NUR 380- Exam 2 Prep: Critical Thinking,
Documentation, etc.
Critical thinking - ANSProcess to sift via statistics to discover what's applicable and determine
on care the usage of EVIDENCE-based totally exercise.
Used in the nursing process and developing a care plan
Clinical Reasoning - ANSUses critical thinking and choice making whilst worrying for a
consumer. Think about a situation as it is going on and observe nursing standards.
Informatics - ANSuse statistics and era to
1) speak
2) manipulate information
3) mitigate errors
four) aid choice making
Example: MAR
What is our CSP laptop assisted instruction? - ANSATI
What does HIPAA stand for? - ANSHealth Insurance Portability and Accountability Act
Computer assisted practise - ANSComputer-assisted training (CAI) is an interactive educational
method whereby a pc is used to offer the educational material and monitor the gaining
knowledge of that takes vicinity. CAI makes use of a aggregate of text, pictures, sound and
video in improving the mastering system.
Example: ATI for our nursing program.
CPOE - ANSComputerized Provider Order Entry
For medicinal drug orders, lab services, imaging research, and different services.
The Joint Commission - ANSAn impartial, non-earnings agency that evaluates and accredits
healthcare agencies
Provides up to date steering approximately suitable clinical abbreviations and logos. You can
visit The Joint Commission's Fact Sheets database and look for the Do Not Use List.
Assessment (and records collection)- collecting data about a consumer's present health
reputation to identify NEEDS; differentiating between relevant statistics not just the whole thing
stated by way of affected person. ORGANIZING records, categorizing, and subsequently
reaching a conclusion/DIAGNOSIS. The nurse must VALIDATE information as nicely.
Analysis- Interpreting or monitoring the accrued records. Reaching nursing judgment. Detect
inferences, identify clusters and cues, however avoid making snap judgments. Recognizing the
actual problem or danger.
Planning- establishing PRIORITIES and premier effects of care. Selecting nursing interventions
within the plan of care to sell, maintain, or restore fitness. Figuring out the right strategies and
interventions for inclusion in plan, will you need a teaching plan?
Implementation- Providing that care. The usage of your expertise base, talents, coaching
techniques. TESTING your theories. Communicating well.
Evaluation- analyzing customer's response. Determine accuracy of theories used. Decide
knowledge of teaching.
Inferences - ANSA conclusion reached on the idea of proof and reasoning. Determining the
RELATIONSHIP between records
What does essential questioning incorporate? (many things) - ANSIntuition- internal sensing
that the records do now not presently assist something.
Knowledge- use of proof based practice, yo degrees, persevering with schooling.
Experience- derives from opportunities to look at, feel, interact with different customers.
Competence- nurse's cognitive process to make judgments.
Language- Precise and clean and unambiguous with clients and different healthcare group
participants.
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