Ch 7 Nursing Process Flashcards
Diagnosis
The registered nurse ANALYZES the assessment data to determine diagnosis or problem
Assessment
Databases gathered from a variety of sources including interviews with the client or family, observation of the client and his or her environment, consultation with other health team members, review of the client’s records, and a nursing physical examination.
The nursing process mnemonic
ADOPIE
Outcome identification
Identify expected outcomes for a plan individualized for the patient. ESTABLISH GOALS! They must be measurable and include a time estimate for attainment. must also be realistic for the client’s capabilities.
Planning
The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. For each diagnosis identified, the most appropriate interventions, based on current nursing practice and research, are selected.
Implementation
The registered nurse implements the identified plan. Intervention selected during the planning stage are executed.
Evaluation
The registered nurse evaluates progress toward the attainment of expected outcomes.
Case management
Contain costs. Provide quality healthcare, decrease fragmentation, enhance the client’s quality-of-life. A case manager coordinates the clients care from admission to discharge and sometimes following discharge. Strive to organize client care within an allotted timeframe (defined by DRGs).
Managed care
Ex/ HMOs and PPOs and social service programs, public health sector, insurance based programs and employer based medical providerships. The amount and type of healthcare that the individual receives is determined by the organization providing the managed-care. Individuals receive health care based on need.
Types of clients that benefit from case management
The frail elderly, individuals with developmental disabilities, physical disabilities, mental disabilities, severely compromised
Clinical pathways of care
May be used as a tool for provision of care in a case management system. It is a type of abbreviated plan of care that provides outcome-based guidelines for goal achievement within a designated length of stay. Intended to be used by the ENTIRE interdisciplinary team. The team decides what categories of care are to be performed, by what date, and by whom. Each member of the team stays in contact with the nurse case manager regarding individual assignments. STANDARDIZED. Intended for uncomplicated cases.
Nursing diagnoses are prioritized according to
Life-threatening potential. Maslow’s hierarchy of needs is a good model to follow.
Concept mapping
A diagram of client problems and interventions. Based off of nursing process
Charting by exception
Documenting only when there is a deviation in the client’s care. Not widely accepted. Many legal decisions still based on the precept that “if it is if it was not charted, it was not done.”
Problem-oriented recording
Type of documentation that focuses on a list of nursing diagnoses. SOAPIE S=subjective data O= objective date A= assessment (how the nurse interprets the data) P= Plan I=intervention (those nursing actions that were actually carried out) aka implementation E=evaluation
