NR 224 FUNDAMENTALS EXAM 1 STUDY GUIDE
Chapter 15 CRITICAL THINKING
Basic critical thinking : limited experience, based on the rules
Complex critical thinking : increase knowledge & intuition
Committtment : making choices with full responsibility
Chapter 16 NURSING ASSESSMENT
Nursing process critical thinking for the client individually
Assess:
Gathering all of the information about patients condition
-observe
Data collection
Diagnosis :
Identify the Problem
Planning:
Evidence Based practice
Establish priorities optical outcomes
Implementation:
Provide care based on assessment
Use critical thinking
Evaluation:
Determine if the plan was effective or needed to change
Nursing process
Assessment
-investigate, immunization, vaccinations, systems, travel history
-recognize risk factors
-medical therapy
-appearance
-laboratory data (WBCS)
Diagnosis
- risk for infection (2 part diagnosis)
- imbalanced nutrients
- risk for impaired skin integrity
- social isolation
- impaired tissue
- readiness for enhanced immunizations
, Planning
-smart goals, realistic
-preventing exposure to infectious organism
-control or reduce extent to infection
-verbalizing understanding of infection prevention and control (hand
watching)
Implementation
-health promotion (prevention of development)
-acute care
Critical thinking : collect/verify data analyze data
Sources of date:
Patient (interview, observation physical exam) BEST SOURCE!!
-use own words & use quotation marks
Family & SO (agreement first)
Health care team
Medical records
Scientific literature
HIPAA- indivuadlly information in verbal and electronical
CHAPTER 26 DOCUMENTATION AND INFORMATICS
CHAPTER 27 PATIENT SAFETY
CHAPTER 28 IMMOBILITY
DVT: unilateral edema, pain, redness in one leg/calf
-elevate affected leg, admin anticoagulants
-increase activity (every 2 hours) and change positions
-SCD cuffs, compression stockings
-NO PILLOW AT KNEES
Cane: 2 points of support, position cane on stronger unaffected side, move
cane forward, move weaker leg to leg, stronger leg past the cane
Walker: advance walker 12 inches, advance affected leg, then unaffected
forward
Crutches: adjust 3 finger widths, elbows flexed @ 30 degrees
Tripod position, move unaffected leg forward above crutches
Sitting/rising: on unaffected side
Chapter 15 CRITICAL THINKING
Basic critical thinking : limited experience, based on the rules
Complex critical thinking : increase knowledge & intuition
Committtment : making choices with full responsibility
Chapter 16 NURSING ASSESSMENT
Nursing process critical thinking for the client individually
Assess:
Gathering all of the information about patients condition
-observe
Data collection
Diagnosis :
Identify the Problem
Planning:
Evidence Based practice
Establish priorities optical outcomes
Implementation:
Provide care based on assessment
Use critical thinking
Evaluation:
Determine if the plan was effective or needed to change
Nursing process
Assessment
-investigate, immunization, vaccinations, systems, travel history
-recognize risk factors
-medical therapy
-appearance
-laboratory data (WBCS)
Diagnosis
- risk for infection (2 part diagnosis)
- imbalanced nutrients
- risk for impaired skin integrity
- social isolation
- impaired tissue
- readiness for enhanced immunizations
, Planning
-smart goals, realistic
-preventing exposure to infectious organism
-control or reduce extent to infection
-verbalizing understanding of infection prevention and control (hand
watching)
Implementation
-health promotion (prevention of development)
-acute care
Critical thinking : collect/verify data analyze data
Sources of date:
Patient (interview, observation physical exam) BEST SOURCE!!
-use own words & use quotation marks
Family & SO (agreement first)
Health care team
Medical records
Scientific literature
HIPAA- indivuadlly information in verbal and electronical
CHAPTER 26 DOCUMENTATION AND INFORMATICS
CHAPTER 27 PATIENT SAFETY
CHAPTER 28 IMMOBILITY
DVT: unilateral edema, pain, redness in one leg/calf
-elevate affected leg, admin anticoagulants
-increase activity (every 2 hours) and change positions
-SCD cuffs, compression stockings
-NO PILLOW AT KNEES
Cane: 2 points of support, position cane on stronger unaffected side, move
cane forward, move weaker leg to leg, stronger leg past the cane
Walker: advance walker 12 inches, advance affected leg, then unaffected
forward
Crutches: adjust 3 finger widths, elbows flexed @ 30 degrees
Tripod position, move unaffected leg forward above crutches
Sitting/rising: on unaffected side
