LM2 - nursing process Flashcards
what is the nursing process?
- organized framework that links the process of thinking with actions in the nursing practice (evidence-based practice)
ex.) handwashing -> proven to decrease infection transmission
how does evidence based practice provide rationale for interventions?
- based on research
- found in research journals
- should be within past 5 yrs or earlier
how would evidence based practice be applied?
- stay current on best practices
- report issues
- continuing education
- join professional organizations
- advocate for patients
what can RNs do?
- assess
- create care plans
- evaluate
- patient teaching
what can LPNs do?
- add to assessment (CANNOT do initial assessment)
- assist (under supervision)
- reinforce RNs teachings
what is ADPIE (nursing process steps)?
A - Assessment
D - Diagnosis
P - Planning
I - Implentation
E - Evaluation
what is done during the Assessment?
recognizing cues
-> inspect - look at patient (facial expressions, color of skin)
-> auscultate - listen w/stethoscope
-> palpate - touch area
-> percussion - tapping
what type of data can be collected during an assessment?
subjective - provided by patient (symptoms - “I feel pain”)
objective - observable and reproducible (VS, labs, - (signs - temp can be proven)
what are the two types of data sources?
primary - directly from patient
secondary - from family, records, patient EMR
what are the types of assessments?
- head to toe
- focused
- special needs
what is a nursing diagnosis?
- “fluid volume overload”
- does not give a disease or condition relating to patient’s s/s but rather a clinical judgement
what happens during the diagnosis?
- identify significant data
- cluster data
- identify gaps and inconsistencies
- make inferences
- identify problem causes (etiology)
- prioritize problems
what happens during planning?
- create SMART goal (positive, patient-focused, fits diagnosis)
S - specific
M - measurable
A - attainable
R - realistic/relevant
T - timely
what happens during implementation?
interventions -> prioritizes care. supports goal accomplishment, evidence-based, measurable/timed
- communication
- documentation
- delegation
what are types of interventions?
- independent (nursing order - VS q4h)
- collaborative
- dependent (doctor’s order)
what happens during evaluation?
- evaluate to know if intervention is working (always after med admin and patient teaching)
required parts:
- date
- goal met/not met/ partially
- justification
- continue, discontinue, revise
- signature w/credentials
what is NANDA?
North American Nursing Diagnosis Association (NANDA)
