NUR 221- Foundations Exam 2
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The process of problem solving
What is critical thinking?
- We gather data, validate data, and
weigh options
- Assessing our patients and making de-
cisions about their care
-Re-evaluating pt's condition and making
changes to the plan
Ways in which nurses utilize critical think-
-Communicating changes in pt's status
ing
to the provider and collaborating in cre-
ating solutions
-Determining relevant data and discard-
ing irrelevant data
-Science based facts
-Pathophysiologic principles
Theoretical knowledge
-Evidence which policies
and protocols are based on
The FACT that Heparin is a medication
Example of theoretical knowledge that reduces blood clots by increasing
blood clotting time
Knowing when and how to do tasks and
Practical knowledge
skills safely.
when we use the technique of pinching
the skin inserting a 5/8-inch needle at a
Example of using practical knowledge 45-degree angle of the abdominal fold
when giving a subcutaneous injection of
Heparin.
Our own preferences or biases that may
Self-knowledge
influence our thinking
-First time I gave a sub-Q injection at clin-
ical last week, the patient flinched and it
made me nervous to do it again.
Example of self-knowledge and possible
repercussions
-This self-knowledge is important to be
aware about as it may influence deci-
sions in an unintended way.
, NUR 221- Foundations Exam 2
Study online at https://quizlet.com/_81wcw5
Contextual awareness Reflection on past experiences
-Helps us to handle situations where
there is an element of right and wrong.
-We can recognize the situations as
sometimes we may need to provide care
Ethical knowledge that it's ethically confusing or not so black
and white.
-Ethical knowledge of boundaries and
guidelines will help us remain true to our
profession in providing this care.
1. Assessment
2. Diagnosis
5 steps of the nursing process 3. Planning
4. Implements
5. Evaluating
Data gathering; interpreting/analyzing
data.
Assessment -This is a nursing professional responsi-
bility as recommended by the American
Nurses Association and therefore cannot
be delegated to assistive personnel.
NO!!!!
We can enlist the help of unlicensed as-
sistive staff in the action of collecting the
Can assistive personnel perform assess-
data - such as taking vital signs, asking
ments?
about the presence of pain or measur-
ing the amount of urine voided, but it is
a nursing responsibility to interpret and
analyze that data
Assessment
- We assess data
- When we implement our interventions,
, NUR 221- Foundations Exam 2
Study online at https://quizlet.com/_81wcw5
we assess its effectiveness and patient's
What is involved in all steps of the nurs- response
ing process? - When we evaluate expected outcome,
we are assessing their success
Accrediting bodies
What is the frequency of assessments -Always check with your facility, as each
regulated by? hospital usually has their own guidelines
about how often and which assessments
are done
1. Initial
2. Ongoing
3. Comprehensive
4. Focused
Types of assessments 5. Cultural
6. Nutritional
7. Psychosocial
8. Community
9. Functional ability
Initiated upon first contact with the pa-
tient.
-This may be in the emergency depart-
ment or ED, pre-operatively, or upon ad-
Initial Assessments mission to the unit.
-The first time the patient has contact
with the health care system an initial as-
sessment is completed.
-This is typically done within twelve hours
of admission.
Continuing the plan of care.
- Nurses generally are required to com-
plete a head to toe assessment every
Ongoing Assessments
shift, and perhaps focused assessments
more often in higher levels of care.
- These follow up assessment are ongo-
ing assessments
, NUR 221- Foundations Exam 2
Study online at https://quizlet.com/_81wcw5
More than a head to toe assessment and
include information about social and sit-
uational status, home support systems,
Comprehensive Assessments holistic assessment of the patient's be-
liefs and spiritual needs, and what kind of
assistance they have or may need at dis-
charge (DISCHARGE IS THE GOAL!!)
When does discharge planning begin? At admission
-Different from head to toe assessment
as it is directed and, well, focused.
-Focused assessment explores a single
patient complaint or symptom, and may
focus on one body system (such as the
respiratory assessment for a patient with
shortness of breath) or several body sys-
tems (such as respiratory, G.I., and car-
diac if the patient is experiencing chest
pain).
Focused assessment -It is concentrated on that primary con-
cern. You may also do a focused assess-
ment at change of shift when there is a
wound or dressing and you go in with that
nurse to assess just the wound dressing
to make sure your initial shift assessment
is not different from her last reported as-
sessment.
-You do not need to do an entire head
to toe assessment at that time, but just
focusing in on that one particular abnor-
mality.
exploring what unique preferences and
Cultural Assessments expectations the patient will bring with
their cultural background.
Nutritional assessments
Study online at https://quizlet.com/_81wcw5
The process of problem solving
What is critical thinking?
- We gather data, validate data, and
weigh options
- Assessing our patients and making de-
cisions about their care
-Re-evaluating pt's condition and making
changes to the plan
Ways in which nurses utilize critical think-
-Communicating changes in pt's status
ing
to the provider and collaborating in cre-
ating solutions
-Determining relevant data and discard-
ing irrelevant data
-Science based facts
-Pathophysiologic principles
Theoretical knowledge
-Evidence which policies
and protocols are based on
The FACT that Heparin is a medication
Example of theoretical knowledge that reduces blood clots by increasing
blood clotting time
Knowing when and how to do tasks and
Practical knowledge
skills safely.
when we use the technique of pinching
the skin inserting a 5/8-inch needle at a
Example of using practical knowledge 45-degree angle of the abdominal fold
when giving a subcutaneous injection of
Heparin.
Our own preferences or biases that may
Self-knowledge
influence our thinking
-First time I gave a sub-Q injection at clin-
ical last week, the patient flinched and it
made me nervous to do it again.
Example of self-knowledge and possible
repercussions
-This self-knowledge is important to be
aware about as it may influence deci-
sions in an unintended way.
, NUR 221- Foundations Exam 2
Study online at https://quizlet.com/_81wcw5
Contextual awareness Reflection on past experiences
-Helps us to handle situations where
there is an element of right and wrong.
-We can recognize the situations as
sometimes we may need to provide care
Ethical knowledge that it's ethically confusing or not so black
and white.
-Ethical knowledge of boundaries and
guidelines will help us remain true to our
profession in providing this care.
1. Assessment
2. Diagnosis
5 steps of the nursing process 3. Planning
4. Implements
5. Evaluating
Data gathering; interpreting/analyzing
data.
Assessment -This is a nursing professional responsi-
bility as recommended by the American
Nurses Association and therefore cannot
be delegated to assistive personnel.
NO!!!!
We can enlist the help of unlicensed as-
sistive staff in the action of collecting the
Can assistive personnel perform assess-
data - such as taking vital signs, asking
ments?
about the presence of pain or measur-
ing the amount of urine voided, but it is
a nursing responsibility to interpret and
analyze that data
Assessment
- We assess data
- When we implement our interventions,
, NUR 221- Foundations Exam 2
Study online at https://quizlet.com/_81wcw5
we assess its effectiveness and patient's
What is involved in all steps of the nurs- response
ing process? - When we evaluate expected outcome,
we are assessing their success
Accrediting bodies
What is the frequency of assessments -Always check with your facility, as each
regulated by? hospital usually has their own guidelines
about how often and which assessments
are done
1. Initial
2. Ongoing
3. Comprehensive
4. Focused
Types of assessments 5. Cultural
6. Nutritional
7. Psychosocial
8. Community
9. Functional ability
Initiated upon first contact with the pa-
tient.
-This may be in the emergency depart-
ment or ED, pre-operatively, or upon ad-
Initial Assessments mission to the unit.
-The first time the patient has contact
with the health care system an initial as-
sessment is completed.
-This is typically done within twelve hours
of admission.
Continuing the plan of care.
- Nurses generally are required to com-
plete a head to toe assessment every
Ongoing Assessments
shift, and perhaps focused assessments
more often in higher levels of care.
- These follow up assessment are ongo-
ing assessments
, NUR 221- Foundations Exam 2
Study online at https://quizlet.com/_81wcw5
More than a head to toe assessment and
include information about social and sit-
uational status, home support systems,
Comprehensive Assessments holistic assessment of the patient's be-
liefs and spiritual needs, and what kind of
assistance they have or may need at dis-
charge (DISCHARGE IS THE GOAL!!)
When does discharge planning begin? At admission
-Different from head to toe assessment
as it is directed and, well, focused.
-Focused assessment explores a single
patient complaint or symptom, and may
focus on one body system (such as the
respiratory assessment for a patient with
shortness of breath) or several body sys-
tems (such as respiratory, G.I., and car-
diac if the patient is experiencing chest
pain).
Focused assessment -It is concentrated on that primary con-
cern. You may also do a focused assess-
ment at change of shift when there is a
wound or dressing and you go in with that
nurse to assess just the wound dressing
to make sure your initial shift assessment
is not different from her last reported as-
sessment.
-You do not need to do an entire head
to toe assessment at that time, but just
focusing in on that one particular abnor-
mality.
exploring what unique preferences and
Cultural Assessments expectations the patient will bring with
their cultural background.
Nutritional assessments
