Nursing Process Flashcards
(34 cards)
What is the nursing process?
A plan of care. Similar to the scientific method.
Why do nurses use it?
A way to think & solve a problem.
How many parts are there?
- ADPIE OR ADGIE.
What is assessment?
Data is collected which is used to identify client problems that can be managed or treated with nursing care.
What are examples of data a nurse would be interested in assessing?
Labs, vitals, pain level, diagnosis, past medical history, situation, appearance, mental status, breathing pattern, I&O, etc.
What does assessment of data include?
Collection, verification, organization, interpretation, + documentation of data.
How do we collect data and what do we keep in mind?
On our SBAR form. Maslow’s Theory of Basic Human Needs + Erikson’s Theory of Growth & Development
What are some sources of client data?
The patient, the chart, the family, & other medical professionals
What is the difference between subjective and objective data?
Subjective: data you can’t feel or see. A symptom. E.g headache
Objective: data you can see. A sign. E.g bruise
What is a nursing diagnosis?
A statement of a client problem which has been inferred from the collected data.
Abnormal findings support the diagnosis.
How is a nursing diagnosis different from a medical diagnosis?
It is a response to a health problem.
What is a clinical judgment about individual, family, or community responses to actual, at risk, or high risk health problems or wellness states?
A nursing diagnosis.
What does a nursing diagnosis have?
Two parts.
What does R/T mean?
Related to
Types of diagnosis?
Problem statement R/T cause
Diagnostic label R/T etiology
Unhealthful response R/T contributing factors
What are actual diagnoses?
Problems that exist.
What are risk diagnoses?
Problems which might occur.
What should not be the same with a nursing diagnosis?
The nursing diagnosis and etiology.
What does a 3 part nursing diagnosis give?
Diagnostic label, the etiology, and the signs + symptoms
What is AEB?
As evidenced by
What is planning?
Involves setting the goals + planning the care.
What do the goals give?
The specific behaviors you expect to see after your plan is put in place.
What should the goal reflect?
The client’s optimal level of wellness.
How is the goal done?
With client collaboration when possible + stated in the client’s point of view.
It is usually the opposite of the problem.
