The Nursing Process/ Thinking Like a Nurse Flashcards
What are the steps of the nursing process? Define them.
ADPIE which stands for;
Assessment; Collecting, validating, and communicating patient data (objective and subjective)
Diagnosis: Analysis of patient data to understand patient strengths and problems
Planning/Outcome Identificiation: Specifiying thereapuetic patient outcomes and appropriate nursing interventions.
Implementing: Execution of care plan
Evaluating: Measuring the extent at which patient reached ideal outcomes.
What is an Initial Nursing assessment?
An Intial Nursing Assessment involves collecting and establishing a complete database that will be used as reference for problem identification, reference, and future comparison.
What is a Problem Focused Nursing Assessment?
Is a short and focused prioritized assessment that typically is used to “flag” risks in a patient. And is an ongoing assessment that is used to identify the problem by the standards of the initial assessment.
What is an emergency Nursing Assessment?
Emergency Nursing assessments are used in a medical crisis to identify a life threatening problem or overlooked problems.
What is a Time-Lapsed Nursing Assessment?
Follows weeks-months after a patients initial assessment and is used to compare a paitents current health status to that of their original baseline status that was gained from their initial assessment.
Differentiate Objective from Subjective Data?
Objective data is data collected from observaions and is seen, heard, or felt by someone other than the patient experiencing the symptoms.
Subjective Data is data collected and percieved from the patient experiencinig the reported symptoms.
Name the Steps, in order, that make up a Nursing Assessment.
1) Preparing for Data Collection
2) Collecting Data
3) Identifying Cues and Making Inferences
3) Validating Data
4) Clustering related data and identifying patterns
5) Reporting and Recording Data
What methods are used to collect Subjective Data? What are possible sources of Subjective Data?
Subjective Data collection involves interviewing and therapeutic communication skills. Of which require empathy, listening, and caring abilities.
Subjective data, while most reliably obtained from the admitted patient, can be obtained from Client Family and SO’s, Client records, and other healthcare professionals.
What methods are used to collect Objective Data and what are their possible sources?
Objective data is obtained from a physical exam and observation of the patient and most relieably is obtained from a health care professionals assessment.
What are the steps that lead to a nursing diagnosis in proper sequence?
1) Assessment (Collecting Data, Identifying Cues and making inferences, Validating Data, Clustering related Data and identifying Patterns, Reporting and Recording data).
2) Clinical Reasoning (Analyzing, synthesizing, Reflecting, making judgements and drawing conclusions).
3) Diagnosis
What are the three parts that make up a Nursing Diagnosis?
1) Diagnosis/Problem
2)Related to (Etiology/Cause)
3) As Evidenced By (Data to back this up)
What is a Problem Focused Nursing Diagnosis? And how is it structured?
A problem Diagnosis is a 3 part Nursing Diagnosis whose make up consists of;
Problem Focused diagnosis->Related To Factors->AEB Factors
What is a Risk Nursing Diagnosis? And how is it structured?
A Risk Nursing Diagnosis is made up off 2 parts of which are;
At risk for BLANK->AEB
What is a Health promotion Diagnosis and how is it Structured?
A Health Promotion Diagnosis is a 2 part diagnosis that does not require any related to factors. Rather HPD involve providing evidence that indicate a patients willing participation in bettering their health.
In order what are the steps to Outcome Identification and Planning?
1)Establish Priorities
2)Identify expected patient outcomes.
3) Select evidence based nursing interventions.
4)Communicate the plan of care.
