answered graded A+ passed
Ability to provide timely and appropriate care to your patients
1. Assessment
- recognizing cues
- analyze cues
(this is to come up with your diagnosis or hypothesis)
2. Diagnosis
- make clinical judgment from the assessment to identify the patient's response to health
problems in the form of nursing diagnosis
3. Planning
- setting goals and expected outcomes for your care and selecting interventions
4. Implementation
- take action
5. Evaluate
- the patient's response and determine whether the interventions were effective - ANS ✔Model
For Clinical Judgement
- synthesize
- recall
- apply
- professional standards of practice - ANS ✔Critical Thinking in Assessment of Clients
,While gathering data, ___________ relevant information and knowledge, _________ prior
clinical experiences, _________ critical thinking and use _________________ to direct your
assessment in a meaningful way
knowledge base, environment, experience, standards and attitudes - ANS ✔(5) Aspects of
Critical Thinking in Assessment of Clients
Basic science
- anatomy, physiology, microbiology
Underlying disease process
- expected findings
Normal assessment findings
Assessment standards
Nursing theory supporting health and wellness
- ex: growth and development, health promotion
Communication principles
Family dynamics - ANS ✔"Knowledge Base" in Critical Thinking in Assessment of Clients
- time pressure
- setting
- task complexity
- interruptions - ANS ✔"Environment" in Critical Thinking in Assessment of Clients
- personal
- clinical experience in assessment, physical examination, knowing what to examine
- skill competence - ANS ✔"Experience" in Critical Thinking in Assessment of Clients
,ANA Standards and Scope of Nursing Practice
Clinical practice guidelines and standards of practice
Intellectual standards in measurement
Agency policies and procedures
Professional
- standards of care
- ethical standards - ANS ✔"Standards" in Critical Thinking in Assessment of Clients
1. Client
- interview, observation, physical examination
*the best source of information*
2. Family and significant others
*obtain client's agreement first or HIPPA violation*
3. Health care team
4. Medical records
- past visits in hospital, out-patient, etc.
5. Scientific literature
- can help guide your care of plan - ANS ✔Developing the Nurse-Client Relationship for Data
Collection (5)
(sources of data you are collecting can come from...)
Types include:
- the client centered interview during a nursing health history
- a physical examination
- the periodic assessments you make during rounding or administering care - ANS ✔Types of
Assessment (3)
, Subjective client cues or Objective client cues - ANS ✔What are the types of cues?
Client's verbal descriptions of their health problems
- feelings, perceptions, and self-reported problems
- report from family
- shift or handoff report
*typically put in quotations* - ANS ✔Subjective Client Cues
Observations or measurements of client's health status
- physical assessment
- medical record/EHR
- lab tests - ANS ✔Objective Client Cues
Effective Communication - ANS ✔What is one of the most important things when doing an
assessment, health history, collecting data, etc.?
Foundation for creating nurse-client relationships
- trust building
- presence
- rounding
(provide comfort and make a connection with the patient -- confirm or rephrase what they're
saying if you don't understand) - ANS ✔What is effective communication?
1. Open-ended questions
- narrative response