NURS 226 - Quiz 1 Questions and Answers

NURS 226 - Quiz 1 Questions and Answers critical thinking the ability to think, analyze, synthesize, reason, consider options, and problem solve clinical judgement result or observed outcome of critical thinking and decision making Name some critical thinking skills and examples -truth seeking or bias -open mindedness or intolerance -anticipating possible consequences without being thoughtless of them -proceeding in a systematic or unsystematic way -being confident in the powers of reasoning or skeptical of thinking What are some ways we can develop critical thinking skills? through experience with multiple different situations with different outcomes How do clinical reasoning and clinical judgment differ from critical thinking? Give examples of each. Clinical reasoning- ways of thinking about patient care issues. -types of clinical reasoning: -deductive reasoning -inductive reasoning Clinical judgment- the result or observed outcome of critical thinking and decision making example: recognizing clues during situation, generating and weighing hypotheses, taking action and evaluating outcomes What is the nursing process? What are the five steps in the nursing process? systematic guide to patient care with a 5 step process (assessment, diagnoses, planning, implementation, evaluation) What is a nursing assessment? gathering of information about a patient's physiological, psychological, sociological, and spiritual status What type of data is subjective and objective data? Give an example of each subjective: information received directly from patient, usually verbalized by patient ex: “I do not feel well” objective: information that is gathered only through observation ex: vital signs What is a nursing diagnosis? clinical judgement about the patient in response to an actual or potential health problem -They provide the basis for selecting necessary nursing interventions to achieve specific outcomes How is a nursing diagnosis different from a medical diagnosis? Nursing diagnosis- clinical judgment about individual, family, community responses to actual or potential health problems. They provide the basis for selecting necessary nursing interventions to achieve specific outcomes -(A nursing diagnosis is a statement of client health status that nurses can identify, prevent, or treat independently) Medical diagnosis- focuses specifically on the diseases to understand the pathology that affects patients for which the physical or advanced practice nurses direct the primary treatment. Remains the same for as long as the disease is present cognitive load the amount of information a person can hold in their memory at one time comprehensive health assessment includes the patient's current health problems, past history, family, a review of body systems, and health patterns initial assessment gathering of baseline data problem focused assessment assessment that addresses a specific issue. Ex -pain quick priority assessment (QPA) short, focused, prioritized assessments you do to gain the most important information you need to have first Emergency assessment done to identify life threatening problems -airway, breathing , circulation time lapsed assessment Scheduled to compare a patient's current status to the baseline data obtained earlier. OLDCART O- onset L- location D- duration C- characteristics A- aggravating factors R- relieving factors T- treatment 3 types of nursing diagnosis problem-focused risk health promotion problem focused diagnosis problem that currently exists risk focused nursing diagnosis a problem hasn't developed yet, but could if preventative measures aren't taken health promotion nursing diagnosis behavior of an individual motivated by a personal desire to increase well-being and health potential diagnostic statement PE/ PES- problem, etiology, symptoms How to write a Diagnostic Statement? Problem/Diagnostic Label + "related to" + etiology + "as evidenced by" + symptoms Impaired Physical Mobility + "related to" + decreased muscle control + "as evidenced by" + inability to control lower extremities Maslow's Hierarchy of Needs physiological, safety, love/belonging, esteem, self-actualization assessment (ADPIE) the collection of data about an individual's health state diagnosis (ADPIE) Identifying the problem Planning (ADPIE) Developing goals and outcomes implementation (ADPIE) perform the nursing actions identified in planning evaluation (ADPIE) measuring the extent to which patient achieved outcomes. Did you meet your goal? Why do we document in the medical record? proof of care data continuity permanent legal record communication Patient adherence the patient's behavior corresponds to with the agreed plan of care recommended by the health providers care plan A plan developed for each resident to achieve certain goals; it outlines the steps and tasks that the care team must perform. documentating vs reporting documentation: is a legal record of patient care completed in a paper chart or electronic health record (EHR) reporting: is oral communication between care providers normal range of oral temperature for Healthy Adult 35.8 - 37.5 C; 96.4 - 99.5 F normal range of pulse rate for Healthy Adult 60 to 100 (80 average) normal range of respirations for Healthy Adult 12 -20 breaths / min normal range of Blood Pressure for Healthy Adult less than 120/80 (4) Standard Vital Signs Temperature, Pusle, Respiration, Blood Pressure (6) Vital Signs Temperature, Pulse, Respiration, Blood Pressure, Pain, Pulse Oximetry (Pulse ox) vital signs indicators of physiologic functioning and reflect the health status of a person body temperature The difference between the amount of heat produced by body and the amount of heat lost to the environment (4) Mechanisms of heat transfer radiation, convection, evaporation, conduction radiation transfer of heat from one surface to another surface without touching convection lose heat through air currents evaporation the conversion of liquid to a vapor conduction transfer of heat through direct contact hypothermia low body temperature; below 95 degrees F hyperthermia high body temperature; above 100 degrees F afebrile without fever Pyrexia (fever/febrile) increase above normal in body temperature / with fever intermittent fever temperature returns to normal at least once every 24 hours remittent fever temperature does not return to normal and fluctuates a few degrees up and down sustained or continuous fever temperature remains above normal with minimal variations relapsing or recurrent fever temp returns to normal for one or more days with one or more episodes of fever, each as long as several days (5) types of devices to access temperature -electronic / digital-tympanic -disposable -temporal -automated monitoring devices pulse rate the number of contradictions over a peripheral artery in 1 minute tachycardia rapid heart rate over 100 beats per minute Bradycardia slow heart rate less than 60 beats per minute Sites for Detecting Peripheral Pulse by Light Palpations temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis ventilation (respiration) movement of air in and out of lungs inhalation breathing in exhalation breathing out diffusion exchange of oxygen and carbon dioxide between the alveoli of lungs and circulating blood Perfusion exchange of oxygen and carbon dioxide between the circulating blood and tissue cells eupnea normal, unlabored respiration; one respiration to four heartbeats tachypnea Increased respiratory rate. Greater than 20 respirations per minute