CH 18 & 19 & 20 planning, implementation, and evaluation Flashcards
ADPIE
Assess Diagnose Planning Implementation Evaluation
What is included in planning?
setting priorities
identifying patient-centered goals and expected outcomes
prescribing individualized nursing interventions
What are the classifications of priorities when planning?
High—Emergent
Intermediate
Low—Affect patients’ future well-being
High priority
if untreated result in harm to the patient -
things like safety, ABCs / basic human needs
Intermediate priority
non emergent and non life threatening needs
Low priority
deals with patients future well-being
what is Maslows hierarchy of needs? Bottom to top
- Physiological needs
- Safety and security
- love and belonging
- self esteem
- self actualization
Goals and outcomes must be…
relevant to patient needs, specific, singular, observable, measurable, and time limited
patient centered goal
a specific and measurable behavior or response that reflects a patients highest possible level of wellness and independence in function
short term goal
an objective behavior or response expected within hours to a week
long term goal
an objective behavior or response expected within days weeks or months
SMART
Singular Measureable(observable) Attainable Realistic Time limited
nurse initiated intervention
independent
physician initiated intervention
dependent - requires order from HCP
collaborative
interdependent - require multiple health care professionals combined knowledge and skill
Clarifying an order
determine whether the therapy is appropriate for the patient and clarify with the physician if needed
Hand-off reporting
important patient information that ensures continuity of care
Critical pathways
are patient care plans that provide the multidisciplinary health care team with activities and tasks to be put into practice sequentially
Consultation
a process by which you seek the expertise of a specialist such as your nursing instructor, a physician, or a clinical nurse educator to identify ways to handle problems in patient management or in planning and implementation of therapies.
nursing intervention
any treatment based on clinical judgement and knowledge that a nurse performs to enhance patient outcomes
5 rights of delegation
Right task Right circumstance Right person Right direction/communication Right supervision/evaluation
Criterion-based standards for evaluation
physiological, emotional, and behavioral responses that are both
patient goals and expected outcomes
Discontinuing a care plan steps
Has the goal been met?
Does the patient agree?
Document the discontinued plan.
What are the steps to modifying a care plan?
Reassessment
Redefining diagnoses
Goals and expected outcomes
What are the two stages of assessment?
Collection and verification
interpretation and validation
What are the 4 areas of critical thinking?
Knowledge base
Experience
Attitudes
Standards
What are the 6 sources of data?
patient family and sig others health care team med records scientific lit nurse's experience
What are the two types of comprehensive approaches?
Structured data base history
problem oriented
Back channeling?
“uh huh” or “go on…”
3 types of nursing DX?
actual or problem focused
Wellness or health promotion
risk
What does PES stand for?
Problem
Etiology
Symptoms
