Nursing process Flashcards
What are the 5 steps of the nursing process?
assessment diagnosis planning implementation evaluation
ADPIE
What is the nursing process?
problem-solving approach to identifying, diagnosing, and treating the health issues of clients
What are the characteristics/traits of the nursing process?
it is: planned problem-oriented (works towards a need) goal directed patient centered
What is the purpose of assessment?
to establish a baseline of data in regards to needs, health problems, responses to health problems, related experiences, health practices, goals, values, lifestyle, and expectations of HC system
What are the 2 steps to assessment?
data collection
data analysis
How do you go about collecting data. what should you be gathering and what is important to recognize?
HOW: interview plus physical assessment (description must be clear, concise, and non-judgemental)
WHAT: subjective and objective data
RECOGNIZE sources as primary or secondary. verify with patient to confirm data
What are the things that coincide with data analysis?
interpreting data
data clustering (recognizing patterns and clues)
compare with the norm
make a conclusion
What is diagnosis?
deliberate and systematic process of data analysis and synthesis which ends in clinical judgement
Make sure it is a nursing diagnosis/intervention
What are the three parts of diagnosis?
IDENTIFICATION of patient problems and strengths (this will help you develop a plan)
FORMULATES diagnosis
WRITING a diagnostic statement (has to be something you can treat as a nurse)
What are the characteristics of the problem being diagnosed?
must be:
response to a life process, event, stressor
require intervention or resolve
results in ineffective coping
is undesirable
nurse must be competent to treat
Why is it important to consider the individuals strengths and weaknesses?
because it will influence the treatment.
Ex. problem may be that they are at risk of skin breakdown because they are incontinent (weakness)
a strength may be that they are very mobile and this will reduce the risk
when do you create a diagnosis statement?
in response to an actual or potential problem
What are the key words of a Diagnosis statement?
PROBLEM: what is wrong
RELATED TO: why is it a problem. (this is not a medical diagnosis)
MANIFESTED BY: your data, how do you know it is wrong
Give an example of a diagnosis statement.
the patient suffers from pain related to a herniated disc manifested by lack of mobility and problems sleeping
when do you not include manifested by in a diagnosis statement?
when it is a potential problem
ex. patient is at risk for skin breakdown related to incontinence
What is important about making a diagnostic statement?
must not be a medical diagnosis as the problem.
incorrect to say that the problem is a herniated disc, but could say the problem is pain as a result of a herniated disc
how do you phrase a nursing diagnosis statement about an actual problem?
“problem related to cause manifested by….
How do you phrase a nursing diagnosis statement about a potential problem?
potential for problem related to cause…..
What is the planning process?
it is where you set patient centered goals and expected outcomes
select nursing interventions to achieve goals
What characteristics should the goals have?
must be clear, measurable, time sensitive, realistic, and mutual/shared
should only address one problem at a time (may have multiple goals, but they must address the same diagnosis)
ex: lungs will be clear at the afternoon assessment
What are the 3 steps to planning?
set priorities
develop goals/expected outcomes
select interventions
What does setting priorities mean?
depend on needs and desires of patient
which problems require immediate attention and which can be dealt with later
priorities change as patient condition changes.
What are the characteristics of goal/outcome statements?
must be: client centered involve one behavior (singular) observable time limited measureable mutual realistic
What is involved in planning?
Selecting interventions:
actions designed to assist patient from present health to that which is described as the goal and measured with expected outcomes
includes activities to assist and enable
or in palliative cases, to experience peaceful death
What is the implementation phase?
- application of actions/interventions
- treatment based on clinical judgement and clinical knowledge to enhance patient outcomes
- reflect all dimensions of the individual
What are direct care interventions?
things that you yourself are doing
What are indirect care interventions?
things you do away from the bedside:
getting a physio consult
documenting
getting the next nurse involved
What is the evaluation phase?
process of determining if the goals have been attained
measure of nursing actions and progress toward achieving goals
MODIFICATION: when goals not met, first examine why; necessitates change in plan of care
Would you go through modification if goals were met?
yes, may be a better way of doing it that will improve the patients care
What are the 5 steps to evaluation?
- identify evaluative criteria/standards
- collect data and determine if the criteria and standards have been met
- interpret and summarize your findings
- document your findings
- terminating, continuing care plan as is, or modifying care plan
