Nursing Process: Assessment Flashcards
It is a systematic client care-centered with 5 processes
Nursing Process
Nursing Process (ADPIE)
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
Gather information about the client’s condition.
What do you under this nursing process?
ASSESSMENT:
o Collect
o Organize
o Validates
o Document
Set goals of care and designed outcomes and identify appropriate nursing actions
What do you under this nursing process?
PLAN:
o Prioritize Problems
o Formulate Goals
o Select Interventions
o Write Interventions
Identify the client’s problems.
What do you under this nursing process?
DIAGNOSIS:
o Analyze
o Identify Problem
o Formulate Nursing Diagnosis
Determines if goals are met and
outcomes achieved.
What do you under this nursing process?
EVALUATION:
o Collect Data
o Compare
o Relate To Goals
o Conclude
o Continue/ Modify
o Terminate
Perform the nursing actions identified in planning.
What do you under this nursing process?
IMPLEMENTATION:
o Reassess
o Implement
o Supervise
o Assist
o Document
Process Involved in Nursing Process
o Critical Thinking
o Problem-solving
o Decision Making
Specific to the nursing profession
Nursing Process
Nursing Process is a framework for
Critical Thinking
“Diagnose and treat human responses to _____ or _____ health problems“
Actual or Potential
Purpose of Nursing Process
o Organized framework guide practice
o Problem solving method
o Systematic
o Goal oriented
o Dynamic-always changing, flexible
o Utilizes critical thinking processes
o Universally applicable
o Client-centered
o Interpersonal and collaborative
ADVANTAGES OF NURSING PROCESS
o Provides individualized care.
o Client is an active participant.
o Promotes continuity of care.
o Provides more effective communication among nurses and health care professionals.
o Develops clear and efficient plan of care.
o Provides personal satisfaction as you see client achieve goals.
o Professional growth as you evaluate effectiveness of your interventions.
Provide direction for planning interventions
Goals of Care
Actions taken by the nurse to
achieve patient goals and get
desired outcomes
Intervention
Critical thinking statements
that explain why a particular
intervention is necessary for
the patient’s care plan.
Rationale
To ensure the desired
outcome has been met
Evaluation
First Step of the Nursing Process
ASSESSMENT
TRUE OR FALSE?
ASSESSMENT - gathering information/collecting data
TRUE
Primary sources of an assessment
Client/Family
Secondary sources of an assessment
Physical Exam, Nursing
History, Team Members, Lab Reports, Diagnostic Tests.
TRUE OR FALSE?
ASSESSMENT - systematic, deliberate process
TRUE
To establish data base about the
client’s response to health concerns or illness and the ability to manage health care needs.
A. ASSESSMENT
B. DIAGNOSIS
C. PLANNING
D. IMPLEMENTATION
E. EVALUATION
A. ASSESSMENT
Collecting, organizing and communicating/recording
client data.
A. ASSESSMENT
B. DIAGNOSIS
C. PLANNING
D. IMPLEMENTATION
E. EVALUATION
A. ASSESSMENT
Assessment is finding all the “_________ ______ ______” to get a picture of your patient’s health status.
necessary puzzle pieces
Analyzes data about the patient, clients human responses, health status, strengths and concerns.
A. ASSESSMENT
B. DIAGNOSIS
C. PLANNING
D. IMPLEMENTATION
E. EVALUATION
A. ASSESSMENT
TRUE OR FALSE?
Assessment is a not continuous data collection.
FALSE
Assessment is a continuous data collection.
TYPES OF DATA
Objective Data and Subjective Data
From the client
Subjective Data
Observable data
Objective Data
