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◉ Interpreting. Answer: Understanding of the situation ◉ intuitive reasoning (interpreting). Answer: based on unstated but understood knowledge about the pt, the care giving context, and their previous experiences. typically expert nurse. ◉ Responding. Answer: Based on what you interpreted the nurse will determine appropriate actions ◉ narrative reasoning (interpreting). Answer: way of making sense of a situation through telling and interpreting stories. nurse hears pt stories of past medical experiences, helps nurse understand specific pt experiences, setting the stage for individualized care
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◉ Interpreting. Answer: Understanding of the situation ◉ intuitive reasoning (interpreting). Answer: based on unstated but understood knowledge about the pt, the care giving context, and their previous experiences. typically expert nurse. ◉ Responding. Answer: Based on what you interpreted the nurse will determine appropriate actions ◉ narrative reasoning (interpreting). Answer: way of making sense of a situation through telling and interpreting stories. nurse hears pt stories of past medical experiences, helps nurse understand specific pt experiences, setting the stage for individualized care ◉ Reflection in action. Answer: Observing patient reaction to the action the nurse chose and deciding if the situation was fixed ◉ responding (tanners). Answer: taking action, ability to carry out nursing skills and effective communication, delegating, setting priorities
◉ Reflection on action. Answer: Patient responses to the outcomes. Nursing refelection after the situation was solved ◉ reflecting (tanners). Answer: pt outcomes, evaluating data- complete actions then reassessment data is collected again used to determine if interventions were effective or any further actions needed, evaluating and correcting thinking. ◉ Novice nurse. Answer: Uses analytic reasoning. Uses textbook in a systemic analysis of a situation ◉ reflecting-in-action (reflect). Answer: understanding of patients response to nursing actions while care is occurring. "real time" during pt care. determine pt statues and adjust care accordingly. ◉ Expert nurse. Answer: Uses intuitive reasoing. Recognizes patterns immediatly. Able to look at the big picture ◉ reflecting-on-action (reflect). Answer: consideration of situation after the care occurs. contemplate a situation and decide what was and wasn't successful. critical for development of knowledge. ◉ Assessment. Answer: Collecting and analyzing data from the patient, family members, health care team
◉ Objective data. Answer: What you can observe or measure. Also known as signs ◉ assessment (nursing process). Answer: 1- collection of info from primary source (pt) and secondary (family, friends, health professionals, medical record). 2 - interpretation and validation of data to ensure a complete data base subjective and objective ◉ Subjective data. Answer: Can not be measured. What the patient is feeling. Also known as symptoms ◉ Cue and Inference (assessment). Answer: Cue is information that you obtain through use of senses. Inference is your judgment or interpretation of these cues. ◉ Clinical judgment. Answer: Interpretation or conclusion about a patients needs, concerns or health problems, and/or the decision to take action ( or not) use or modify standard approaches, or improvise as one deems appropriate to the patients response ◉ diagnosis (nursing process). Answer: clinical judgment concerning a human response to health conditions/ life process, or
vulnerability. Educated judgment about health concern. use NANDA. used to make care plan ◉ Reasoning. Answer: Leads to clinical judgment ◉ Types of Nursing Diagnoses (diagnosis). Answer: Actual Risk Possible Wellness Syndrome ◉ Case management. Answer: Planning and the coordination of care, patient advocate for providing quality care, cost effective outcomes for the patient ◉ 3 part nursing diagnosis (diagnosis). Answer: P:problem; ex impaired physical mobility E: etiology/ related factor; ex incisional pain S: symptom or defining characteristics; ex evidence by restricted turning and positioning ◉ Analysis and database. Answer: Lead to the identification of nursing diagnosis
◉ expected outcome (planning). Answer: is the measurable change (pt behavior, physical state, or perception) that must be achieved to reach a goal. sometimes several expected outcome need to be met for a single goal. "measure how many out of 3 questions the pt answers correct for infection identification" ◉ Cue. Answer: A piece or pieces of data that often indicate that an actual or potential problem has occured or will occur ◉ Biographic data. Answer: Facts or events in a persons life ◉ interventions (care plan). Answer: independent- a nurse initiates, dependent- require and order, collaborative- require the combined knowledge, skill, and expertise of multiple providers. Includes; actions, frequency, quantity, method, and person to perform them ◉ Direct thinking. Answer: Purposeful and outcome- oriented ◉ implementation (nursing process). Answer: putting plan into action. reassessing, review and revise care plan, ◉ Problem- oriented thinking. Answer: Focuses on a particular problem to find a solution
◉ standing order. Answer: preprinted document containing orders for routine therapies, monitoring guidelines, and or diagnostic procedures for specific patients with identical problems. ◉ Critical thinking. Answer: An advanced way of thinking or problem solving method. How can we do this better? ◉ delegation (implementation). Answer: transferring to a competent individual the authority to perform a selected nursing task. assess, plan, supervise, and evaluate ◉ Principles of critical thinking. Answer: 1. Collect data in an organized way
& planning= interpretation
◉ Stage 2: advanced beginners (benners). Answer: marginally acceptable performance, has prior experience in actual situations. skillful in parts of practice, occasional cues. may be delayed in time. knowledge developing. ◉ Application. Answer: Ability to apply learned material to a situation. ( highest level of understanding) ◉ Stage 3: competent (benners). Answer: same or similar job 2- 3 years. demonstrates efficiency, coordinated and confident. plan established based on considerable conscious abstract, analytic contemplation of the problem. conscious, deliberate planning; helps achieve efficiency and organization. completed in suitable time without cues. ◉ Analysis. Answer: Ability to break down complex information ( organize and prioritize) also higher level of application ◉ Stage 4: proficient (benners). Answer: see and understand situation as a whole. learn from experiences, what to expect from a situation, how the plan needs to be modified. decision making becomes less labored. the nurse has perspective on existing attributes and aspects of the situation
◉ Desired patient outcome. Answer: Observable result. Focuses directly on what the patient will accomplish. ( not what the nurse will do) ◉ Epworth Sleepiness Scale (ESS). Answer: An index of sleepiness during the day as perceived by patients, derived from the answers to 8 questions ◉ Evaluation. Answer: Compares actual outcomes to expected outcomes ◉ Maslow's Hierarchy of Needs. Answer: basic human needs (level 1) Physiological Needs, (level 2) Safety and Security, (level 3) Relationships, Love and Affection, (level 4) Self Esteem, (level 5) Self Actualization ◉ Nursing process. Answer: ADPIE ◉ knowing the patient (clinical judgement). Answer: in depth knowledge of a patients patterns of response within a clinical situation and knowing the pt as a person. ◉ Goals. Answer: Realistic, measurable, time-limited statements of resolution to a problem or need
◉ components of critical thinking. Answer: - knowledge
◉ Planning. Answer: The LPN assists the RN in the development of the planning of the goals and outcomes as well as interventions for the patient ◉ ANA Standards of Professional Nursing Practice. Answer: standard of care provided to patients.
Tool used to flag areas that may need more assessing or more data collection Assessing systemically and comprehensively, gathering complete and accurate data ◉ RRT (Rapid Response Team). Answer: prevent/ minimize deterioration of a pt ◉ Advanced begginer nurse. Answer: Shows acceptable performance, has gained prior experience in actual nursing situations. Looks for support through their peers and supervisors but not constantly ◉ Benner's Theory. Answer: Novice to expert. The theory that nurses develop skills and understanding of patient care over time from a combination of strong educational background and personal experiences ◉ Noticing. Answer: Vital Signs, is the patient in pain, color of their skin what are their suroundings ◉ interpretation. Answer: your understanding of the situation when you put all your data together to come up with the diagnosis ◉