What are the 5 client variables?
Physiological
Psychological
Sociocultural
Developmental
Spiritual
What are the two steps of nursing assessment?
Collection of information from the patient, family, friends, other health professionals, and the medical record
The interpretation and validation of data to ensure a complete database
What is an expected outcome?
the measurable change that must be achieved to reach a goal
What is a nursing intervention?
any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes
What are the steps in the nursing process?
Assessment
Diagnosis
Planning
Implementation
Evaluation
What are the three categories of stressors?
Intrapersonal - illness or injury within a person
Interpersonal - occurs between individuals
Extrapersonal - concerns that alter a person's sense of well-being outside the person
What is the relationship between cues and inferences?
Cues are information that the nurses acquires through their senses, an inference is the judgment or interpretation of these cues
What is the time difference between short-term and long-term goals?
Short-term is usually less than a week or even a few hours
Long-term is usually over several days, weeks, or even months
When do nurses evaluate?
Constantly - during each phase of the process, any time the nurse is with the patient
What are ways to develop critical thinking skills?
Reflective journaling
Meeting with colleagues
Concept mapping
What is the central core?
the basic structure and energy reserves (basic survival factors such as normal body temp, functioning of the organs)
What is the format of nursing diagnoses?
Problem
Etiology or related factor
Symptoms or defining characteristics
What should a goal be? (it has an acronym)
Specific
Measurable
Attainable
Realistic
Timed
What are the types of interventions?
Direct care - treatments performed through interaction with the patient
Indirect care - treatments performed away from the patient, but on behalf of the patient (managing environment, safety and infection control, documentation)
What is the definition of critical thinking?
the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process
What are flexible lines of defense?
outer boundary, adaptive responses that fluctuate and protect from stressor penetration
Differentiate subjective and objective data
Subjective data is the patient's verbal descriptions or perceptions about their health problems - only the client can provide this data
Objective data is observations or measurements made by the data collector about the patient's health status
What are the parts of Maslow's Hierarchy?
Physiological
Safety
Social
Esteem
Self-actualization
What happens when a care plan needs revision?
Reassess
Redefine nursing diagnosis
New patient goals and expected outcomes
New nursing interventions
What are the levels of critical thinking in nursing?
basic - learner trusts that experts have the right answers for every problem, thinking is based on a set of rule, see one right answer for every problem
complex - learner begins to separate themselves from the experts, learn to adapt, look for alternate solutions
commitment - learner anticipates choices without assistance from others, is independent, accepts accountability for decisions made
What are lines of resistance?
protection factors that are activated when stressors have penetrated the normal line of defense, usually unconscious in nature, last line of defense against stressors
What is different about a "risk or potential for" problem and why?
Two-part problem
Does not include as evidenced by because there are currently no manifestations
What are the types of interventions?
Independent - nurse-initiated, does not need an order
Dependent - physician or healthcare provider-initiated, requires an order
Collaborative - therapies of multiple health care providers - interdisciplinary
How do you document evaluation on care plan forms?
Met + behavior that demonstrates achievement
Unmet + behavior that demonstrates movement toward the goal
Partially met + patient behavior that demonstrates the goal is still not attained
What are the roles of clinical judgment in nursing practice?
RN's make decisions based on clinical information
Nurses must learn to question, wonder, explore different perspectives and interpretations
creatively seek new knowledge, act quickly when events change, and make quality decisions for patients