The Nursing Process Flashcards
adpie
- assessment
- diagnosis
- planning
- implementation
- evaluation
assessment data collection
- tests to see results
- objective: vitals, diagnostic test results, facts, numbers
- subjective: pain, what client is telling you, their feelings, what family sees
assessment sources of data
- primary: client
- secondary: family, care taker, their chart
- tertiary: journal articles, nurses past experiences
- primary and secondary are directly related to client and tertiary is more general data
nursing diagnosis vs medical diagnosis
nursing: persons response to a condition, clinical judgement, wellness promotion or potential risks, may change, shows our autonomy
- medical: the condition and causes, remains same
steps in nursing diagnosis
1) identification
2) identify related factors
3) provide evidence to support diagnosis
identification
- identify focus that nursing diagnosis will address by looking at patterns in data that has been collected
- focus on experience of client and this around them
- likely to have more than one diagnosis
- verify diagnosis with client
identify related factors
- figure out why the client is having specific problem
- medical diagnosis can be of assistance
provide evidence to support diagnosis
- summarize data in AEB statement
- justifying why they have diagnosis
3 types of nursing diagnosis
- actual
- wellness or health promotion
- risk
focusing on entire person not just diagnosis
actual
- as issue for the client at the moment
wellness or health promotion
readiness for enhanced education
risk
things they are at risk for due to symptoms
why is standardized nursing language important
- improved communication among nurses and other professionals
- increase visibility of nursing interventions
- improved patient care
North American Nursing Diagnosis Association
- NANDA
- creates language to identify clients or communities responses to situations
- works closely with NIC and NOC
Nursing intervention Classification
- NIC
- what we are going to do
Nursing Outcome Classification
- NOC
- what we hope to see
International Classification for Nursing Practice
- ICNP
- nursing diagnosis classification system supported by WHO
- language similar to NANDA
- more used for electronic records and documentation
- linked with committee for international nursing language
- includes outcome statements
planning
- goals: resolution of the area of concern or achievement of the goal
- both short and long term (immediate vs future)
- outcomes: specific, measurable and patient specific. how goal will be measured, what we will see in client
Goals should be…
- specific
- measurable or meaningful
- attainable or action-oriented
- realistic of results-oriented
- timely or time-oriented
- start with “increase, decrease, improve, maintain, or stabilize”
implementation
- interventions: what we as nurses can to do address the areas of concern or to support wellness
evaluation
- reassess or evaluate to see if desired outcomes have been met
goals vs objectives
- both measurable
- goals: broad
- outcomes: measurable piece of a goal
- ex: goal- decreased work of breathing
objective- respiratory rate between 16 and 20
