Ackley Section 1 Flashcards
The 5 phases of the Nursing process:
Assessment, Diagnosis, Planning, Implementation and Evaluation. (ADPIE)
Primary source for obtaining patient story.
Communication with patient and their family.
Objective and subjective information about the client that describes who the client is as a person in addition to their usual medical history.
“Patient’s story”.
Perform a nursing assessment.
Assess.
Make nursing diagnoses.
Diagnose.
Formulate and write outcome/goal statements and determine appropriate nursing interventions based on evidence.
Plan.
Implement care.
Implement.
Evaluate the outcomes and the nursing care that has been implemented. Make necessary revisions in care as needed.
Evaluation.
The information that is obtained verbally from the client is considered ___ information.
Subjective.
Information obtained by performing a physical assessment, taking vital signs and noting diagnostic test results.
Objective information.
The ability to think through a clinical situation as it changes, while taking into account the context and what is important to the client and the family.
Clinical reasoning.
Factors that appear to show some type of patterned relationship with the nursing diagnosis: such factors may be described as antecedent to, associated with, relating to, contributing to, or abeting.
Related factors - two part system of working nursing diagnosis.
Observable cues/inferences that cluster as manifestations of an actual or wellness nursing diagnosis.
Defining Characteristics - three part system of working nursing diagnosis.
Two part system of working nursing diagnosis:
- Nursing diagnosis. 2. Related to.
Three part system of working nursing diagnosis:
- Nursing diagnosis. 2. Related to. 3. Defining characteristics. (PES System)
