nursing process Flashcards
Name all 6 steps of the nursing process
1) first assessment (S&S)
2) second assessment (causes)
3) nursing diagnosis
4) goal setting
5) nursing intervention
6) evaluation
ADPIE
What are the steps in the first assessment?
-collecting data
- critical thinking
- validate data
Describe collecting data
-asking personal question, day to day lifestyle questions, head to toe assessment, relationship with people
-from primary and secondary source, to establish database which helps for nursing diagnosis, plan and implementation
How should the data be?
descriptive and relevant
Describe critical thinking
Noticing if you have to assess a certain area further, connect data to form a conclusion, allows nurse to see big picture
Describe to validate your data
identify missing data, compare info that nurse and client gave, classify the info as (Adaptive or Ineffective)
Can you identify why effective communication and caring are so important while gathering data?
to get accurate info to help the client
How to gather data?
see in collecting data and by looking at signs n do tests as palpation and inspection and symptoms
when first assessment is complete, what do we prioritize
signs and symptoms, are they harmful
describe second level assessment
it is the causes
describe the causes
why is the patient experience the s&s, identified through observations and interview and validate with patient
what are the 3 steps of causes
1) primary cause
2) secondary cause
3) possible cause
describe nursing diagnosis
identification of the health care of the client through analysis
name all 3 of nursing diagnosis
1) identify strengths = positive diagnosis
2) look at actual problems = actual diagnosis
3) look at potential problems = potential risk diagnosis
describe goal
determine priorities of diagnosis = set goal, identify criteria that prove the goal is met
