three domains of learning
cognitive, psychomotor, and affective
includes memorization, recall, comprehension, and ability to analyze, synthesize, apply, and evaluate ideas
cognitive
includes sensory awareness involved in learning along imitation and performance of skills and creation of new skills
psychomotor
includes ability to receive and respond to new ideas. respond, caring part are you empathetic, can you identify anxiety
affective
is a combination of reasoned thinking, openness to alternatives, an ability to reflect, and a desire to seek
critical thinking
exploring and imaging as many ways as you can thinking of for the situation. not just defending our beliefs, but willing to seek the truth
openness to alternatives
critical thinking includes
reasoned thinking, open to alternatives, ability to reflect, and a desire to see truth
objectively, recongnize the need for more information and question credibility and usefulness of sources of information
gathering information
recongnize the gaps in ones knowledge and make inferences about the meaning of the data
analyze
explore the advantages and disadvantages and consequences of each potential solution
finding solutions to the problem
look at the entire process to learn, without this miss what went well, what didnt go well, and how to fix it
reflect
identifying a problem and finding a solution. requires critical thinking skills such as organizing data, identifying relevant and important data, making infernces, making decisions projecting consequences of actions, and applying theroretical knowledge to
problem solving
choosing the best action to take. the action that is likely to produce the desired patient outcome. Able to make judgements about what is important and makign choices.
decision making
linking thoughts together to create a meaning. Hoping to utilize what we learned. this is used in the nursing process.
clinical reasoning
critical thinking separates ___ nurse from ____ nurse
technical professional
nurses use critical thinking to rely on ____ and ____ when deciding what a patient needs
knowledge and experience
cilincal judgements require nurses to ___ on knowledge, experience and information from the patient
reflect
before you can critically think must attain knowledge, and ask these types of questions
evidence based knowledge, and why, what am i missing, what do i know about my patient, what arae my options
Nursing process
Assessment
Diagnosis
Planning
Implementation
Evaluation
observe, use correct techniques for collecting data, differentiate between relevant and irrelevant data, organize, catergorize, validate data, and interpret assessment data and draw conclusions
critical thinking and assessment
obtain information from many sources: client via history or physical exam, client record, lab or test results, other health professionals, clients family or support system, and the professional literature. Purpose is to gather data that you will use to dr
assessment
identifies clusters and cues, detect inferences, recongnize an actual or potential problem or risk, and avoid making judgements
diagnosis & critical thinking
identify clients health needs based on careful review of assessment data. Need to analyze data, synthesize and cluster information, and hypothesize about clients health status.
diagnosis
reflect the clients responses to actual or potential health problems.
nursing diagnoses
�Identify goals & outcomes for client care
�determine appropriate strategies & interventions
�create outcome criteria
set priorites
�take knowledge & apply it to more than one situation
theorize
consider the consequences of implementation
critical thinking and planning
predicting outcomes and planning interventions. Finished product of this is a holistic nursing care plan, individualized to reflect the clients problems and strengths. Written or electronic document that has detailed instructions for clients nursing care.
planning
work with client to decide goals for care, clients outcomes that you want to achieve through nursing activities. These outcomes drive your choice of intervention.
ex. nutritional status will improve as evidenced by a weight gain of 3lb by July 1st.
planning outcomes
phase you develop a knowedge and choose most likely to help client achieve the stated goals. Best interventions are evidence based, adn supported by sound reserach.
planning interventions
used knowledge base, use appropriate skills and teaching strategies, test theories, delegate and supervise care, communicate appropriately in response to a situation.
learn about leadership, communication
critical thinking and implementation
action phase. Carry out or delegate the action that were previously planned. Document your actions and clients response.
implementation
determined accuracy of theories, evaluate outcomes based on specific criteria. determine understanding of teaching
critical thinking and evaluation
determine whether desire outcomes have been achieved, and judge if your actions were successsfully treated or prevented. Then, modify care plan as needed.
evaluation
T/F nursing process is linear
F
a critical thinking process that professional nurses use to apply the best avaliable evidence to caregiving and promoting human functions and responses to health and illness
Nursing process
the nursing process is the ___ of practice for registered nurse to deliver holistic, patient-focused care
standard
Describes a competent level of nursing care demonstrated through the nursing process: assessment, diagnosis, outcome identification and planning, implementation, and evaluation.
standards of nursing practice
enables you to fully use your knowledge and skills
critical thinking
skills, procedures, and processes (including nursing process)
practical knowledge
awareness of your values, beliefs, and biases
self-knowlege
physical, psychosolical, spiritual
patient data
principles, facts, theories: what you have to think with
theoriteical knowledge
everything you know about patient including context
assessment and evaluation
what you do for patient
planning and implementation
understanding you obligations: sense of right and wrong
ethical knowledge
context for care, environment, relaionships, culutre, resources, and supports
patient preferences and context
use ____ in every single step of nursing process, and alot of ____ as well
assessment; analyzing
�systematic gathering of information related to the:�physical
�mental
�spiritual
�socioeconomic
�cultural
�status of an individual, group, or community.
nursing process: assessment
�Collecting data: patterns emerge, start categorizing. Start record
�Using a systematic and ongoing process
�Categorizing data
�Recording data
assessment phase includes
�Data are used to identify the client's actual or potential health problems and strengths.
�Planning outcomes and interventions
�Data help you formulate realistic goals and choose the interventions most likely to be acceptable to and effective for the cli
analysis/ diagnosis
�You gather data by observing the client's responses as you perform interventions.
implementation
�You assess client responses to interventions; client responses are data.
evaluation
is used to create plan of care that could be used from other disciplines. Ensure patients get proper care.
to ensure clients recieve proper care, by qualified individuals, and at the time needed.
how is data used
focuses on disease and pathology while __ focuses on clients responses to illness. THEY CROSS PATHS ALOT
medical assessments, nursing assessment
�Subjective is What the client STATES or says to the nurse
�Objective is What the nurse OBSERVES
primary source of data
�Subjective: is what others tell the nurse based on what the client has told them
�Objective: data the nurse collects from other sources (family, friends, health care professionals, literature review & medical records).
secondary source of data
includes demographic data, ongoing is dynamic. identifys patient, DOB, Sex, married, parents, children
initial and ongoing assessment
�structured databases
�general to specific
�Some model of assessment is followed (ie Gordon's functional health pattern).
�Interview/assessment
general infroamtion to specific. ususlly is holistic physical and mental health
comprehensive type of assessment
�Presenting situation
�Actual, potential, or possible problems
�Follows up on patient's presenting problem
�Pain: before and after intervention
what is patient present with, intital signs and symptoms
problem-orientated approach
eg. nutritional, functional ability, spiritual
special needs assessment
The nurse is completing a head-to-toe assessment on her client at the beginning of the shift for the hospital unit. This would be considered a/an
a.Focused assessment
b.Initial assessment
c.Ongoing assessment
d.Special needs assessment
C
Basic physical assessment techniques
Inspection
Palpation
Percussion
Auscultation
�Purpose is to gather subjective data for the nursing database, purposeful communication, structured communication, and involves questioning the client
the nursing interview
�Know the ______ of the interview and how the data will be used
�Read the client's __
�Form some ___ and opening
___
�Schedule uninterrupted time
�Have your forms and equipment ready
�Compose yourself _____ entering the room
PREPARING FOR INTERVIEW
purpose
chart
goals; opening questions
before
�preparing for client
introduce yourself
call client by name
tell client what you will be doing and why
assess readiness to discuss health issues
assess and provide for comfort
assess for anxiety
Which action by the nurse might be a barrier to obtaining complete and reliable information from an interview with the client?
a.Noting that the client's body language indicates that he or she is fatigued
b.Maintaining eye contact with the client if it is
D
When should you validate data
�Subjective/objective data do not agree or make sense
�Client's statements differ at different times in the interview
�Data are far outside normal range
�Factors are present that interfere with accurate measurement
When gathering admission assessment data, the nurse obtains a weight of 200 pounds. The client states, "I've never weighed that much!" The nurse should
a.Explain to the client how weight gain occurs.
b.Check the calibration and re-weigh the client.
c.Docu
B
Most important part of assessment
Document Data
Document ___
Write legibly without using any ___
Avoid using ____, just the facts
use ___ own words
as soon as possible,
acronyms
infernces
clients
are my data complete, accurate, and validated
did I record data, not just conclusions
did I follow up with special needs assessment if indicated
think about client interview
review physical assessment observation and examination
Reflecting the assessment
�Creating a judgement of the client's health status after the analysis of data
�It includes strengths, problems & factors contributing to problems
�Requires critical thinking
diagnosis
A nurses judgement
diagnosis
what requires a nurses diagnosis
a client with a need
health problems are conditions that require _____ to treat a disease or illness
intervention
treatment can be ___ or _____
independent or collaborative
cannot predict nursing diagnoses from medical diagnosis because
each client has a unique medical response is different.
types of nursing diagnosis
actual, potential risk, possible, wellness
most common nursing diagnosis.
problem is present
a problem response that exists at the time of assessment.
signs and symptoms (cutes) that are present.
actual nursing diagnosis
a problem response that is likely to develop in a vulnerable patient if the nurse and patient do not intervene to prevent it.
no signs/ symptoms of the problem, but the risk factors are present that increase the patient's vulnerability
the patient is more
potential risk
use when your institution and experience direct you to suspect that a diagnosis is present, but you do not have enough data to support the diagnosis. Main reason for including this type of diagnosis on a care plan is to alter other nurses to continue to c
possible nursing diagnosis
no problem is present
we want to enhance persons state of well being even more
describes health status, but does not describe a problem; can apply to an family, group, or community
Wellness nursing diagnosis
uses critical thinking to analyze and interpret data, draw conclusions, verify the problems with the client, and prioritize the problems
diagnostic reasoning
are data that influence your conclusions about the clients health status.
significant data (cues)
group of cues that are related to each other. They may suggest a health problem.
cluster cues
analyzing data steps
identify significant data
cluster cues
identify gaps and inconsistencies
draw conclusions about health status
make inferences
identify problem etiologies
verify problems with patient
clients medical diagnosis or treatment indicates the need to monitor for deleopment of complications and to take some emeasure to prevent the complication, bu tyou cannot prevent or treat the problem independetly
collaborative problem
nurses are not licensed to do this. if recongnize signs and symptoms suggestive of medical diagnosis refer patient to a physician for diagnosis and treatment.
medical diagnosis
if data seem to meet standards and norms, you can condlude the paitent has strength in that area.
patient strengths
if data seem to meet standards for normal and no nursing interventions are needed, you can conclude no problem exists in that area. if in addition the patient expresses the wish to achieve higher level of wellness, you can make a wellness diagnosis
no problem
conclusions (judgements/interpretations that are based on the data. can never be sure that this is accurate. ex. patient is crying and trembling may be signs of anxiety.
inferences
consists of factors that are causing or contributing to the problem. can be pathophysiological, treatment related, situational, social, spritual, maturational, or enviornmental. what is the cause of the problem?
etiologies.
interpretation of data
diagnositc statement.
Malsow's hierarchy of needs
- Physiological
- safety/security
- love/belonging
-self esteem
congnitive
aethetic
self actualization
transcendence
food, air, water, temperature regulation, elimination, rest, sex, and physical activity
physiological
protection, emotional and physical safety and security, order, law, stability, shelter
safety and security
giving and receiving affection, meaningful relationships, belonging to groups
love and belonging
pride, sense of accomplishment, recongnition by others
self esteem
knowledge, understanding, exploration
congnitive
symmetry, order, beauty
aesthetic needs
personal growth, reach potential
self-actualization
of self-helping others self-actualize
transcendence
�Which statement is a priority nursing diagnosis?
�A. Impaired Verbal Communication related to Altered Central Nervous System
�B. Fluid Volume Excess related to Compromised Regulatory Mechanism
�C. Impaired Physical Mobility related to Discomfort
�D. Acti
B
nursing diagnosis universal language.
NANDA-I
represents a pattern of related cues and describes a problem or wellness response.
diagnostic label
explains the meaning of the label and distinguishes it form similar nursing diagnoses.
definition
the cues that allow you to identify a problem or wellness
defining characteristics.
the cues, conditions, or circumstances that cause, precede, influence, contribute to, or are in some way associated with the problem
related factors
events, circumstances, or conditions that increase the vulnerability of a person or group to a health problem
risk factors
�The client has reddened skin and an open abrasion on the elbow from prolonged bedrest. When examining the components of the nursing diagnosis Impaired Skin Integrity, what would be the reddened skin and open abrasion?
C
problem suggest the ____ and the etiology suggest the ____
desired outcome (goal) and intervention
beings at initial contact and is ongoing. Includes care plan and discharge planning, and includes goals and interventions
planning
guide holistic care, guide goal orientate care, address each clients unique needs. Extensive, document plan of action, cover head to toe, unique to every individual
comprehensive care plan
ensures complete care, provide continutiy of care, promote efficient care, guides assessming and documentation, and required by accrediting agencies.
what we put here acutally implement and effect our reinbursement.
written plans
Contains basic needs and ADLs
medical/mutidisciplinary treatment
nursing diagnosis and collaborative problems
special discharge needs or treating needs.
comprehensive patient care plan
types of comprehensive care plans.
preprinted/standardized.
detail the nursing care that is usually needed for a particular nursing diagnosis or for all nursing diagnoses that commonly occur with a medical condition. this is detailed care for clients with common medical conditions
standardized nursing care plans
describe the care that nurses are expected to provide for al patients in defined situations. apply evener patient in a defined situation, rather than a subgroup, do not become apart of the patietns care plan, but keep file on unit. do not usually include
unit standards of care
used to manage care systems. outcome-based, interdiciplinary plans that sequence patient care according to case type.
minimal standard of care related to DRG/medical problems and interventions. Not nursing specific
critical pathways
creates standardized vocabulary for describing outcomes, can be used with differend types of standardized nursing diagnosis systems. outcomes describe what we want the patient to demonstrate and behave. not specific to person, but to label.
Nursing outcome classifications (NOC)
designed for learning, very detailed, include rationales and references, and include mind mapping
student care plans.
state the scientific principles or research that supports nursing interventions, helps ensure that you understand the reasons for the interventions
rationales
technique for showing relationships among ideas and concepts in a graphical or pictorial way. Thought to stimulate whole brain and critical thinking
mind mapping
student care plans
create problem list form assessment data
analyze/identify priority problem
describe goal or outcome
describe interventions that will help client acheive goal or otutcome.
broad statement that describes resolution of the problem. Can be short term or long term
short: within few hours or day
long: weeks months years
goal
specific measurements that client displays prove resolution of problem.
SMART
used as an evaluation of client improvement
outcome
subject, action verb, performance cirteria, target time, special conditions
components of goal statement
actions based on clinaicl judgement and nursing knowledge, that nurses perform to achieve client outcomes.
interventions
purpose is to achieve client otucomes, also known as nursing actions, measures, strategies, activities.
Based on clinical judgement and nursing knowledge. Reeflct direct and indirect care
planning: interventions
Nurse A makes a nrusing diagnosis of anxiety related to deficient knowledge about brariumenema; she writes a nursing order to teach the patient what to expect form upcoming diagnostic test
intependent interventions
one that registered nurse are licensed to prescribe, perform, or delegate based on their knowledge and skills.
independent intervention
nurse b reads a physicians prescription in a pateints chart: give cephalothin sodium though IV before surgery, and then every 6 hr for 24 hrs. she prepares and administers the medicaiton
dependent intervention
one that is prescribed by a physician or advanced practice nurse but carried out by the beside nurse.
dependent intervention
nurse c notes that a client newly diagnosed with diabetes has been seen by a dietitian, who taught and provided material about a diabetic diet. nurse observes the clients menu choices. She notes the client is eating candy brought by visitors. Explains to
collaborative iterdependent interventions
one that is carried out in collabroation with other healthcare team members. because nurses care for the whole person, their responsibilities often overlap with those of other team members.
interdependent collaborative intervention
nurses rely on professional standards, theories, nursing research, clinical practice guidelines, safe effective nursing care, and quality and safety education for nurses
nurses use these to create interventions
nurse will access skin intergridty every 4 hours ex of __________ nursing intervention
observation and assessment
include how, flyer, or demonstration is an ex of __________ nursing intervention
teaching
vaccines, immunization, preventing problems
health promotion/ prevention
with all other disciplines in healthcare field
collaboration
problem status influences interventions
observation/ assessment, treatment, and health promotion
actual, potential, possible, collaborative, and wellness
obsevation/assessment
actual and collaborative
treatment
wellness ex. teach moms how to breastfeed
health promotion
review the nursing diagnosis
review desired client outcomes
identify several interventions/actions
choose the best interventions for the client
individualize the standardized intervention
how to create/select intervention
when writing a nursing order include:
date, who will do it (student nurse), action verb (vital signs)
times and limits (how many time will vital signs be looked at)
students will include rationale when writing an intervention
how does the intervention improve/maintain your clients status
�Mandates that nurses take responsibility for the implementation of the patient's plan of care
ANA standard 5
implementation process
reassess the patient
review and revise existing nurse care plan
organize resources and care deliver
anticipate and prevent complications
introduced new intervention old didnt make sense. focus on problem to make sure interventions are still relevant
reassess the patient
all possible nursing actions
all possible consequences of each action
probability that consequences occur
value (positive and negative) of the consequence to the patient
review plan of care and consider
compare data and validate the nursing diagnosis
modify if patient status has changed
-revise data, review nursing diagnosis, revise interventions, revise outcomes
revise existing care plan
organize resources and care delivery
equipment, personnel, enviorment, and patient
identify adverse reactions
experience
use evidence-based knowledge
anticipate and prevent complications
nurse implements the interventions identified in POC
active phase of implementation
active phase includes 3 thing
do
delegate
document
assess own skills
include patient in their care
collaborate
coordinate
Do
treatments performed through interactions with patients. Give ADLs, ROM, and give medications
do: direct care
treatments performed away from the patient but on behalf of the patient or group of patients. Getting consults, creating a plan, making sure patient has a nurse every shift, and communicate with lab doctor or radiology
Do: indirect care
accountable
assessment belong to licensed RN
5 rights: right task ,right circumstance, right person, right communication, and right supervision.
delegate
record nurses activity and record the patients response to intervention
documentation
nurse evaluates the patients progress toward attainment of outcomes. evaluating where or not patient is getting coser and closer to meeting outcomes and goals
ANA standard 6
evaluation in 2 components
patients progress toward goal/outcome
and effectiveness of interventions
how to evaluate outcomes
examine outcome criteria, evaluate patients response to intervetion, compare the outcome criteria with actual response, judge the degree of agreement between the outcome criteria and response, and if no or only partial agreement what are the barriers
evaluation statement should include
date, whether outcome was met, partially met, or not met.
data to support judgement
resolve actual health problems, prevent potential health problems, and maintain a healthy state
nursing care plans
evaluation of care 3 things to consider
reassessment, modification of plan, and discontinue of plan
review existing nursing diagnosis and etiology, review patient current condition, and extend time frame of plan of care
reassessment
goal are not met, you identify factors that interfere with patient status changes
revising a care plan.
client teaching should be ___ and __________
learners only retain 10% of what they read, but 90% of what they speak and do. Think of ways to retain information
goal driven and interactive
why teaching is important
clients can: take part in own health, make certain health decision, recieve care at home, and educate helps increase compliance
who do we educate
clients, client family members, client caretakers, other employees, and nursing student/new grads
very imporant that while teaching nurses ensure hey are using effective communication skills so hey can:
adequately convery information, asses verbal and nonverbal feedback
and accommodate various learning styles
what to consider when teaching
Literacy, developmental and physical limitations, financial limitations, language barriers, culture, and religious practices
vAssess your client's knowledge on the topic
vDiagnose if your client has a readiness for enhanced learning
vPlan your teaching strategies and set learning objectives
vMaterials
vCater to their learning style
vPut your teaching plan into action
vEvaluate
teaching meets nursing process
as a result of our teaching, clients should develop a change in:
behavior, knowledge, skills, and attitudes.
setting stage for learning
right time, right context, right goal, right content, right method (different learning styles)
Objectives: Include an action verb, an activity that can be measured or observed, the circumstances of the learner's performance, and how learning will be measured
usually accomplished in 1 or 2 sessions, be short term and specific.
goals
blooms learning domains
remember, understand, apply, analyze, evaluate, and create
factors that affect learning
motivation, readiness, timing, active involvement, feedback, repetition, learning envionrment, and special populations
greatest when clients recongnize the need for learning
motivation
client may not absorb information if timing is not right
readiness
when will they be able to put learning to use?
timing
more meaningful if client is engaged
active involvement
postitive reinforcement
feedback
more likely to retain information
repetition
create an adequate __________
learning environment
appropriate resources and strategies
special populaitons
child beings to acquire language skills and find mining through use of symbols and pictures
preoperational stage 2-7
child learns best by manipulating concrete, tangible object, and can classify objects in two or more ways. can understand relationship between numbers and the idea of reversibility. can also begin to recongnize and adapt to the perspective of others.
concrete stage 7 to 11
which can use abstract thinking and deductive reasoning. can relate general concepts to specific situations, consider aternatives, begin to establish causes and try to find meaning in life. not everyone can reach this stage
formal operational stage 11 or older
we always need to assess _____ and ____________
cognitive development and literacy
barriers need to be aseesed as well and if there are any due to their ________
age
it can be easy to see a clients state of health and label them with defiecient knowledge on a particular topic, but saying _______ could offend them
deficient
in reality there may hold the knowledge, but are not applying it due to
fear, anxiey, and feeling powerless
be sure to assess abilty to ___ before labeling them as deficient.
leanr
teaching strategies
one to one
role modeling
printed info
use each back techniques
drawings or models
videos
group discussion
lecture
encourage them to ask questions.
should include inforamtion to help reach _____g
goal
____ content accordingly
organize
use _____ material to reinforce information
instructional
consider patients ___
learning style
oral questions/interviews/checklists
direct observation of client performance
reports and client records
test, checklists, and written exercises
used for evaluation process
research based method for judging nursing interventions
evidence based practice
objectively gathering information on a problem or issue
critial thinking skill
recongnizing the need for more information
critical thinking skill
evaluating the credibility and usefullness of sources of information
critical thinking skill
recongnizing gaps in ones knowledge
critical thinking skill
listening carefully; reading thoughfully
critical thinking skill
separating relevant from irrelevant data and important from unimporant data
critical thinking skill
organizing or goruping information in meaningful ways
critical thinking skill
making inferences about the meaning of the information
critical thinking skill
visualizing potential solutions to a problem
critical thinking skill
exploring the advantages, disadvantages, and consequences of each potential action.
critical thinking skill
independent thinking
critial thinking attitude
intellectual curiosity. love to learn new things
critial thinking attitude
intellectual jumility. Aware they dont know everything, and are not embarrassed to ask for help
critial thinking attitude
intellectual empathy, try to understand feelings and perceptions of others
critial thinking attitude
intellectual courage. rethink or reject previously help beliefs
critial thinking attitude
fair mindedness. treat all view poins fairly
critial thinking attitude
finding reasonable solutions. needs skills such as organizing data, identifying relevant and important data, making inferences, decisions, projecting consequences and actions, and applying theorietic knowledge to specific patient context.
problem solving
chooses besst action to take to produce desired patient outcome. skills such as making judgements, choices.
decision making
reflective, concurrent, creative thinking about patients and patient care. logical thinking related to create meaning
clinical reasoning
gather data that will be used to draw conclusions about clients health
assessment
work with client to find goals, drives choice of intervention. ex. nutritional status will improve as evidenced by a weight gain of 3 lbs by july 1st
planning outcomes
develop a list of interventions basedon knowledge and chose the most likely to help client achieve the stated goals.
planning interventions
action phase. carry out or delegate the actions you previously planned. also document actions and clients response to them
implementation
judge whether outcome was met and what you used, can modify here.
evaluation
tied to data, integral to nursing role allows you to form patient database
assessment
uses physical, mental, spiritual, socioeconomic, and cultural status of an individual, gorup, or community.
assessment
Symptom from NANDA-I Label
defining characteristic