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Questions and Answers
What does 'Charting by Exception' (CBE) philosophy entail?
What does 'Charting by Exception' (CBE) philosophy entail?
Nurses document progress notes only when a patient's condition does not meet standard normal criteria.
Nurses document progress notes only when a patient's condition does not meet standard normal criteria.
True
What is the primary purpose of a Change of Shift Report?
What is the primary purpose of a Change of Shift Report?
What does 'WDL' stand for in nursing documentation?
What does 'WDL' stand for in nursing documentation?
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What is included in an Incidence or Occurrence Report?
What is included in an Incidence or Occurrence Report?
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TO stands for ______ order.
TO stands for ______ order.
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Match the following record keeping forms with their descriptions:
Match the following record keeping forms with their descriptions:
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The HCP receiving a telephone order must document it clearly in the patient's chart.
The HCP receiving a telephone order must document it clearly in the patient's chart.
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What is the Nursing Process?
What is the Nursing Process?
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Which of the following are phases of the Nursing Process? (Select all that apply)
Which of the following are phases of the Nursing Process? (Select all that apply)
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What types of data are collected during the Nursing Process?
What types of data are collected during the Nursing Process?
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The ______ is concerned with the objective, abstract, and general knowledge that is quantifiable in nursing.
The ______ is concerned with the objective, abstract, and general knowledge that is quantifiable in nursing.
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What does critical thinking in nursing refer to?
What does critical thinking in nursing refer to?
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Which factor is NOT a component of a nursing diagnosis?
Which factor is NOT a component of a nursing diagnosis?
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Nursing diagnoses are static and do not change over time.
Nursing diagnoses are static and do not change over time.
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What is a concept map in nursing?
What is a concept map in nursing?
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Which of the following is a method of documentation?
Which of the following is a method of documentation?
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What is the importance of documentation in nursing?
What is the importance of documentation in nursing?
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What should be avoided during documentation?
What should be avoided during documentation?
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SOAP stands for Subjective, Objective, ______, Plan.
SOAP stands for Subjective, Objective, ______, Plan.
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What does the 'A' in SOAPIER stand for?
What does the 'A' in SOAPIER stand for?
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Study Notes
Nursing Process Overview
- Systematic approach utilizing critical thinking for patient health issue identification and treatment.
- Framework organizes nurses' knowledge, judgments, and actions during patient care.
- Focused on client strengths, needs, and collaborative intervention development.
- Emphasizes client-centered, individualized care, and fostering collaboration and trust.
Phases of the Nursing Process
- Assessment: Data collection to establish a client's baseline and health concerns; involves physical assessments.
- Diagnosis: Analyzing collected data to identify strengths, problems, and create nursing diagnoses.
- Planning: Developing an individualized care plan with SMART goals based on identified issues.
- Implementation: Executing the care plan by performing nursing interventions and documenting results.
- Evaluation: Measuring whether outcomes were achieved, identifying barriers, and modifying the care plan if necessary.
Types of Data
- Objective Data: Quantifiable measurements such as vital signs (e.g., BP, HR).
- Subjective Data: Patient-reported symptoms (e.g., pain level).
- Primary Source: Direct data from the client.
- Secondary Source: Information from charts, reports, and family.
Data Collection and Validation
- Importance of validating collected data for accurate analysis and interpretation.
- Cues: Observable indicators (objective and subjective).
- Inferences: Nurse's judgments based on cues.
Concept Maps
- Visual tools representing connections between client issues.
- Promote critical thinking in the assessment process.
Nursing Diagnosis
- Judgments made post-analysis of data; establish priority based on urgency and patient safety (e.g., airway clearance first in emergencies).
- Differentiates nursing diagnoses from medical diagnoses, focusing on holistic care rather than disease processes.
Writing a Nursing Diagnosis (NANDA)
- Uses the PES format:
- P: Problem
- E: Etiology
- S: Signs/Symptoms.
- Examples:
- Impaired skin integrity due to immobility with pressure ulcer.
- Ineffective airway clearance secondary to thick secretions from COPD.
Critical Thinking in Nursing
- Defined as the ability to make informed judgments and solve problems.
- Ongoing process, essential for decision-making in clinical settings.
- Involves systematic, reflective, and logical thinking guided by ethical principles.
Characteristics of Critical Thinkers
- Curiosity in understanding how and why.
- Systematic and organized problem-solving methods.
- Open-mindedness to consider alternatives.
- Analytical ability to connect different knowledge areas.
Clinical Judgment
- Application of knowledge, experience, and critical thinking to make informed patient care decisions.
- Compiles data from various sources for effective treatment planning.
Ways of Knowing
- Empirical: Objective, science-based knowledge.
- Aesthetic: Contextual understanding influenced by personal creativity and approach.
- Ethical: Informed by personal and professional values regarding patient dignity and privacy.
- Personal: Relational knowledge based on interactions with clients.
Importance of Planning and Implementation
- Prioritizes nursing diagnoses, focusing first on life-threatening conditions.
- Incorporates patient goals, cultural values, and change mechanisms into individualized care plans.
Evaluation Phase
- Continuous assessment of all nursing process phases post-implementation.
- Collaborates with the patient to determine goal achievement status.
Documentation Essentials
- Critical for patient progress tracking and care accountability.
- Must be clear, accurate, timely, objective, and respect patient diversity.
- Legal implications tied to the content and quality of documentation.
Confidentiality and Privacy
- Managed by the Canadian Health Infoway, ensuring patient information security.
- Nurses must follow agency policies to maintain confidentiality.
Common Documentation Methods
- Narrative: Traditional storytelling format for recording care.
- POMR: Organized by patient problems rather than data origin (SOAP and SOAPIER formats).
- Focus Charting: Concentrates on patient concerns through Data-Action-Response (DAR) notes.
Incident Reports
- Document occurrences not part of standard care; useful for quality improvement.
- Maintained confidentially and not mentioned in medical records.
Summary
- Nursing process is a structured approach essential for effective patient care and requires skilled critical thinking, accurate documentation, and respect for ethical standards.
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Description
This quiz explores the Nursing Process, focusing on its systematic approach and critical thinking in patient care. It covers how nurses identify client health issues, strengths, and develop specific interventions. Strengthen your understanding of this essential framework in nursing practice.
