Lecture 11 Flashcards
What is the Nursing Process?
An assertive problem-solving approach to the identification and treatment of problems
Five phases of Nursing Process
AAPIE
Assessment
Analysis
Planning
Implementation
Evaluation
What are the types of Assessments?
Complete: provides baseline data (all body systems
Focused: specific health problem/complaint (acute distress)
Ongoing: assessment with every interaction
Methods of Clinical Data in Assessment
Inspection
Palpation
Auscultation
(EXCEPT WITH ABDOMEN IT IS:)
Inspection
Auscultation
Palpation
What is the patient problem?
The judgment or conclusion that occurs as a result of assessment and data collection
What is pathophysiology?
The study of physical and biological abnormalities in the body which occur because of a condition or disease
Five Steps to formulate a Nursing Analysis
- Highlight relevant symptoms
- Make short list of symptoms
- Cluster similar symptoms
- Analyze the symptoms
- State a pt problem that is in line with factors and defining characteristics
What are the two Types of Patient Problems?
Actual Problem and Potential Problem
Three types of planning
Immediate
Ongoing
Discharge/Long-term
Steps involved in Planning
Setting priorities
Identifying goals
Planning Nursing Interventions
Two types of goals
Long term (weeks to months)
Short term (7-10 days, b/f discharge)
Four components of a goal
Subject: “The pt will”
Verb: (a desired behavior) (“ambulate, drink”)
Condition: (if relevant) (“with walker, at home”)
Time Frame: (specific dates) (“at discharge”)
What does SMART stand for with goals?
S: Specific
M: Measurable
A: Attainable
R: Relevant
T: Timely
What is implementation?
To move into action or carry out the nursing intervention
Questions to ask during Evaluation
Did the pt meet the planned outcome?
Were the interventions appropriate/effective?
Should the goals or interventions be modified?
