nursing process Flashcards
ADPIE
Assessment, Diagnosis, Planning, Implementation, Evaluation
Assessment
first step
data collection (objective and subjective)
Sources of data (primary, secondary, tertiary)
objective data
BP, vitals, blood work, diagnostic test results no judgement
subjective date
pain, source of pain, pain scale, what they tell you, their feelings or family account
primary
client
secondary
family or caretaker, chart, past doctors/nurses
tertiary
journal articles, past experience (general: research, science behind understanding the illness/ symptoms)
diagnosis
second step in the process
nursing vs medical
nursing diagnosis
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
Medical diagnosis
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
Maslow hierarchy of need
- physiological
- safety
- love/belonging
- esteem
- self-actualization
nursing diagnosis steps
- identification
- identify related factors
- provide evidence to support diagnosis
step one: identification
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
step two: identify related factors
figure out why client is having specific problem, medical diagnosis can be of assistance here
step three: provide evidence to support the diagnosis
summarize data in the As Evidence By (AEB) statement
3 types of nursing diagnosis
actual (issue for them right now), wellness or health promotion (education), risk (potential)
why is standardized nursing language important
improved communication among nurses and other professionals, increased visibility of nursing interventions, improved patient care
North American Nursing Diagnosis Association
NANDA: created the language to identify clients or communities responses to situations (updated every 2 yrs)
Nursing Intervention Classification
NIC: what were going to do
Nursing Outcome Classication
NOC: what we want to see
International Classification for Nursing Practice
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
Planning
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
goals should be…
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**
outcomes
never what nurse is going to do but what the patient will do
