nursing process

Question 1

ADPIE

Answer 1

Assessment, Diagnosis, Planning, Implementation, Evaluation

Question 2

Assessment

Answer 2

first step
data collection (objective and subjective)
Sources of data (primary, secondary, tertiary)

Question 3

objective data

Answer 3

BP, vitals, blood work, diagnostic test results no judgement

Question 4

subjective date

Answer 4

pain, source of pain, pain scale, what they tell you, their feelings or family account

Question 5

primary

Answer 5

client

Question 6

secondary

Answer 6

family or caretaker, chart, past doctors/nurses

Question 7

tertiary

Answer 7

journal articles, past experience (general: research, science behind understanding the illness/ symptoms)

Question 8

diagnosis

Answer 8

second step in the process

nursing vs medical

Question 9

nursing diagnosis

Answer 9

clinical judgement about an individual, family, or community responses to actual and potential health problems or life processes. The goal of nursing diagnosis is to identify actual and potential responses. may change from day to day as the patients response may change

Question 10

Medical diagnosis

Answer 10

identification of a disease condition based on a specific evaluation of physical signs, symptoms, history, diagnostic test and procedures. The goal is to identify the cause of an illness or injury and design a treatment plan. REmains the same as long as the disease is present

Question 11

Maslow hierarchy of need

Answer 11

1. physiological
2. safety
3. love/belonging
4. esteem
5. self-actualization

Question 12

nursing diagnosis steps

Answer 12

1. identification
2. identify related factors
3. provide evidence to support diagnosis

Question 13

step one: identification

Answer 13

identify the focus that the nursing diagnosis will address by looking at patterns of data. the focus is on the experience of the client and those around them, not medical diagnosis
clients likely to have more than more diagnosis, verify diagnosis with patient

Question 14

step two: identify related factors

Answer 14

figure out why client is having specific problem, medical diagnosis can be of assistance here

Question 15

step three: provide evidence to support the diagnosis

Answer 15

summarize data in the As Evidence By (AEB) statement

Question 16

3 types of nursing diagnosis

Answer 16

actual (issue for them right now), wellness or health promotion (education), risk (potential)

Question 17

why is standardized nursing language important

Answer 17

improved communication among nurses and other professionals, increased visibility of nursing interventions, improved patient care

Question 18

North American Nursing Diagnosis Association

Answer 18

NANDA: created the language to identify clients or communities responses to situations (updated every 2 yrs)

Question 19

Nursing Intervention Classification

Answer 19

NIC: what were going to do

Question 20

Nursing Outcome Classication

Answer 20

NOC: what we want to see

Question 21

International Classification for Nursing Practice

Answer 21

ICNP: nursing diagnosis program that is approved by the WHO, similar to NANDA, difference is that ICNP is used more for electronic documentation, linked with SNOWMED, internationally accepted for health care, actually includes outcome statements

Question 22

Planning

Answer 22

goals- broad, resolution of the area of concern or achievement of the goal (both short and long term)
outcomes-specific measurable piece of the goal and patient-specific (client will…)
establish patient goals

Question 23

goals should be…

Answer 23

specific, measurable or meaningful, attainable or action-oriented, realistic or results-oriented, timely or time-oriented
** goals start with increase, decrease, improve, maintain or stabilize**

Question 24

outcomes

Answer 24

never what nurse is going to do but what the patient will do

Question 25

implementation

Answer 25

interventions: what can we as nurses do to address the areas of concern or to support wellness

Question 26

evaluation

Answer 26

the final step, reassess or evaluate to see of desired outcomes have been met