Nursing Process Flashcards
What does ADPIE stand for?
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
Assessment involves the gathering of information of what sources?
- Pt’s S/S
- Pt Hx
- Subjective findings from the pt (Interviewing)
- Objective findings (Physical Assessment/Vital Signs/Diagnostics/Labs)
Nursing diagnoses are related to the ____ or _____ a patient is experiencing.
needs, problems
Are nursing diagnoses the same as medical diagnoses?
No, they are completely different in that nursing diagnoses are selected based on definitions and defining characteristics
The process of determining priorities and what nursing actions should be performed to help resolve or manage a pt’s problem is done in which step of the nursing process?
Planning
In the planning step, in order for the pt to meet the nursing diagnosis, the nurse should determine what?
- Expected outcomes within a realistic time frame
- Appropriate interventions
Implementation is the process of taking _____ to resolve the pt’s problem/nursing diagnoses.
action
The actions that are taken to resolve a pt’s problem/nursing diagnoses are called _____. When the nurse performs these interventions, it is called _____.
- Interventions
- Implementation
What occurs during Evaluation?
The nurse reflects on the interventions performed and decides whether the pt is closer to achieving the goals and outcomes set in the planning step.
What should you do if the pt does not achieves the goals and outcomes set in the planning step?
- Revise and change interventions
- Revise and change goals
Always tailor interventions and goals to the pt.
A care plan is a documented plan for giving patient care and includes three components which are?
- HCP’s orders
- Nursing diagnoses
- Nursing orders/interventions
How is objective data limited?
It is limited to that which you can detect with your senses – vision, hearing, smell, or touch.
Give some examples of objective data that can be collected via vision.
- Directly observing the pt’s physical characteristics, facial expressions, actions, or behavior
- Directly observe characteristics of bodily fluids (blood, emesis, urine, stool, or drainage)
- Read results of diagnostic/lab test results
- Read reports and documentation within the patient’s medical record
- Read results and discern the function of equipment
- Observe the measured volume of urine or drainage in a graduated container, the volume of fluid remaining in the IV bag and/or the amount of liquid drunk from a cup with graduated markings
- Read reputable sources (medical journals, and multimedia devices) to research medical diagnoses, and treatments
Give some examples of objective data that can be collected via sight.
- Note sounds made by the patient heard (spoken words, belching, passing flatus, crying, moaning, snoring)
- Note sounds heard during auscultation (respiratory, cardiac, GI)
What are some examples of objective data that can be collected via smell?
Detect patient body- or bodily fluid-related odors (foul, sweety, fruity, ammonia-like, sulfurous, fresh, or musty)
What are some examples of objective data that can be collected via touch?
- Assess pulse rate
- Palpate for edema, firmness or softness, nodules, skin masses, or tissue
- Detect the pt’s skin temp
- Detect the moisture of the pt’s skin
- Detect the texture of pt’s skin, hair, or nails
- Measure the strength of muscular contractions
What are some examples of subjective data?
What the patient feels:
- Pain
- Nausea
- Anxiety
- Fear
- Depression
- Discouragement
Primary data refers to information provided by the patient whereas secondary data refers to information from?
- Family members
- Friends
- Patient’s chart
How would subjective data from a pt be documented in the chart?
Pt states/stated “(What they said)”
How would you document objectively when you see a patient is crying?
Pt’s eyes are red and the patient is wiping away tears.
Do not draw a conclusion or inference i.e. the pt is sad, depressed, or discouraged.
When meeting/interviewing a pt for the first time, it is important to establish _____.
Rapport (creating a relationship of mutual trust and understanding)
How can you establish rapport with the pt?
- Introduce yourself and explain your role in the pt’s care.
- Ensure that you have already reviewed the pt’s chart to avoid asking the pt questions that they have already answered and instead validate the information.
- Inform the pt the purpose of the interview and approx. length of time it will take
- Ask some general questions/make small talk to ‘break the ice’ before the interview
Why should nurses be concerned with the pt’s medical diagnoses?
- Pt’s medical diagnoses affect the pt’s abilities to care for themselves and their families; and their quality of life
In addition to asking questions from an interview form, it is important to also ask for additional information (that is not specified on the form) because valuable information can be obtained that would be crucial in providing appropriate nursing care. TRUE or FALSE.
TRUE
If the admission form asks about previous hospitalization and the pt responds by listing two recent surgeries, how can you ask for more additional information concerning this question?
“What about when you were a child, or a young adult? Were you ever hospitalized then?”
If a pt is giving more detail than is necessary for you to obtain relevant information or is going on a ‘tangent’, how can you redirect the pt to the subject at hand?
- “Can you tell me more about the pain you have been experiencing?”
- “After that happened, what did you do to relieve the pain?”
When performing a physical assessment, what are you inspecting for?
- Appearance of and breaks in the skin
- Appearance of the eyes, ears, nose, mouth, chest, abdomen, limbs, and genitals
When performing a physical assessment, what are you palpating for?
Touching the torso and limbs for:
- Pulses
- Temperature
- Moisture
- Vibrations
- Abnormal lumps
During a patient interview, if the pt hesitates before answering a question. How would you respond?
Give the pt time because they may be thinking through an answer. If they continue to hesitate, you may need to reword the question.
During a patient interview, if the pt responds w/ a vague answer using phrases such as “not exactly,” “sort of”, “maybe,” or “you could call it that” in replay. How would you respond?
Ask the pt to provide more detail or to be more specific so that you can get a clear picture of what is being described
During a patient interview, if the pt looks away or acts uncomfortable when you ask a question. How would you respond?
Apologize if the question seems intrusive and explain that the information is necessary for you to better understand how the illness is affecting the pt’s life and relationship.
When performing a physical assessment, what are you auscultating for?
Listening for abnormal sounds in the lungs, heart, or bowels
When performing a physical assessment, what are you percussing for?
Detect abnormalities of internal organs