NR224 FUNDAMENTALS EXAM 1
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conclusion about a patients needs or
health problems and/or the decision to
take or avoid action, use or modify stan-
Clinical Judgement
dard approaches, or create new ap-
proaches based on the patient's re-
sponse
A type of logic in which generalizations
inductive reasoning are based on a large number of specific
observations to general
reasoning in which a conclusion is
reached by stating a general principle
and then applying that principle to a spe-
deductive reasoning
cific case (The sun rises every morning;
therefore, the sun will rise on Tuesday
morning.)
separates professional nurses from as-
sistive personal (AP). RNs:
>Observe
Clinical decision
>Collects data
>Recognizes and identifies
>Takes action
Critical thinking and critical judgement
skills (table)
Review your practice experiences to:
Describe
Analyze
Evaluate
,NR224 FUNDAMENTALS EXAM 1
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Time (seta time for plan of care to be
completed
Critical thinking
model
The nursing process is a five-step clinical
decision-making approach
ADPIE
Nursing Process
Assess
Diagnosis
Planning
Evaluation
Nursing Process chart
Deliberate systematic collection of infor-
mation about a patient
Assessment
2 part
1.Collection of information
2.Interpretation of data
To establish a database about the pa-
Why do we assess? tient's perceived needs, health problems,
and responses to these problems.
>Patient (interview, observation, physi-
Types of Assesment cal examination)—the best source of in-
formation
, NR224 FUNDAMENTALS EXAM 1
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Subjective- What the patient tells you
subjective vs objective data
Objective- what you detect during exam
Open-ended
•You want the patient to use their own
words.
Back Channeling
•Use active listening and phrases such
as:
Types of questions for data collection •"all right," "go on," or "uh huh"
Probing
•Trying to get the patient to open up more
by asking them "Is there anything else
you can tell me?"
Closed-ended
•One or two word answers
Nursing health history
-The last component of a complete as-
sessment
Data documentation -Legal and professional responsibility
-Requires accurate and approved termi-
nology and abbreviations
Diagnostic Label:
Describes the patient's response to a
health condition in as few words as pos-
sible
Components of Nursing Diagnosis
Related Factors:
The reason the patient is displaying the
nursing diagnosis. It is not cause and ef-
fect. It indicates etiology that contributes
to the diagnosis.
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