Enter Category Name
a decision making framework used by all nurses to determine the needs of their patients and to decide how to care for them.
Nursing Process
Using skillful reasoning and logical thought to determine the merits of a belief or action.
Critical Thinking
This can be used with source-oriented or problem-oriented records. Stands for Subjective data, Objective data, Assessment data, Plan/Intervention, Evaluation, and Revision
SOAP/SOAPIER
It is an exchange of information, feelings, needs, and preferences between two people.
Communication or communication process
The ____________ behavior style is characterized by the desire to avoid confrontation and the inability to share feelings or needs with others.
passive or avoidant
Information that is known only to the patient and family members is ____________.
subjective data
It is the overall direction in which one must progress to improve a problem.
nursing goal or goal
This form of therapeutic communication encourages elaboration and discourages answering questions with one or two words. An example would be “Tell me more about. …”
Open-Ended Questions or Statements
This form of therapeutic communication reflects the same words back to the patient. This encourages verbalization of feelings. An example would be: Patient: “I’m so anxious about what my tests will show.” Nurse: “You are anxious about your test results?”
Using Reflection
True or False: You should always raise your voive when talking to a visually impaired patient.
False
It is the process of taking actions to resolve the patient’s problems (i.e., the nursing diagnoses).
Implementation
It is the process of determining priorities and what nursing actions should be performed to help resolve or manage each patient problem.
Planning
It is performed when the nurse reflects on the interventions he or she has performed and decides if they have brought the patient closer to achieving the goals and outcomes set in the planning step.
Evaluation
It is the formulation of nursing diagnoses through an analysis of the assessment information that you have gathered.
Diagnosis
It is the gathering of information through signs and symptoms, patient history, and both subjective and objective findings.
Assessment
Interventions that involve working with other health-care professionals in the hospital setting, such as therapists, social services workers, and dietitians.
Collaborative interventions
These are things that you can observe through your senses of hearing, sight, smell, and touch. Examples include “pale, cool, moist skin” and “dark brown, formed bowel movement.”
Objective data
The statement: “Mr. Alan Jones received 1,000 mg of metformin and a 100-mg Januvia tablet as well as an 81-mg aspirin that were not prescribed for him" is what part of the ISBARr communication tool.
B (Background)
The statement: “To prevent such an error from happening again, we have flagged both Mr. Alan Jones’ and Mr. Alex Jones’s medication administration records with a similar name alert, as well adding an alert to the computer and the medication armband. Would you like us to keep checking his finger stick blood sugars and, if so, at what intervals?” is what part of the ISBARR communication tool?
R (Recommendation)
The statement: “I did a finger stick blood sugar on Mr. Alan Jones at 9:45 a.m. when I realized the error. It was 84 mg/dL. I gave him a glass of orange juice to drink. He is alert, oriented, and says he does not feel weak. His skin is warm and dry.” is what part of the ISBARR communication tool?
A (Assessment)