Noticing
Indicate when a situation is normal, abnormal or has changed. Get an
initial grasp on the situation
Application to thinking noticing
Collect: Subjective & objective data
VS, Complaints, self-described symptoms. What nurse notices, such as rashes, swelling,
bruising, etc
Id...
Indicate when a situation is normal, abnormal or has changed. Get an
initial grasp on the situation
Application to thinking noticing
Collect: Subjective & objective data
VS, Complaints, self-described symptoms. What nurse notices, such as rashes, swelling,
bruising, etc
Identifying signs and symptoms
Noticing
Gathering Complete and Accurate Data
Noticing
Assessing Systematically and Comprehensively
Noticing
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Predicting (and Managing) Potential Complications
Noticing
Identifying Assumptions
Noticing
5 concepts of critical thinking
Standards Attitudes Competencies Experience Specific Knowledge Base
Nursing Process
The nursing process is a variation of scientific reasoning that involves five
steps: assessment, nursing diagnosis, plannin g, implementation, and
evaluation.Assess (collection verification of data and analysis of data)
Diagnose, Plan, Implement, Evaluate
cue
obtain information that you obtain through sense. (Lies still with arms
along side: tense. States has not turned i n some time. Reports pain a 7 and
on scale of 0-10)
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Sources of Data
Patient, family and significant other, health care team, medical records,
other records and scientific literature
An initial patient-centered interview involves
(1) setting the stage, (2) gathering information about the patient's
problems and setting an agenda, (3) collecting the assessment or a nursing
health history, and (4) terminating the interview.
A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6
months since you've been here, but your appointment was for every 2 months. Tell me about
that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell
me how successful you've been in following his plan?" The nurse's assessment covers which of
Gordon's functional health patterns?
Health perception-health management pattern
The nurse observes a patient walking down the hall with a shuffling gait. When the patient
returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the
information gained to suspect that the patient has a mobility problem. This conclusion is an
example of:
Clinical inference.
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A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse
enters the patient's room and notices him to be diaphoretic, holding his chest and breathing
with difficulty. The nurse immediately checks the patient's heart rate and blood pressure and
asks him, "Tell me where your pain is." Which of the following assessment approaches does this
scenario describe?
A problem-oriented approach
The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall
asleep? Do you have difficulty falling or staying asleep? This series of questions would likely
occur during which phase of a patient-centered interview?
Working phase
A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has
diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for
gallbladder disease. Which of the following approaches demonstrates the nurse's cultural
competence in assessing the patient's health care problems?
"You have four children; do you have any conc erns about going home and
caring for them?"
A nurse is checking a patient's intravenous line and, while doing so, notices how the patient
bathes himself and then sits on the side of the bed independently to put on a new gown. This
observation is an example of assessing:
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