nursing process Flashcards

1
Q

ADPIE

A

Assessment, Diagnosis, Planning, Implementation, Evaluation

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2
Q

Assessment

A

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

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3
Q

objective data

A

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

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4
Q

subjective date

A

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

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5
Q

primary

A

client

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6
Q

secondary

A

family or caretaker, chart, past doctors/nurses

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7
Q

tertiary

A

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

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8
Q

diagnosis

A

second step in the process

nursing vs medical

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9
Q

nursing diagnosis

A

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

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10
Q

Medical diagnosis

A

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

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11
Q

Maslow hierarchy of need

A
  1. physiological
  2. safety
  3. love/belonging
  4. esteem
  5. self-actualization
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12
Q

nursing diagnosis steps

A
  1. identification
  2. identify related factors
  3. provide evidence to support diagnosis
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13
Q

step one: identification

A

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

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14
Q

step two: identify related factors

A

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

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15
Q

step three: provide evidence to support the diagnosis

A

summarize data in the As Evidence By (AEB) statement

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16
Q

3 types of nursing diagnosis

A

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

17
Q

why is standardized nursing language important

A

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

18
Q

North American Nursing Diagnosis Association

A

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

19
Q

Nursing Intervention Classification

A

NIC: what were going to do

20
Q

Nursing Outcome Classication

A

NOC: what we want to see

21
Q

International Classification for Nursing Practice

A

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

22
Q

Planning

A

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

23
Q

goals should be…

A

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**

24
Q

outcomes

A

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

25
Q

implementation

A

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

26
Q

evaluation

A

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