voc 33-37 & 44 Flashcards
Steps to the nursing process
ADPIE ASSESS DIAGNOSE PLAN INTERVENTION EVALUATION
Guidelines when caring for each client using critical thinking skills
Nursing care plan
systematic and continuous collection of data
Assessment
The statement of a clients actual and potential problem
Diagnosis
The development of goals for care and possible activities to meet
Planning
Giving actual care
Implementation or intervention
Measurement of effectiveness
Evaluation
A&O
Alert and oriented
C/O
Complains of
Objective data
Observations
Subjective data
Things patient states
Observations are
Visual
Tactile
Auditory
Olfactory
NSG
Nursing
HX
History
ADL
Activities of daily living
Febrile
Fever
A febrile
No fever
At risk for needs
potential needs
Existing needs are more important than potential needs
Measurable and observable info about client and his or her overall state of health
Objective data