Week 1 Flashcards
What is the Nursing process
ADPIE
Assessment
Collect and analyze data
Medical diagnosis
Focuses on disease and pathology
Nursing diagnosis
Focuses on patient response to illness
How is data used
By other disciplines
For Nursing Care
To ensure clients receive
-proper care
-by qualified individuals
-at the correct time
Cana RN delegate assessment
No.
CNA and LPNs can collect data such as vital signs. However it is the RNs responsibility to assign those tasks, confirm accuracy of data, conduct interview and do physical assessment.
What are the types of data
Objective, subjective, primary, and secondary
Objective data
Data the nurse observes.
Data that comes from lab, etc.
Can be measured
Subjective data
What the patient reports
Primary data
Obtained directly from the patient or observed the patient.
Vitals.
Secondary data
From someone other than patient. Includes patient record.
Skills of the nursing assessment/how to obtain data
Observation
Physical assessment
Interviewing
Nursing interview
Structured communication
To gather subjective data
Can be done direct or nondirect
Directive interview
Closed ended. Nurse in charge
Nondirective interview
Open ended.
Patient in charge.
When to verify data
Subject and objective data conflict
Clients statement are inconsistent
Data is far out of normal range
Factors that impact accuracy are present
Documentation Guidelines
-do so soon as possible
-rarely use acronyms
-use patient’s own word when possible
-use concrete specific information
-document cues but not inferences
Diagnosis
Analyze and interpret the data
Draw conclusion
Very conclusion
Prioritize problems
Health problem
Disease or illness that requires intervention
Nursing Diagnosis
Health problem that nurse identifies, prevents, or treats independently.
Diagnostic reasoning
Use critical thinking to analyze and interpret data
Draw conclusions about health status
Verify problems with client
Record diagnostic statement
Prioritizing problem
Maslows hierarchy of needs guides priority for nurses. Multiple problems can be addressed at once.
