Critical Thinking

-analyzing or solving the problem.

Problem-thinking-solution

- reviews data and considers potential

explanations and outcomes

-Generating- Come up with the plan

-Implementing- nursing interventions or

actions that is needed by patient

-Evaluating- outcome of the interventions

*Why is important

- this is how nurses make desicions on patient

care

*ancillary staff- staff in xray dep. or medical

technologist

Components of Crit

-Scientific- Senior Yyear

- Experience

- Compentencies

- Attitudes

- Standards

What is nursing

- protection, promotion, prevention of illness

and injury

- the family members are also the patients

because they are affected once the fam member

is sick.

Nursing Process

-gathering and analyzing data, identify client

responses and outcomes to make appropriate action

-critical thinking skills

Phases of NUrsing Prcoess (ADPIE)

- Assesment

- collecting subj and obj

- Diagnosis

- analyzing sub and obj

- after collecting sub and obj

we will cluster them and identify

the patient problem like for example

is it a nursing diagnosis or nursing

problem.

- Planning

- it like an objective

S- Specific

M- Measurable

A- attainble

R- ealistic

T- Time Bound

- Implementation

- Carrying out the plan

- Evaluation

- revising the plant as necessary

PRIMARY

-sa patient mo talaga makukuha

through interview and physical exam

secondary

-data from clients family member abd

medical records

Impoortance

- to establish data

*every 4 hrs we need to check the patient

vital signs

-To supplement, confirm or question

data

* para sa confirmation baka nag llie lang

-to obtain data

-to evaluate the appropriateness

*assess the patient if maganda ba

yung nursing intervention na

ginawa mo

Partial Ass

-Reass

ask the patient if masakit parin ba

yung chuchu
Problem Oriented ass

- does not replace comprehensive

- specific health concern

*focus dun sa constipation na

nahihirapan na siya

*USE COLDSPA

EMERGENCY ASS

CPR IS AS EASY AS C-A-B

-Performed in life-threatening

situations.

- Very Rapid

Holistic Data

- Physiologic

-head to toe, body system

- Physchological

- attitudes of the patients

- Sociocultural

- Patients way of living, beliefs

- Developmental

- Good for the kids

-Spiritual

- DATA ABOUT THE CLIENT

Collection of Sub data

- It can be verified only by the

patient like for example kapag

tinanong mo if may masakit ba sa may

certain part ng katawan ng patient

Collection of Objective data

- You can get if from physical

Examination like taking vital Signs

Validation of Data

- double checking

or verifying data to confirm that

they are accurate and factual

Documentation of Data

- information about patient

characteristics and care outcomes

INTERVIEW PHASES

PREINTRO

- REVIEWS MEDICAL RECORDS and

information of the patient, condition

INTRODUCTORY

- INTRODUCING OF SELF para makakuha

ng full disclosure ng information or

sensitive topics

Working pHASE

- Uses Critical Thinking to validate

information
SUMMARY/CLOSING PHASE

-Summarizes information obtained

VERBAL COMMUNICATION

OPEN-ENDED QUESTIONS

- Begins with the word HOW OR WHAT

*HOW ARE YOU FEELING TODAY

CLOSE-ENDED QUESTIONS

-Obtain the facts

- begins with when or did

*mam when did the pain start

LAUNDRY LIST

-choices of the patient, bigay ng

example like is it sharp pain ganun

ano klase ng type ng pain

REPRHASING

- just refrace the question na mej

hindi naiintindihan ng patient.

WELL-PLACED PHRASES

- TO ENCOURAGE THE PATIENT

*YE, YAH I AGREE

INFERRING

- kunware masakit yung abdomen niya

pero yung sinabi niya is he/she having

a stomachpain pwede mo na rin gamitin

yung stomach pain para parang agree

sa nararamdaman niya

PROVIDING INFO

- ANSWERING THE PATIENT

SPECIAL CONSIDERATION DURING INTERVIEW

-GERONTOLOGIC VARIATIONS

- GEN Z WORDS

-CULTURAL VAR

- FEMALE TO FEMALE

-EMOTIONAL VAR

- RAPE VICTIM (PHYISCAL EXAM)

PHYISCAL EXAMINATION TECH

INSPECTION

- VISION, SMELL, AND HEARING

*APPEARANCE OF BODY PARENTS

* WE SHOULD PERFORM THIS

IN EVERY PATIENT THAT WE HAVE

ABDNOMINAL EXAMINATION

- Introduce yourself and explain

examination

- confirm the identity of patient

- establish a good communication

- take consent

GENERAL PHYISCAL EXAM

-INSPECTION

(LF SCAR, VEINS)

*lateral position first and next

is legged if di mo makita

-PALPATION

(LF LUMP, MASS)

*normal palpation

*superficial palpation

*deep palpation

*LIVER

-START FROM THE RIGHT LOWER QUADRANT

*SPLEEN

-PALPATE FROM RIGHT LOWER TO UP

*KIDNEY

- USE BOTH HANDS (BIMANUAL EXAMINATION)

*HEAD RAISE TEST

- TO PALPATE SUPRAUMBILICAL SEGMENT

*RAISED LEG TEST

- TO PALPATE INFRAUMBILICAL SEGMENTS

-PERCUSSION

- TAPPING OF BODY PARTS TO PRODUCE

SOUND WAVES

*DIRECT

*BLUNT
*INDIRECT

-AUSCULTATION

- RIQUIRES STETHOSCOPE

*DIAPHRAGM USED FOR HIGH PITCH

*BELL USED FOR LOW PITCH SOUND