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199 Cards in this Set
- Front
- Back
Clinical decision making
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product of critical thinking that focuses on problem resolution
judgment that includes critical and reflective thinking and action and application of scientific and practical knowledge (Benner, 1984) |
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Concept map
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a visual representation of client problems and interventions that shows their relationships to one another (Schuster, 2003)
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Critical thinking
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an active, organized, cognitive process used to carefully examine one's thinking and the thinking of others (Chaffee, 2002)
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Decision making
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a product of critical thinking that focuses on problem resolution
leads to informed conclusions that are supported by evidence and reason |
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Diagnostic reasoning
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process of determining a client's health status after assigning meaning to the behaviors, physical signs, and symptoms presented by the client.
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Evidence-based knowledge
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knowledge based on active, organized, cognitive process used to carefully examine one's thinking and the thinking of others (Chaffee, 2002)
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Inference
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the process of drawing conclusions from related pieces of evidence (Smith Higuchi and Donald, 2002)
part of diagnostic reasoning |
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Nursing process
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1. Assessment
2. Diagnosis 3. Planning 4. Implementation 5. Evaluation |
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Problem solving
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involves evaluating the solution over time to make sure it's effective
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3 levels of critical thinking
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1. basic
2. complex 3. commitment (Kataoka-Yahiro and Saylor, 1994) |
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4 requirements of critical thinking
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1. cognitive skills
2. curiosity 3. honesty in facing personal bias 4. willingness to reconsider and think clearly (Facione, 1990) |
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Scientific method (5 steps)
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1. identify problem
2. collect data 3. formulate hypothesis 4. test hypothesis 5. evaluate results of test or study |
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Prognosis
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likely outcome of diagnosed problem
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6 steps in decision making
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1. to recognize and define the problem/situation
2. assess all options 3. weigh each option against set of criteria 4. test possible options 5. consider consequences of decision 6. make final decision |
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3 steps of diagnostic reasoning
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1. see context of client situation
2. observe patterns and themes 3. make decisions quickly |
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What's the vision of nursing practice according to DiVito-Thomas (2005)?
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the ability to think critically, improve clinical practice, and decrease errors in clinical judgments
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Attitudes of inquiry involve an ability to recognize that _____ exist and that there is a need for _______ to support what you suppose is true.
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problems
evidence |
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As confidence grows, focus shifts from _______ to _______.
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self
client |
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A critical thinker doesn't accept another person's ideas without _______.
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question
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A critical thinker deals with situations ______.
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justly
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Standards of practice
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the minimum level of performance accepted to ensure high-quality care
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2 things for which a professional nurse is accountable
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1. decisions
2. outcomes |
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A critical thinker's favorite question
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Why?
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3 things to do when taking a risk
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1. consider all options
2. analyze any danger to a client 3. act in a well-reasoned, logical and thoughtful manner |
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2 characteristics of a disciplined thinker
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1. misses few details
2. follows an orderly or systematic approach when making decisions or taking action |
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Perseverance
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to continue to look for more resources until you find a successful approach
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A perseverent critical thinker works to achieve _______.
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the highest level of quality care
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Creativity involves _______ thinking.
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original
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A person of ______ is honest and willing to admit to mistakes or inconsistencies in his or her own behavior, ideas, and beliefs.
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integrity
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Humility
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the ability to admit to any limitations in knowledge or skill
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11 attitudes of critical thinking
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1.confidence
2. independent thinking 3. fairness 4. responsibility and accountability 5. risk taking 6. discipline 7. perseverance 8. creativity 9. curiosity 10. integrity 11. humility |
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Intellectual standards
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a guideline or principle for rational thought
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Professional standards
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ethical criteria for
1. nursing judgments 2. evaluation 3. professional responsibility |
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Professional standards promote the highest level of ___________.
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quality nursing care
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Critical thinkers maintain a sense of self-awareness through conscious awareness of 4 things
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1.beliefs
2. values 3. feelings 4. the multiple perspectives that clients, family members, and peers present in clinical situations |
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Evidence-based criteria for making clinical decisions
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clinical practice guidelines
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Standards of professional responsibility that a nurse tries to achieve are those standards cited in ________, _______, and ________.
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1. nurse practice acts
2. institutional practice guidelines 3. professional organizations' standards of practice |
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To develop critical thinking skills, it is important to learn how to connect ________ and ________ with _______.
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knowledge
theory practice |
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Reflection
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process of purposefully recalling a situation to discover its meaning
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Tool in developing critical thought and reflection through clarifying concepts
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reflective journal writing
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Keeping a journal of your client care experiences will help you become aware of how you use _______.
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clinical decision-making skills
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Assessment
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gathering and analysis of information about client's health status
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Back channeling
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tools like active listening skills which encourage client to give more details
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Closed-end questions
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yes or no questions
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Cue
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information obtained through use of senses (all except taste!)
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Data analysis
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1. recognizing patterns or trends in clustered data,
2. comparing them with standards, 3. then coming to reasoned conclusion about client's responses to a health problem |
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Database
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information gathered about a client
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Functional health patterns
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models offering holistic framework for assessment of any health problem
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Inference
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your judgment or interpretation of cues
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Interview
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an organized conversation with client
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Nursing health history
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information obtained by exploring:
1. client's current illness, 2. health history, and 3. expectations of care |
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Nursing process
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continuous process of:
1. assess 2. diagnose 3. plan 4. implement 5. evaluate |
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Objective data
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information obtained through observation or measurement
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Open-ended questions
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queries posed to elicit explanation
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Review of systems (ROS)
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systematic method for collecting data on all body systems
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Standards
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generally accepted theoretical framework
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Subjective data
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information provided by client
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Validation
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comparison of data with another source to determine data accuracy
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2 types of data
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1. subjective
2. objective |
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6 data sources
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1. client
2. family/significant others 3. health care team 4. medical records 5. other records and literature 6. nurse's experience |
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3 phases of nursing interview
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1. orientation phase
2. working phase 3. termination phase |
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A good interview environment is free of _______, _________, and _______.
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distractions
noise interruptions |
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5 dimensions of client health history
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1. physical and developmental
2. intellectual 3. spiritual 4. social 5. emotional |
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T/F: The nurse practice acts of all states and the ANA's Nursing's Social Policy Statement (2003) mandate accurate data collection and recording as independent functions essential to the role of the professional nurse.
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True
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When recording data, pay attention to ____ and be as _______ as possible.
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facts
descriptive |
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3 steps of data analysis
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1. recognize a pattern or trend
2. compare with normal standards 3. make reasoned conclusion |
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How do you record subjective information from a client?
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use quotation marks
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Concept mapping is an effective learning strategy to understand the ________ between client problems.
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relationship
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Perhaps the best lesson a new nursing student can learn is to value every _______ _______, which become stepping stones for building new knowledge and inspiring innovative thinking.
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client experience
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11 attitudes for critical thinking
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1. confidence
2. independence 3. fairness 4. responsibility 5. risk taking 6. discipline 7. perseverance 8. creativity 9. curiosity 10. integrity 11. humility |
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14 intellectual standards for critical thinking
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1. clear
2. precise 3. specific 4. accurate 5. relevant 6. plausible 7. consistent 8. logical 9. deep 10. broad 11. complete 12. significant 13. adequate 14. fair |
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standards of practice
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minimum level of performance accepted to ensure high-quality care
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medical diagnosis
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identification of a disease condition based on
1. a specific evaluation of physical signs, symptoms, client's medical history, and 2. results of diagnostic tests and procedures |
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nursing diagnosis
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clinical judgment about individual, family/community responses to actual and potential health problems or life processes (NANDA-I, 2007)
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collaborative problem
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complication requiring treatment by several disciplines
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T/F: A nurse can independently treat a medical diagnosis.
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False
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4 things used in reaching nursing diagnosis
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1. knowledge
2. standards (ANA Scope of Nursing Practice) 3. attitudes (critical thinking) 4. experience |
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When was nursing diagnosis first introduced in nursing literature?
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1950
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When was first national conference for classification of nursing diagnosis?
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1973
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NANDA was established in _____ with the purpose to ______, _____, and _____ a taxonomy of nursing diagnostic terminology of general use for professional nurses.
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1982
develop refine promote |
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ANA endorses ________ as having the responsibility to classify nursing diagnosis.
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NANDA-I
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All/Most/No state Nurse Practice Acts include nursing diagnosis as part of the domain of nursing practice
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Most
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diagnostic reasoning
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process of using assessment data to logically explain a clinical judgment/nursing diagnosis
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3 decision-making steps of diagnostic process
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1. data clustering
2. identifying client needs 3. formulating diagnosis/problem |
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defining characteristics
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clinical criteria/assessment findings supporting a nursing diagnosis
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3 clinical criteria
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1. objective/subjective signs & symptoms
2. clusters of signs & symptoms 3. risk factors leading to a diagnostic conclusion |
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The ______ of certain defining characteristics suggests that you ______ a diagnosis under consideration.
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absence
reject |
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Always examine the _____ _______ carefully to support/eliminate a nursing diagnosis.
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defining characteristics
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Review a client's ________ before finalizing a nursing diagnosis.
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general health care needs or problems
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It is critical to select the correct ____ _____ for a client's need.
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diagnostic label
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4 types of nursing diagnoses (NANDA-I, 2007)
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1. actual diagnoses
2. risk diagnoses 3. wellness diagnoses 4. health promotion nursing diagnoses |
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actual nursing diagnosis
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describes human responses to health conditions/life processes that EXIST in a person.
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Selection of an actual nursing diagnosis indicates that sufficient ______ ____ are available to establish the nursing diagnosis.
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assessment data
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risk nursing diagnosis
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describes human responses to health conditions/life processes that will POSSIBLY develop in a vulnerable person.
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health promotion nursing diagnosis
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clinical judgment of a person's motivation and desire to increase well-being and actualize human health potential
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wellness nursing diagnosis
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describes human responses to levels of wellness in a person that have a readiness for enhancement
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2 components of a nursing diagnosis
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1. diagnostic label
2. related factors 3. in addition, all NANDA-I approved diagnoses include a definition |
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diagnostic label
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the name of the nursing diagnosis as approved by NANDA-I
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related factor
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a condition/etiology identified form the client's assessment data
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4 categories of related factors for NANDA-I diagnoses
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1. pathophysiological
2. treatment related 3. situational 4. maturational |
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The etiology of a nursing diagnosis is always within the domain of ______ and a condition that responds to ________.
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nursing practice
nursing interventions (do NOT use medical diagnosis as etiology for nursing diagnosis!) |
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risk factors
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environmental, physiological, psychological, genetic/chemical elements that increase the vulnerability of a person to an unhealthful event.
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A client's culture influences the type of _________ he/she faces.
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health care problems
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When making a diagnosis, consider how culture influences the ______ ______ for your diagnostic statement.
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related factor
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Few clients have _______ problems.
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single
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concept map
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a scheme that displays visual knowledge in the form of a hierarchical graphic network
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Concept mapping _______ and _____ information and links information to allow you to see new wholes and appreciate the complexity of client care. (Ferrario, 2004).
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organizes
links |
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Assessment data needs to support the ____________ and the related factor needs to support the _________.
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diagnostic label
etiology |
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Data sources include these 3 domains:
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1. physical
2. psychological 3. sociocultural |
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4 error sources in nursing diagnosis process
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1. data collection
2. clustering 3. interpretation 4. statement of diagnosis |
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To avoid errors in data collection, be _______ and _________ in all assessment techniques.
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knowledgeable
skilled |
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4 errors in collecting data
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1. lack of knowledge or skill
2. inaccurate data 3. missing data 4. disorganization |
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5 errors in interpreting data
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1. inaccurate interpretation of cues
2. failure to consider conflicting cues 3. using an insufficient number of cues 4. using unreliable or invalid cues 5. failure to consider cultural influences or development state |
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5 errors in labeling
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1. wrong diagnostic label selected
2. evidence exists that another diagnosis is more likely 3. condition is a collaborative problem 4. failure to validate nursing diagnosis with client 5. failure to seek guidance |
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Use of standardized language from NANDA-I helps ensure ______.
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accuracy
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Identify the client's ______, not the medical diagnosis.
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response
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Identify a NANDA-I diagnostic statement rather than the ________.
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symptom
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Identify a _______ ________ rather than a clinical sign or chronic problem.
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treatable etiology
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Identify the ________ caused by the treatment or diagnostic study rather than the treatment or study itself.
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problem
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Identify the client ______ to the equipment rather than the equipment itself.
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response
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Identify the ______ problems rather than your problems with nursing care.
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client's
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Identify the ______ _______ rather than the nursing intervention
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client problem
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Identify the client problem rather than the _____.
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goal
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Make _______ rather than prejudicial judgments.
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professional
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avoid legally inadvisable ________.
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statements
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Identify the ______ and _______ to avoid a circular statement.
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problem
etiology |
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Identify only one ____ _______ in the diagnostic statement.
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client problem
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When initiating the original care plan, always place the highest-priority nursing diagnosis _______.
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first
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planning
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category of nursing behaviors in which a nurse sets client-centered goals and expected outcomes and plans nursing interventions
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priority setting
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ordering of nursing diagnoses or client problems using notions of urgency and/or importance to establish a preferential order for nursing actions
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5 things on which priorities should be based
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1. problem urgency
2. client safety 3. client desires 4. nature of treatment indicated 5. relationship among diagnoses |
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Establishing priorities is not merely a matter of numbering the nursing diagnoses on the basis of ______ or _______ __________.
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severity
physiological importance |
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3 classifications of priorities
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1.high
2. intermediate 3. low |
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What nursing diagnoses have highest priority?
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those involving ABCs and safety
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Intermediate nursing diagnoses involve the _________, ________ needs of the client.
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non-emergent
non-life-threatening |
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Low priority nursing diagnoses are not always directly related to a specific _______ or ________ but affect the client's ______ __________.
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illness
prognosis future well-being |
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Ongoing _____ ______ is CRITICAL to determine the status of your client's _______ ________.
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client assessment
nursing diagnoses |
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3 phases of nursing care
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1. initial
2. ongoing 3. discharge |
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What does initial planning involve?
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1. development of preliminary plan of care
2. initial selection of nursing diagnoses |
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What does ongoing planning involve?
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continuous updating of care plan
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What does discharge planning involve?
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critical anticipation and preparation for meeting client's needs after discharge
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Involve ______ in priority setting whenever possible.
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client
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Always assign priorities on the basis of good ______ _________.
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nursing judgment
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Nursing care is a ________ process.
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nonlinear
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cognitive shift
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shift of attention from one client to another during the conduct of the nursing process
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3 keys to staying organized when working with multiple clients
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1. work from your plan of care
2. use priorities to organize the order for delivering interventions 3. use priorities to organize documentation of care |
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goal
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a broad statement that describes the desired change in a client's condition/behavior
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expected outcome
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measurable criteria to evaluate goal achievement
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2 purposes of goals and expected outcomes
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1. provide clear direction for selection and use of nursing interventions
2. to provide focus for evaluating effectiveness of the interventions |
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6 ways that goals and outcomes need to meet established intellectual standards
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1. by being relevant to client needs
2. specific 3. singular 4. observable 5. measurable 6. time-limited |
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client-centered goal
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a specific and measurable behavior/response that reflects a client's highest possible level of wellness and independence in function
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A goal is ______ and based on client ______ and ________.
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realistic
needs resources |
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short-term goal
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objective behavior/response that you expect a client to achieve in a short time (1 week or less)
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long-term goal
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objective behavior/response that you expect a client to achieve in a period of weeks or months
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Goal setting establishes the framework for the __________.
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nursing care plan
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For clients to participate in goal setting, they need to be ______ and have some degree of ____________.
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alert
independence |
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If a client is not able to participate in goal development, the nurse ______ ________.
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assumes responsibility
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expected outcome
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specific measurable change in client's status that you expect to occur in response to nursing care
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Always write expected outcomes ________, with ____ _______, and in _______ ______.
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sequentially
time frames measurable terms |
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Nursing Outcomes Classification (NOC)
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Iowa Intervention Project published the NOC and linked outcomes to NANDA diagnoses
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nursing-sensitive client outcome
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a person's state, behavior, or perception that is measurable along a continuum in response to a nursing intervention
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NOC contains outcomes for ________, ________, __________, and _________ for all types of health care settings.
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individuals
family caregivers the family the community |
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The NOC standardizes the way to measure ______ ___________.
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client outcomes
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number of outcomes included in NOC
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330
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NOC include 3 things for each outcome
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1.definitions
2. indicators 3. measurement scales |
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7 guidelines for writing goals and expected outcomes
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1. client-centered
2. singular goal/outcome 3. observable 4. measurable 5. time-limited 6. mutual factors 7. realistic |
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nursing interventions
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treatments/actions, based upon clinical judgment and knowledge, that nurses perform to meet clients' outcomes.
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3 competency areas for selecting interventions
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1. knowing scientific rationale for the intervention
2. possessing necessary psychomotor and interpersonal skills 3. being able to function within a particular setting to use the available health care resources effectively |
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3 categories of interventions
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1. nurse-initiated
2. physician-initiated 3. collaborative |
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Nurse-initiated interventions do not require ______ or ________.
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direction
order from another health care professional |
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As a nurse, you act __________ on a client's behalf.
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independently
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According to MOST states' Nurse Practice Acts, independent nursing interventions pertain to what 3 things
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1. ADLs
2. health education and promotion 3. counseling |
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2 publications for which Iowa Intervention Project is responsible
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NOC (nursing outcomes classification)
NIC (nursing interventions classification) |
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3 levels of the NIC model
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1. domains
2. classes (there are 30) 3.interventions (there are 542) |
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NIC interventions are linked with ________ for ease of use.
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NANDA-I nursing diagnoses
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T/F: Both NIC and NOC are linked to NANDA-I nursing diagnoses.
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true
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3 parts of written nursing care plan
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1. nursing diagnoses
2.goals and/or expected outcomes 3. specific interventions |
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A nursing care plan is a written guideline for what 3 things
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1. coordinating nursing care
2. promoting continuity of care 3. listing outcome criteria to be used in evaluation |
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3 things made possible by a written nursing care plan
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1. coordination of nursing care
2. coordination of sub-speciality consultations 3. coordination of scheduling of diagnostic tests |
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A written plan should be designed to reduce the risk of _______, ________, or _______ care.
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incomplete
incorrect inaccurate |
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4 areas in which student care plans are useful
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1. learning problem-solving technique
2. learning nursing process 3. learning written communication skills 4. learning organizational skills needed for nursing care |
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6 categories of student care plan
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1. assessment
2. goals 3. expected outcomes 4. interventions 5. rationale 6. evaluation |
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4 frequent errors in writing nursing interventions
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1. failure to precisely/completely indicate nursing actions
2. failure to indicate frequency 3. failure to indicate quantity 4. failure to indicate method |
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Kardex nursing care plan
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card-filing system used in many hospitals
|
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How does an institutional care plan differ from a student care plan?
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institutional plan lacks scientific rationale
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The focus of a nursing care plan will differ by ___ and ___________.
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setting
the evolving client situation |
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EHR
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electronic health record
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Most hospitals now have some type of _______.
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EHR and documentation system
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Failure to ________ a standarized care form for a particular client results in incomplete and inaccurate care.
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customize
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Care plans for community-based settings require a more comprehensive assessment of __________, _______, and _______.
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community
home family |
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critical pathways
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multidisciplinary treatment plans outlining treatments/interventions clients needed in a health care setting for a specific disease/condition
|
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concept map
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a visual representation of client problems and interventions that shows their relationships to one another
|
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consultation
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process in which you seek expertise of a specialist
|
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2 problems solved through consultation
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1. problems in delivery of nursing care
2. problems related to use of resources |
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when to consult
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when you identify problem you can't solve using
1. personal knowledge, 2. skills and 3. resources |
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6 steps of consultation
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1. identify problem
2. direct consultation to the right professional 3. provide consultant with relevant information 4. avoid bias by not overloading consultants with subjective/emotional conclusions about client/problem 5. be available to discuss consultant's findings and recommendations 6. incorporate consultant's recommendations into care plan. |
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The success of advice gained through consultation depends on the _______ of the problem-solving techniques.
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implementation
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Always give the consultant _______ regarding outcome of the recommendations.
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feedback
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When it comes to implementation, ALWAYS ______ before you ____.
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think
act |