the nursing process Flashcards
what are the steps for the nursing process (think AAPIE)
- A = assessment
- A = analysis
- P = planning
- I = implementation
- E = evaluation
what is the point of assessment in AAPIE or the nursing process?
- assessment is for findings, documenting findings, organize data
what is the importance of analysis in AAPIE or the nursing process?
- analyzing queues, make hypothesis, look for potential problems, looking at risks for the PT
what is the importance of planning in AAPIE or the nursing process?
- coming up with goals for the PT, goals could be short term or long term, what can we do for that pt, setting a care plan, ect
what is the importance of implementing in AAPIE or the nursing process?
- using nursing interventions to provide care using clinical judgement model, use judgement to decide what to do for my patient
what is the importance of evaluation in AAPIE or the nursing process?
- evaluate the outcome of the patient, of my work, and plan for the pt
what is primary data related to assessment?
- patient interview, lab results, ect
what is secondary assessment data
- info that comes from sources other than the patient, family members, medical records, ect
what is subjective assessment data?
- patients verbalized symptoms, health history, ect
what is importance of analysis for the nursing process
- take all the info and put it together to recognize priories
- compare the information to expected findings
- make a plan and take action
what in the “planning” part of the nursing process
- involve the patient and maybe their support system in planning goals
- be sure the patient understands the plan or goal
- plan and organize data and next steps
what does nursing planning consist of?
- setting priorities
- establishing client goals / desired outcomes
- selecting nursing interventions
- writing individualized nursing interventions on care plans
how do nurses make appropriate goals for PT’s?
- make them smart goals
S = specific = begins with patient will
M = measurable = must have indicators
A = achievable = the outcome can be achieved
R = realistic = the patient must be able to complete the task
T = Timley = must have a limited time
what is an example of a SMART goal?
- pt will be able to walk to the bathroom independently at the end of the week
what are nursing interventions and activities?
- actions nurses perform to achieve goals
- ex: giving meds when patient is in pain
- treating signs & symptoms and defining characteristics
- interventions should promote, maintain or restore client health
what are examples of direct nursing care?
- basic care (bed bath, feeding, bed making, ect)
- reassessments
- ADL’s
- physical care, anything that’s touching, ex: wound dressing
- informal counseling (therapeutic communication)
- teaching
what is indirect nursing care?
- nursing interventions that are performed to benefit patients but don’t involve face to face contact with patients
ex: team communication, shift report, consulting with other staff
what is importance of evaluation for the nursing process
- final step of nursing process
- focuses on pt and pt response to nursing interventions & outcomes
- use pt outcomes to judge success (and use that to change care plan)
why is critical thinking important for nursing?
- it gives nurses foundations for clinical reasonings
- it allows nurses to do questioning, analysis, interpretation, and deductive reasoning
- it also allows us to listen to intuition & be creative
what is clinical reasoning
- it’s the interpretation of relevant data
- goes along with critical thinking and becomes critical decisions
- also has lots of reflection as what we can do better in the future
what is the NCSBN clinical measurement judgment model?
- it has different layers & is a framework for measuring clinical judgment and decision - making skills
- it shows 6 key cognitive skills needed for appropriate clinical judgement
what are the 6 NCSBN clinical judgment Measurements
- recognizing cues
- analyzing cues
- prioritizing cues
- generalizing solutions
- taking action
what is the ABCDE of nursing?
A = airway
B = breathing
C = circulation
D = disability
E = Exposure
- critical situations in nursing are preformed through instant clinical reasoning & do not involve patient input
what is priority setting framework?
- safety & risk reduction (ex: what is my risk of entering PT room
- least restrictive / invasive
- survival potential (mostly w/ mass casualties, with limited resources)
- acute vs chronic (work on pt with new symptom vs old ones)
- urgent vs non urgent: (some pt will just come first due to severity)
- stable vs nonstable = pt stable vital signs will be seen after unstable vital signs
what are the 5 rights of delegation?
- right task
- right circumstances
- right person
- right directions and communications
- right supervision & evaluation
