Meet and acknowledge visitors in the patient's room.
Sit next to the patient
Ask the patient to summarize the discussion
Ask, "How would you prefer I address you?
Ask for permission to conduct the interview
Say, "Tell me how you want us to help you
Step one ‐ Identify abnormal data and
strengths
- Subjective data
- Objective data
Step two ‐ Cluster data
- Identify abnormal findings and strengths that are
related.
- Consider, again, if additional data are needed
Step three ‐ Draw inferences
- Write down "hunches."
- Consider nursing diagnosis, collaborative problem and referral
• May need referral (notification) to other to other
discipline
• Nurse may need to collaborate with
physician, physical therapy to best meet patient needs
Step four: Propose possible nursing diagnoses
- Actual diagnosis - a problem the client is currently experiencing or had a dysfunctional pattern
- Risk diagnosis - client does not have but has
potential to develop
- Health promotion diagnosis ‐ opportunity for
enhancement of health state
Step five - Check for defining characteristics
- Use reference text such as NANDA Nursing
Diagnoses: Definitions and
Classifications 2007 -
2008.
-
Defining characteristics list criteria to meet a
certain diagnosis
• For example, in order to use the nursing diagnosis
"Impaired Gas Exchange", one criteria may be to have a low oxygen saturation documented.
- Compare your findings to NANDA
Step six ‐ Confirm or rule out diagnosis
- Validate diagnosis with client and other health
care providers who are caring for the client.
- Validation is also important if client
has
collaborative problem or requires a referral
Step seven ‐ Document conclusions
- Actual nursing diagnoses
- Risk diagnosis
• In 3320 we will focus on Actual and Risk Diagnoses
The nurse cared for a 14-year-old with renal failure who died near the end of the work shift. The health care team tried for 45 minutes to resuscitate the child with no success. The family was devastated by the loss, and, when the nurse tried to talk with them, the mother said, "You can't make me feel better; you don't know what it's like to lose a child." Which of the following examples of journal entries might best help
the nurse reflect and think about this clinical experience? (Select all that apply.)
1. Data entry of time of day, who was present, and condition of the child
2. Description of the efforts to restore the child's blood pressure, what was used, and questions about the child's response
3. The meaning the experience had for the nurse with respect to her understanding of dealing with a patient's death
4. A description of what the nurse said to the mother, the mother's response, and how
the nurse might approach the situation differently in the future
A nurse has multiple clients assigned at the beginning of a shift on the surgical unit. Which client should be assessed first?
1.
Female, posthysterectomy, blood pressure 90/52 mm Hg
2.
Male, postappendectomy, pain medications administered 15 minutes ago
3.
Male, posthip arthroplasty, to be up and ambulating
4.
Female, postcholecystectomy, being discharged with wound care and diet instruction
A. The history of the child's illness
B. Data entry of time of day, who was present, and condition of the child
C. The meaning the experience had for the nurse with respect to her understanding of dealing with a patient's death
D. Description of the efforts to resuscitate the child, what was used, and questions about the child's response
E. A description of what the nurse said to the mother, the mother's response, and how the nurse might approach the situation differently in the future
Answer: (C, D, E)
Rationale
The nurse can reflect on the effects of the treatment and what was difficult or confusing about the outcome. The nurse reviews the meaning of the experience to help improve understanding of personal comfort and competence in dealing with death and how to respond in the future. The nurse reflects on the communication approach used with the mother to consider if it was appropriate.
Reflecting is thinking that examines actions and beliefs. The history of the child's illness and data concerning dates, attendees, and the condition of the child do not contribute to this reflection. (p. 55)
A. Clear
B. Intuitive
C. Plausible
D. General
E. Complete
Answer: (A, C, E)
Rationale
According to Paul, there are 14 intellectual standards that are universal for critical thinking: clear, precise, specific,
accurate, relevant, plausible, consistent, logical, deep, broad, complete, significant, adequate (for purpose), and fair. These are guidelines or principles to enhance rational thinking that can be used in daily nursing practice. Intuition is an example of inference, and general is not an intellectual standard. (pp. 56-57)