Shared Flashcard Set

Details

Clinical decision making
N/a
40
Nursing
Undergraduate 1
09/19/2013

Additional Nursing Flashcards

 


 

Cards

Term
  • Continuious process
  • open-mindedness
  • recognize an issue exists
  • Determine which idnetified assumtions are true and relevant (patients can lie)
Definition
Critical thinking as related to nursing
Term
  • Gather information
  • Analyze information
  • Evaluate information
  • Make conclusions
Definition

When an issue exists

(How the nursing process works)

Term
  • Basic
  • complex
  • commitment
Definition
Levels of Critical Thinking
Term
  • Based on specific rules 
  • Learner trusts the experts to have the right answer to every problem
Definition
Basic Critical Thinking
Term
  • Analyze and examin chouce more indenpendently 
  • Consider risks and benefits of decisions
  • After you get comfortable with what you are doing you are able to do this but may have to ask sometimes
Definition
Complex Critical Thinking
Term
  • Anticipates when to make choices without assistance from others
  • Accepts accountability for decisions made
  • Can make desicions by yourself and know it is right
Definition
Commitment Critical Thinking
Term
  • Problem solving activity
  • Defines a problem
  • Selects an appropriate action
  • Requires careful reasoning
  • Priorities are not Automatic
Definition
Clinical Decision Making
Term
  • Assessment
  • Diagnosis
  • Planning
  • Implementation 
  • Evaluation
Definition
Nursing Process
Term
Part where you form a patient goal and intervention
Definition
Planning
Term
  • Subjective 
  • Objective
  • Assessment
  • Plan
  • Evaluation
Definition
Component of Nursing Process
Term
Data collection
Definition
Assessment
Term
  • Based on the data collected
  • What is the patients problem?
  • Health care Needs
Definition
Diagnosis
Term
  • What goal will solve the patient's problem
  • What interventions will achieve the goal
  • Why do these interventions achieve the goal-- rationales
Definition
Plan
Term
  • Putting the interventions into action
Definition
Implementation
Term
  • Was the goal achieved?
  • Has the problem been resolved?
  • What needs to be adjusted?
Definition
Evaluation
Term
Subjective data collected
Definition
S in SOAPE: Subjective
Term
Objective data collected
Definition
O in SOAPE : objective
Term
based on the subjective and objective data collected and what the patient's problem needs i.e. diagnosis
Definition
A in SOAPE : Assessment
Term
What needs to be done to resolve the patient's problem i.e. diagnosis
Definition
P in SOAPE : Plan
Term
Did the plan work ? is the problem resolved? what needs to be adjusted?
Definition
E in SOAPE : Evlauation
Term
  • This is where the nursing process begins!
  • Supports critical thinking
  • ONGOING
Definition
Assessment
Term
Any information that is subjective data that did not come from the patient
Definition
Secondary Subjective Data
Term
Primary purpose is to recognize clients response to an illness or situation
Definition
Nursing Diagnosis
Term
NOT a medical diagnosis
Definition
Nursing diagnosis
Term
3 Components of Nursing diagnosis
Definition
  • Problem
  • Etiology
  • Signs and Symptoms
Term
Problem
Definition
Use an Approved NANDA diagnosis
Term
Etiology
Definition
Related to ( what caused the problem)
Term
As evidence by
Definition
signs/symptoms
Term
Types of Nursing Diagnosis
Definition
  • Actual
  • Health Promtion
  • Risk
  • Syndrome
Term
Goals
Definition
  • Patient centered
  • Mutually agreed on
  • Realistic and attainable
  • Clear, concise,singular
  • Action/verb
  • Measurable
  • Time 
  • Prioritize
Term
SMART Outcomes
Definition
  • Specific
  • Measurable
  • Attaintable
  • Realistic
  • Timed
Term
Types of Goals
Definition
  • Short terms
  • Long term 
Term
Short term goal
Definition
  • Usually <1 week
  • Direct, immediate
Term
Long Term Goals
Definition
  • Usually over weeks or months
  • Discharge planning
  • Long term Care
  • Rehab
  • Mental health settings
  • Community Nursing settings
Term
Interventions
Definition
  • What needs to be done to achieve the goal
  • Physicans order NOT mandatory
Term
Interventions
Definition
  • Individualized and specific
  • clearly written
  • Action Verb
Term
Impementation
Definition
  • ACTION PHASE
  • initiaction of the nursing care plan
Term
Evaluation
Definition
  • Were the goals met, partially met, or not met.
  • Patient centered
  • effectiveness of intervention
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