NR 226- Fund II Exam 1 Notes
CHAPTER 15- CRITICAL THINKING IN NURSING PRACTICE
*Critical Thinking and Clinical judgement Skills:
Interpretation-
... [Show More] Apply reasoning. Categorize the data. Gather additional data or clarify any data you are uncertain about. Analysis- be open-minded as you look at patient info. Don’t assume. Does data reveal problem or trend that is true?
Inference- look at meaning or significance of findings. Any relationships among findings? Does data help see that a problem exist? Evaluation- look at situation objectively. Use criteria to determine results of nursing actions. Reflect on own behavior.
Explanation- Support findings and conclusions. Use knowledge and experience to choose strategies to use in the care of patients. Self-regulation- reflect on your experiences. Be responsible for your actions. Identify ways you can improve. What will make you believe that you have been successful?
*Caring for groups of patients:
-identify the nursing diagnosis and problems w/ each patient and then decide which is most urgent
-consider time it will take to care for those patients, the resources available, and how to involve pts in their care
-decide how to combine activities and which to delegate, discuss complex cases w/ healthcare team
*Prioritization: ABCDSIP
➢ Airway - patency, jaw thrust, chin lift, oral airway, nasopharyngeal airway
➢ Breathing – tachypnea, bradypnea, oxygen saturation, chest tube management
➢ Circulation – pulse, blood pressure, neurovascular checks, ECG dysrhythmias, sepsis, IV fluids, cap refill
➢ Disability or neuro- loc, mental status, acute status change (ex-slurred speech, confusion, etc)
➢ Safety – Risk for injury/falls, altered LOC, mobility, side effects, medication dosage and appropriate indication, monitoring
➢ Infection
➢ Pain
CHAPTER 16- ASSESSMENT
*Componets Nursing Health History- good for older ppl, things we want to know before laying our hands on them
1. biographical data; name, address & phone #, age/birth date, etc
--source of history: who’s giving the info, judge the reliability of the info and how willing they are to communicate
2. chief concern or reason for seeking: brief reason for visit, subjective symptom, sign (objective abnormality)
3. patient expectations- receiving information, being diagnosed properly, alleviating pain, etc
3. history of present illness (HPI: what makes better or worse, what does it feel like, where is it located/spreading, how severe, time
4. health history- ever been hospitalized (when/how long), surgery, injury, all medications including herbs, allergies-note reaction and treatment, habits and lifestyle patterns, alcohol, tobacco, caffeine, any other drugs, patterns of sleep, nutrition
5. family history- disease or conditions that may put patients at risk
6. psychological history- support system, behavior to cope with stress, any recent losses/grief, occupation, home life
7. spiritual health- patients belief about life, their source that guides them to this belief,
8. ROS- subjective data about all systems and general overall health. Physical assessment is done to confirm
9. functional assessment or activities of daily livings (ADLs): self-esteem, self-concept, activity and exercise, sleep and rest, nutrition
*Prioritization:
-Acute v. chronic -Emergent v. routine -Assessment first -Safety v. risk reduction -ABC’s -Hierarchy of needs -Wellness issues [Show Less]