/place? Ask the client questions, orient a client to their environment, keep the room lit during daylight hours and dark during nighttime hours, place a calendar and clock in the patient's room
What are ways to communicate effectively with a confused client? Speak clearly and calmly, allow time for a response, provide clear and concise explanations of each treatment procedure, wear a name tag, address the person by name, introduce yourself frequently
What are ways to protect a confused client from sensory deprivation and overload? Eliminate unnecessary noise and light, allow for adequate sleep, keep glasses, hearing aids, and other sensory receptor aids within reach, ensure adequate pain management
What does the evaluation step include? Determining the effectiveness of Nursing Care Plans by collecting data related to outcomes, comparing initial data and nursing activities to client outcomes, drawing conclusions about problem status, and continuing, modifying, or terminating nursing care
What should you do after a patient outcome has been met? Discontinue that portion of the care plan
What should an evaluation statement include? Assessment of the data collected in the nursing process, including a conclusion of how well outcomes have/have not been met along with supporting data.
What are the guidelines for writing a Nursing Care Plan? 1. Date2. Signature3. Approved medical abbreviations4. Be specific5. Inc. proof of nursing interventions in evidence-based practice6. Individualize7. Inc. collaborative interventions for ongoing assessment8. Inc. discharge plans
A type of plan standardized for a specific group of patients: Standardized Care Plans
A type of plan tailored to meet a specific client's needs: Individual Care Plan
Standards of care: 1. Describe nursing actions that are achievable, include nurse's accountability, are written from the nurse's perspective, and include no medical abbreviations
Indicate commonly required actions for a particular client group, including physician's orders and nursing interventions: Protocols
Giving Tylenol to patients with an extremely high fever is what? A protocol
Policies and procedures: Set up to govern an individual nurse and their clinical area, especially with frequently occurring situations
A hospital has a set number of visitors allowed for each patient. This rule is: A policy/procedure
What are some factors to consider when setting priorities? Urgency, client values and beliefs, resources available to the nurse and client (esp. in the home setting), and medical treatment plan established by provider
A long-term or short term plan set from a diagnostic label Goal
A description of what you want your patient to achieve and how you intend to help them achieve it Outcome
Nursing Outcomes Classification and Nursing Intervention Classification: Taxonomy for describing client outcomes to respond to nursing interventions
"Client will ambulate 15 feet with physical therapy by discharge" is an example of what? Patient outcome statement
Guidelines for a patient outcome statement: 1. Realistic and measurable2. Ensure compatibility with other professionals3. Derive from only one Nursing Dx
Nursing intervention guidelines: Focus on eliminating the etiology and treating the signs and symptoms
"Nurse will reduce patient pain from a 6 to a 3 on a scale of 1-10," is an example of what? A nursing intervention
A plan that uses a standardized care plan, consisting of preprinted and nurse-created sections, but includes the unique plans of a client in unusual cases that need special attention: Individualization of Standardized Care Plan
What are some formats for nursing care plans? 1. Student2. Concept maps3. Computerized care plans4. Multidisciplinary care plans
Types of nursing interventions: 1. Direct2. Indirect3. Independent4. Dependent5. Collaborative
Nursing Orders should include: 1. Date2. Action Verb3. Content4. Time element5. Signature6. Title
A nursing order that includes observations regarding potential complications and client's current responses Observation Nursing Orders
A nursing order that directs nursing care in the reduction of risk factors and complications Prevention Nursing Orders
A nursing order that includes teaching, referrals, or physical care necessary to the treatment of an existing problem Treatment Nursing Orders
A nursing order that encourages behaviors that lead to a higher level of wellness Health Promotion Nursing Orders
The ongoing, systematic process that evaluates and promotes excellence in provision of health care Quality Assurance
What are 3 things evaluated in Quality Assurance? 1. Level of care provided2. Performance of a nurse, unit, agency, or country3. Environment of a unit
Focuses on using a systematic approach to improve the quality of care in regards to things such as infection prevention and safety Quality Improvement
3 Types of nursing audits 1. Retrospective2. Concurrently3. Peer Review
A nursing audit regarding patient charts that ensures procedures and care plans were done correctly and documentation is clear and correct Retrospective Nursing Audit
A nursing audit done by shift leaders and management throughout the patient's stay to ensure interventions and documentations are done correctly in patient charts Concurrent Nursing Audit
A nursing audit wherein peers evaluate a nurse based on her performance Peer Review Nursing Audit
Quality Evaluation is composed of structure, process, and outcome. What does structure refer to? The effect of the patient settings on a patient
Quality Evaluation is composed of structure, process, and outcome. What does process refer to? The quality of care given to a client based on relevance to the client's problem
Quality Evaluation is composed of structure, process, and outcome. What does outcome refer to? Audits, such as for performance improvement and persistent quality improvement
Normal body temperature: 98.6 to 99.5 degrees Fahrenheit
When body temperature is above normal range: Pyrexia
Four types of pyrexia: 1. Intermittent2. Remittent3. Relapsing4. Constant
Dizziness, nausea, vomiting, loss of consciousness, temperature increase to the low 100's, and sweating are all symptoms of what? Heat exhaustion
Lack of perspiration, warm, red skin, delirium, loss of consciousness, seizures, and temperature increase to above 106 degrees are all symptoms of what? Heat stroke
What is a true fever? A raise in temperature due to factors such as illness, but NOT including heat exhaustion or heat stroke
What are factors that increase pulse? 1. Exercise2. Fever (through vasodilation)3. Hypovolemia/Dehydration4. Stress
What are factors that decrease pulse? 1. Immobility
What are factors that can either increase or decrease pulse? 1. Gender (males have a lower pulse than females)2. Age (elderly have a decreased pulse)3. Medications4. Position (Standing increased pulse, sitting decreases it)5. Pathology (heart conditions)
9 Pulse sites: 1. Temporal2. Carotid3. Popliteal4. Posterior tibial5. Apical6. Brachial7. Radial8. Femoral9. Dorsalis pedis
When should you palpate femoral, popliteal, posterior tibial, or dorsalis pedis pulses? When you have suspicions that blood flow to the lower extremities is weak or cut off
When checking a patient's pulse, a nurse wants to get the point of maximal impulse as a baseline. Which pulse is this? How should she take it? Apical; She must use a stethoscope since it is non-palpable
An excessively fast heart rate: Tachycardia (>100 per min.)
An excessively slow heart rate: Bradycardia (<60 per min.)
2 types of irregular pulse rhythms: 1. Dysrhythmia2. Arrhythmia
The strength of a pulse, which ranges from absent to bounding: Pulse Volume
What are the two components of respiration? 1. Inspiration2. Expiration
What is normal breathing called? Eupnea
What is slow breathing called? Bradypnea
What is fast breathing called? Tachypnea
What is a lack of breathing called? Apnea
What are some factors that affect respirations? 1. Exercise2. Stress3. Environmental temperatures4. Low O2 levels5. Medications6. Intercranial pressure increase (swelling in brain)
Deep, rapid respirations are called: Hyperventilation
Low respirations are called: Hypoventilation
Labored breathing is called: Dyspnea
Inability to breathe while lying down: Orthopnea
What is the measure of exertion of blood flowing through arteries and away from the heart? Arterial blood pressure
What is the first number you hear while taking blood pressure measurements? Systolic blood pressure, which is a contraction of the Ventricles
What is the very last number you hear while taking blood pressure measurements? Diastolic blood pressure, which is the ventricles at rest
Which blood pressure measurement is always lower? Diastolic
What are some factors that cause B/P to rise? 1. Age2. Exercise3. Stress4. Obesity
What are some factors that can either cause B/P to rise or decrease? 1. Race (African and Asian Americans have higher B/P)2. Gender (Females have higher B/P)3. Medications4. Diurnal Variations (rises throughout day, lowers at night)5. Medical conditions6. Temperature (heat causes it to rise)7. Disease processes
When should you assess patient vitals? 1. Admission2. Changes in health status3. Before/after surgery4. Before/after medication5. Before/after invasive procedure6. Before/after nursing interventions
What is the first step of the Nursing Dx? Finding a patient's problem and applying a NANDA Label
What is the second step of the Nursing Dx? Finding the patient's related risk factors, assessing why they're experiencing them, and writing them out as an etiology
What is the third step of the Nursing Dx? Supporting your NANDA Label with signs and symptoms
"Pain, Acute, R/T lower back, AED patient pulse rate 98, patient temperature 99 degrees F, patient respirations shallow and 22 per. min., patient C/O pain in lower back, patient rates pain 7 on a 1-10 scale," is an example of what? A Nursing Dx
Goals should be: 1. The opposite of the NANDA Nursing Dx2. Brief and broad3. Realistic
Outcomes should be: 1. Measurable2. Realistic3. Include target times and evaluation intervals4. Indicate resolution of the NANDA Dx with achievement of at least 1 outcome5. Move patient towards goal attainment
Interventions should be: 1. From the nurse's point of view2. Prioritized3. Individualized4. Detailed so that another nurse could provide care based off of interventions5. Include ongoing assessments, patient teaching, collaborative activities, and nursing treatments
Evaluations should: 1. Assess data to decide whether or not the client is achieving each outcome (if so, continue with plan; if not, decide where to revise, modify, or discontinue the Nursing Dx, patient outcome criteria, and/or nursing interventions)

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