Nursing Process- Ch. 11-17 Flashcards
What is the acronym for the nursing process?
ADPIE
What are the 5 steps of the nursing process?
Assessment, Diagnosis, Planning, Implementation, Evaluation
What is done during the assessment step?
Collect and organize data
What is done during the diagnosis step?
Analyze data, identify nursing diagnoses and collaborative problems
What is done during the planning step?
Prioritize problems, identify measurable outcomes/goals, select nursing interventions, document the plan of care. BE SURE TO ALWAYS INCLUDE THE PATIENT IN THE PLAN.
What is done during the implementation step?
Carry out the nursing orders, document the nursing care and patient responses
What is done during the evaluation step?
Monitor client outcomes; resolve/con’t/revise the current plan for care
When you cluster data and organize info into similar categories, what does this do?
Facilitates ID of the patient’s problem
Assessment is a systematic process of ____, verifying, and ____ data about a patient.
collecting, analyzing
Why is documentation so critical?
It is a method of communication and other healthcare members like respiratory will see it, and it represents you.
The nursing process ensures that nurses are ____ centered rather than ____ centered
patient, task
What are sources of data?
Patient, family, medical record, social worker, literature resources
What are some methods of data collection during the assessment process?
Interview, Nursing Health History, Physical exam
What is important to remember about the interview?
It is your first impression to the patient.
It is an organized conversation where you obtain the patient’s health history and info about current illness.
What is included in the health history?
Bio info, reason for seeking health care, pt expectations, allergies, meds, family history, psychosocial, lifestyle patterns, review of systems
What are the 2 types of data?
Subjective from pt, and objective which is observed and can be verified by another person.
In what ways can you inspect someone?
visual, hearing and smelling
What is palpation?
Touch
What is percussion?
sound produced by striking one object against another
What is auscultation?
Listening w/ a stethoscope
What kind of data are part of the physical assessment?
diagnostic and laboratory data. Diagnostic is palpation, percussion, and auscultation.
What is the difference b/w a medical and nursing diagnosis?
Medical identifies diseases. Nursing focuses on unhealthy responses to health and illness. A medical diagnosis remains the same for as long as the disease is present, whereas a nursing diagnosis may change from day to day as the patient’s responses change.
What needs to happen in order to make a nursing diagnosis?
Data interpretation and analysis.Most experienced nurses begin the work of interpreting and analyzing data while they are still collecting (assessing) it.
What are the 5 different types of nursing diagnoses?
Actual, Risk, Possible (need more data), wellness and syndrome
What should be included in the diagnosis stmt?
Problem (NANDA), etiology, defining characteristics (S&S)
ex. bathing/hygiene self-care deficit related to/ fear of falling in the tub and obesity/ as manifested by strong body and urine odor, unclean hair: “i’m afraid I’ll fall in the tub and break something.” (5’4”, 170 lb)
When you prioritize problems, what must you remember?
You have to meet their most basic needs first–water, oxygen, food…ABC (airway, breathing, circulation)
During the planning process, you have to identify the ____ and determine the expected ______ as well as what?
GOAL, OUTCOME
As well as the time frame to achieve the goal.
Who is involved in the planning of goals?
The nurse AND PATIENT.
List 4 requirements of expected outcomes.
they should be patient focused, measurable, time limited, realistic.
Goal should be supported by S&S displayed by patient
T or F: Nursing interventions are based on rationale.
FALSE, it is scientific; evidence-based
Types of nursing interventions
monitor health status, anticipate and prevent complications, resolve, prevent, manage a problem, facilitate independence or assist w/ self-care and ADLs, promote well-being.
They can by MD initiated, or collaborative w/ other health care team
Evaluating the outcomes of intervention, require what skills?
CRITICAL THINKING. Was it the correct nursing diagnosis? Correct time frame?
