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Final Exam Study Guide
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Final Exam Study Guide Week 1-13 Notes
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PNUR 124Final Test Study Guide
Week 1
1. What is the Nursing Process and 11-
Needs Assessment Guide?
• The Nursing Process is a 5 step
clinical decision-making
approach
• Nurses apply the nursing
process as a critical thinking
competency when delivering
patient care.
• The purpose of the nursing
process is to assist nurses in
identifying and treating
patients' health-related concerns and help patients attain agreed-upon
health outcomes
• When you use the nursing process, you identify a patient's health-related
concerns, clearly define a nursing diagnosis or collaborative problem,
determine priorities of care, and set goals and expected outcomes of care.
• Then you develop and communicate a plan of care, perform nursing
interventions, and evaluate the effects of your care. Involving your patient in
each step of the nursing process helps ensure that care is patient centered.
• As you become more competent in using the nursing process, you will be
able to focus on multiple problems or diagnoses and move back and forth
between steps when considering all the information available to you about a
patient's concerns.
1. Assessment
a. Data collection
b. Data validation
c. Data analysis
2. Diagnosis – analyze the assessment data to determine issues and make a clinical
judgement
a. NANDA format
b. Establishin priorities
3. Planning – create a plan to attain an expected outcome
a. SMART patient goals
b. Nursing interventions/orders (what, when, how)
4. Implementation – carry out the plan
a. Carry out the intervention
5. Evaluation – response to the interventions/determine if it was effective
a. Seeing if patient goal is met or not
• The Needs Assessment Guides are used to assist in collecting data according to
,PNUR 124
“Needs Assessment Guides.” o Each guide will outline the usual data for the need,
under subjective, objective, and diagnostic tests
2. Define Clinical Reasoning
• Clinical reasoning is the process used to examine and analyze patient care issues at the
point of care
• It involves understanding the medical and nursing implications of a patient’s situation
when decisions regarding patient care are made.
• Nurses use clinical reasoning when they identify a change in a patient’s status, take into
account the context and concerns of the patient and caregiver, and decide what to do
about it.
• Because of the complexity of patient care today, nurses are required to learn and
implement critical thinking and clinical reasoning skills long before they obtain those
skills through the experience of professional practice.
3. Sources of Knowledge:
• Knowing the profession
• Knowing self
• Knowing the case
• Knowing the patient
• Knowing the person
4. Variety of Thinking Strategies: ▪ Deductive reasoning
Inductive reasoning
Dialectic reasoning
Divergent thinking
Reflective thinking (reflecting in action; reflecting on action)
Systematic thinking
Creative thinking
,PNUR 124
5. Distinguish clinical reasoning from clinical judgment and critical thinking.
6. Describe role of critical thinking and clinical reasoning in the nursing process.
• Thinking critically is a benchmark or standard for professional nursing competence.
• Kataoka-Yahiro and Saylor developed a model of critical thinking for nursing judgement
• The model helps explain what is involved as you make clinical decisions and judgements
about your patients. It also defines the outcome of critical thinking: nursing judgement
that is relevant to
nursing problems in a variety of settings
7. The Knowledge to Action Framework. From Graham I, Logan J, Harrison M, Strauss S, Tetroe J,
Caswell W, Robinson N: Lost in knowledge translation: time for a map? The Journal of Continuing
Education in the Health Professions 2006, 26, p. 19. Reprinted with permission from John Wiley
and Sons.
8. What are the principles of documentation?
, PNUR 124
• Factual
• Accurate
• Complete
• Current
• Organized
• Compliant with Standards
10. Methods of Documentation
• Source-oriented and problem-oriented medical
records
• Assessment-Problem-Intervention-Evaluation (APIE)
model
• Focus charting (DAR)
• Computerized documentation
• Charting by exception
* Give example of a.) Narrative, b.) SOAP (Subjective-
Objective-Assessment-Plan), c.) PIE (Problem-
Intervention-Evaluation) and d.) Focus Charting DAR
(Data-Action-Response) notes.
Discuss confidentiality, the Circle of Care and principles
of effective documentation relating to CNO practice
standards.
• https://www.ipc.on.ca/wp-content/uploads/resources/circle-of-care.pdf
How to maintain confidentiality of information?
• Personal Information Protection and Electronic Documentations Act (PIPEDA).
In change-of-shift report, what are Dos and Don’ts?
DOs DON’Ts
Provide current information Don’t assume, speculate or ramble
Be clear and specific Don’t report irrelevant information
When in doubt, ask for clarification
Record everything
• SBAR (Situation-Background-Assessment-Recommendation) or I- SBAR-R (Identification-
Situation-Background-Assessment-Recommendation-Read Back) for Communication?
o The assessment part of SBARR involves communicating your objective clinical
assessment of the patient including: Vital signs: blood pressure, pulse,
respiratory rate, SPO2 and temperature.
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