harding ch. 1 - professional nursing Flashcards
what is ADPIE
- Assessment: collect data
- Diagnosis: interpret data, related factors, document nursing diagnosis, outcome identification (SMART)
- Planning: priorities, time frame
- Implementation: collab, involve patient
- Evaluation: evaluate, summarize
what is SBAR
- Situation: current problem, identify self and unit
- Background: leading up to now, current meds, vital signs
- Assessment: changes from prior assessments, patient condition worsening/unstable
- Recommendation: request, specific treatments or tests
care model: a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes
case management
care model: the delivery of health care and information through telecommunication technologies, including high-speed Internet, wireless, satellite, and video communications
telehealth
made up of providers from various disciplines, working together and sharing their expertise to provide customized care. It may consist of physicians, nurses, pharmacists, occupational and physical therapists, and others
interprofessional team
what data is included in assessment of ADPIE
- review of clinical record
- interview
- health history
- physical examination
- functional assessment
- consultation
- review of the literature
what is included in diagnosis of ADPIE
- interpret data
- validate inferences
- compare clusters
- identify related factors
- document diagnosis
what is included in outcome identification (in ADPIE)
-identify expected outcomes
-individualize to person
-realistic and measurable
-includes time frame
(SMART)
what is included in planning in ADPIE
- establish priorities
- develop outcomes
- set time frames for interventions
- document plan of care
what is included in implementation in ADPIE
- schedule and coordinated total health care
- collaborate with other team members
- involve patient in healthcare
- document care provided
what is included in evaluation in ADPIE
- evaluate patient’s outcome with expected outcomes
- identify reasons for patient’s failure to meet outcomes
- take corrective action to modify plan if necessary
- document evaluation
what are the 5 ‘rights’ in delegation
- right task
- right circumstances
- right person
- right directions and communication
- right supervision and evaluation
what tasks can be delegated to LPN/LVN
-stable situation/patient
-med admin
-sterile dressing changes
-most interventions
CAN’T PLAN INTERVENTIONS OR TEACH
what tasks can be delegated to UAP
-vital signs
-PO feeding
-walking patients
-obtaining specimens
-report observations
NO PART OF ADPIE
what are the five skills of a nurse
- evidence-based practice knowledge and skills
- critical thinking skills
- moral/ethical skills
- documentation
- legal issues
