Intro Chapter 4 Flashcards
What is the purpose of the nursing process
Problem-solving to care for patients based on priority
Steps of nursing process
ADPIE
- Assessment
- Diagnosis
- Planning/goals
- Interventions
- Evaluation
Assessment
Collection of objective and subjective data from the patient or family and labs
Diagnosis
Nurses determination of the patient’s problem, assigning a nurses diagnosis from the official NANDA list
Planning/goals
Setting a goal the patient will meet to solve the problem, congruent with patient goals
Interventions
Actions the nurse will take to help the patient reach the goal
Evaluation
Looking at how everything turned out (did the patient meet the goal? Did the intervention work?
Establish new goal and start again
T/F The nursing process is the foundation of a nursing care plan
T
Subjective data
Things that the patient tells you, personal stories, can come from family
Objective data
Measurable data, labs, vitals call mom diagnostic test
What Does observation mean in reference to objective data
Seeing
What does palpitation mean in reference to objective data
Touching
What does percussion mean in reference to objective data
Thumping (finger tapping method)
Assesses organ size or inflammation
What does auscultation mean in reference to objective data
Listening
What is a nursing diagnosis
Patient’s response to an illness or medical diagnosis
How is a nursing diagnosis written
In three parts
Problem patient is dealing with) related to (the original cause of the problem) evident by (sign or symptom of problem
How is Maslow‘s hierarchy of needs used with nursing diagnosis
It guides prioritization of nursing diagnosis
What is the most important priority as a nurse Taking care of a patient
Physiological needs
we must be able to breathe before we can do anything else!!!
How are goals for nursing plans written
SMART
S- pecific (dictates days activities M- easurable (objective) A- ttainable R- ealistic T- time framed
Read the Example of a goal below
The patient will demonstrate an effective breathing pattern by 2:30 PM May 25, 2020 AEB a respiratory rate between 12 to 20 breaths per minute
What is the most important thing to remember about to goal
They are typically the opposite of the problem
Example
Problem: pain:: goal: no pain
What do patient goals describe
Goals the patient is going to accomplish
Three types of interventions
- Independent
- Dependent
- Collaborative
Independent interventions
Without orders, what the nurse does within her scope of practice
Repositioning, teaching patient
Dependent intervention
Orders from physician
Administering medication, starting a tube feed
Collaborative Intervention
The nurse works with other disciplines
What does evaluation assess and reflect
assess the effectiveness of interventions and reflect goals
How do you know if you are interventions were effective or not
If the goals were met not met or partially met will have to be modified
Communication is vital between nurses
Done during shift exchange by report
What is the golden rule with documentation
If you didn’t document it did not happen
