Foundations of Nursing: Exam 2
Ch. 10 – Critical Thinking
Critical thinking skills
Analyzing – separating/ breaking whole into parts
Applying standards – judging according to established personal
Discriminating - recognizing differences
Information seeking – search for evidence
Logical reasoning – drawing inferences
Predicting – envision a plan
Transforming knowledge – changing/converting the condition, nature, form/function of concepts
Problem-solving Process
Trial & error
Intuition
Research process
Examples of problem solving situations: safety/infection
o Everything we do as a nurse is backed up by research (evidence-based practice)
Decision-making Process
Choosing the best actions to meet a desired goal
o Make value decisions time management decisions
o Scheduling decisions
o Priority decisions
Ch. 11-14 - Nursing Process
*The nursing process is client centered
Assessment
o Collect data
Database – contains all the information
about the client
Subjective (symptoms/what client says)
Objective (signs/vital signs, chart – can
be seen, heard, felt, smelled or observed
by physical examination)
Sources of data
Observing/Interviewing
Closed ended questions
Open ended questions
Don’t ask, “Why?”
Instead say, “tell me about…”
1
, o Organize data
o Validate data
o Document data
Nursing Diagnosis
o Analyze data
o Identify health problems, risks, and strengths
o Formulate diagnostic statements
Types of diagnoses:
Actual diagnosis
Risk diagnosis
Health promotion diagnosis
Wellness diagnosis
NANDA-1 nursing diagnoses
Prioritization – Maslow’s Hierarchy of Needs
Planning
o Prioritize problems/diagnoses
o Formulate goals/desired outcomes
o Select nursing interventions
o Write nursing interventions
Implementation
o Reassess the client
o Determine the nurse’s need for assistance
o Implement the nursing interventions
o Supervise delegated care
o Document nursing activities
Evaluation
o Collect data related to outcomes
o Compare data with outcomes
o Related nursing actions to client goals/outcomes
o Draw conclusions about problem status
o Continue, modify or terminate the client’s care plan
Writing Nursing Diagnoses
o Basic Two-Part Statement (at risk) 2 part
Problem (P)
Etiology (E)
o Basic Three-Part Statement (actual) 3 part
Problem (P)
Etiology (E)
Signs and symptoms (S)
**If the goal is not met, always go back and re-assess**
2
, Ch. 49 - Fecal Elimination
Defecations is the process of elimination of waste from the digestive system
o Feces or stool
Feces
o Cases distention of rectum
o Stimulates distention of receptors
o The sitting position increases the downward pressure on the rectum, making it easier to pass stool
Characteristics of Feces Normal Abnormal Possible Cause
Color Adult: brown Clay or white Absence bile pigment (bile
Infant: yellow obstruction); diagnostic study using
barium
Drug (e.g., iron); bleeding from upper
Black or tarry gi track (e.g., stomach and small
intestine); diet high in rich meat and
dark green vegetables (e.g., spinach)
Bleeding from lower gi tract (e.g.,
rectum); some foods (e.g., beets)
*Other causes of red:
Hemorrhoids
Red Coumadin
Cancer
Malabsorption of fats; diet high in milk
Pale and milk products and low in meat
Intestinal infection
Orange or green
Consistency Formed, soft, semisolid, moist Hard, dry Dehydration; decreased intestinal
motility resulting from lack of fiber in
diet, lack of exercise, emotional upset,
laxative abuse
Shape Cylindrical (contour of rectum) about Narrow, pencil- Obstructive condition of the rectum
2.5 cm (1 in.) in diameter in adults shaped, or
string like stool
Amount Varies with diet (about 100-400
g/day)
Odor Aromatic; affected by ingested food Pungent Infection, blood
and individual’s own bacterial flora
Constituents Small amounts of undigested Pus Mucus
roughage, sloughed dead bacteria Parasites Bacterial infection
and epithelial cells, fat, protein, dried Blood Inflammatory condition
3
Ch. 10 – Critical Thinking
Critical thinking skills
Analyzing – separating/ breaking whole into parts
Applying standards – judging according to established personal
Discriminating - recognizing differences
Information seeking – search for evidence
Logical reasoning – drawing inferences
Predicting – envision a plan
Transforming knowledge – changing/converting the condition, nature, form/function of concepts
Problem-solving Process
Trial & error
Intuition
Research process
Examples of problem solving situations: safety/infection
o Everything we do as a nurse is backed up by research (evidence-based practice)
Decision-making Process
Choosing the best actions to meet a desired goal
o Make value decisions time management decisions
o Scheduling decisions
o Priority decisions
Ch. 11-14 - Nursing Process
*The nursing process is client centered
Assessment
o Collect data
Database – contains all the information
about the client
Subjective (symptoms/what client says)
Objective (signs/vital signs, chart – can
be seen, heard, felt, smelled or observed
by physical examination)
Sources of data
Observing/Interviewing
Closed ended questions
Open ended questions
Don’t ask, “Why?”
Instead say, “tell me about…”
1
, o Organize data
o Validate data
o Document data
Nursing Diagnosis
o Analyze data
o Identify health problems, risks, and strengths
o Formulate diagnostic statements
Types of diagnoses:
Actual diagnosis
Risk diagnosis
Health promotion diagnosis
Wellness diagnosis
NANDA-1 nursing diagnoses
Prioritization – Maslow’s Hierarchy of Needs
Planning
o Prioritize problems/diagnoses
o Formulate goals/desired outcomes
o Select nursing interventions
o Write nursing interventions
Implementation
o Reassess the client
o Determine the nurse’s need for assistance
o Implement the nursing interventions
o Supervise delegated care
o Document nursing activities
Evaluation
o Collect data related to outcomes
o Compare data with outcomes
o Related nursing actions to client goals/outcomes
o Draw conclusions about problem status
o Continue, modify or terminate the client’s care plan
Writing Nursing Diagnoses
o Basic Two-Part Statement (at risk) 2 part
Problem (P)
Etiology (E)
o Basic Three-Part Statement (actual) 3 part
Problem (P)
Etiology (E)
Signs and symptoms (S)
**If the goal is not met, always go back and re-assess**
2
, Ch. 49 - Fecal Elimination
Defecations is the process of elimination of waste from the digestive system
o Feces or stool
Feces
o Cases distention of rectum
o Stimulates distention of receptors
o The sitting position increases the downward pressure on the rectum, making it easier to pass stool
Characteristics of Feces Normal Abnormal Possible Cause
Color Adult: brown Clay or white Absence bile pigment (bile
Infant: yellow obstruction); diagnostic study using
barium
Drug (e.g., iron); bleeding from upper
Black or tarry gi track (e.g., stomach and small
intestine); diet high in rich meat and
dark green vegetables (e.g., spinach)
Bleeding from lower gi tract (e.g.,
rectum); some foods (e.g., beets)
*Other causes of red:
Hemorrhoids
Red Coumadin
Cancer
Malabsorption of fats; diet high in milk
Pale and milk products and low in meat
Intestinal infection
Orange or green
Consistency Formed, soft, semisolid, moist Hard, dry Dehydration; decreased intestinal
motility resulting from lack of fiber in
diet, lack of exercise, emotional upset,
laxative abuse
Shape Cylindrical (contour of rectum) about Narrow, pencil- Obstructive condition of the rectum
2.5 cm (1 in.) in diameter in adults shaped, or
string like stool
Amount Varies with diet (about 100-400
g/day)
Odor Aromatic; affected by ingested food Pungent Infection, blood
and individual’s own bacterial flora
Constituents Small amounts of undigested Pus Mucus
roughage, sloughed dead bacteria Parasites Bacterial infection
and epithelial cells, fat, protein, dried Blood Inflammatory condition
3
