Nursing Process Flashcards
What is the nursing process
Framework to identify diagnose and treat human responses to health and illness
Requires critical thinking
ADPIE
What is ADPIE
Assessing
diagnosing
planning
implementing
evaluating
What are the characteristics of the nursing process
Analytical, Dynamic, Organized, Outcome oriented, Collaborative, Adaptable
What does it mean to be adaptable
To be able to adjust according to what’s wrong with the patient, constantly prioritizing
What are the steps to the nursing process and brief decription
Assessment: data is gathered through observations
Diagnosis: Data is analyzed, validated and clustered. problem is then stated in the diagnosis’ provided
Planning: Diagnoses are prioritized and goals are identified
Implementation: Interventions are set and treatments designed to achieve goals and outcomes
Evaluation: Nurse determines: were goals met? What was effective? What wasn’t?
What is critical thinking
Using thinking to provide clarity and increase precisions to specific situations
Allows nurses to collect essential patient data
Care plans
Developed using the nursing process
Handwritten or part of EMR
All patients have their own unique, patient centered plans designed to meet their specific needs
Assessment
Data collection begins at the first direct or indirect encounter with the patient
Collected through patient interview, health history, physical assessment
Collected from variety of sources, family, friends, records, labs
Data is organized, validated and established un database
Direct encounter
Nurse controlled, very structured, to obtain specific info
Indirect encounter
Patient controlled, helps build rapport
What is primary data
Information obtained directly from a patient
What is Secondary data
Collected from family members, friends, health care professionals. or medical records and tests
What is subjective data
Spoken data ( symptoms )
Patients feeling about a situation or comments about how they are feeling
Documented in the patients medical records as quotations “I didn’t get much sleep”
What is objective data
Observable or measurable
Data collected from medical records, laboratory, diagnostic test results
( pale skin, vomited 50 mL )
Diagnosis
Identifies a problem, potential problem, or opportunity of improvement
3 types: Actual, Risk and Health promotion
What is a risk nursing diagnosis
Where a problem does not exist but there are risk factors indicating it’s likely to develop unless intervened
What is a health promotion diagnosis`
Reflects the patient’s readiness to improve an aspect of health, awareness of well-being and the desire to maintain or enhance this state
What is actual diagnosis
Patient problem that is PRESENT at the time of the nursing assessment
Planning
Prioritizes nursing diagnosis, establishes short and long term goals
Chooses outcome indicators,
Identifies interventions to address specific goals
How do you prioritize diagnosis
Priority goes to the most severe
severity depends on symptoms and the patients preference
What are short term goals
Extend less then 1 week
What are long term goals
Last weeks to months
Implementation
Focuses on the initiation of appropriate interventions designed to meet needs of patient
Interventions can be dependent, independent or collaborative
Care can be direct or indirect
3 types of clinical plans
Direct care
Interventions that are carried out by having personal contact with the patient
Cleaning incision, administering injection
Indirect care
Interventions performed to benefit patients but do not involve face to face
giving change of shift report, communicating with other team members
Dependent interventions
Tasks the nurse undertakes that are within nursing scope of practice but require the order of a primary care provider
( administering oxygen or meds )
Clinical pathway care plan
Care pathway, maps or critical pathways.
Multidisciplinary resources that guide patient care
Protocol care plan
Written plans that can be generalized to groups of patients with same or similar needs
Standing order care plan
Physician orders that are pre-approved
Evaluation
Focuses on the patients response to the nursing interventions and goals
Identifies the effectiveness of interventions
Determines if the short and long term goals were met and if desired outcomes were achieved