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MCC Nrsing Process 2

Nursing Process II Exam 3

What is Nursing Intervention? Are actions, based on clinical judgement and nursing knowledge that are used to achieve clients outcome.
What is Independent nursing intervention? Are actions that the nurse can prescribe, perform or, delegate based on their knowledge and skill. Does not require a providers order. They are usually in response to a nurses diagnosis.
What is dependent nursing intervention? Are actions that are prescribed by the clinician but are carried out by the nurse at the bedside. IE diagnostic testing, IV therapy, medications
What is interdependent (collaborative) intervention? Are actions that are carried out with other health care team members. IE PT, OT, Dietitians, physicians
What is a direct care intervention? Performed through interactions with the client
What is indirect care intervention? Performed away from the client but on the behalf of the client. IE advocacy , referrals, consulting with other member of the healthcare team.
What is ADPIE? A~ assessment D~ diagnosis P~ Planning and outcomes I~ implementation E~ evaluation
Implementations is...? Performance of nursing actions. Involves direct and indirect intervention. Reassessing the patient to see if change have occurred. Organize Resources and Care Delivery and anticipate and prevent complications
What happens during the Evaluation step? Determines if the client goals have been met. Goals are created in this step. An ongoing process of continuous evaluation to make informed decisions.
What are the five steps of objective evaluation? Identify evaluative criteria and standards Collect Data Interpret and summarize findings Document findings Terminate, continue, or revise the care plan
What are the 5 different types of nursing diagnosis? Actual, Potential (Risk for), Possible, Collaborative Problem, and Wellness diagnosis
What are nursing orders? Instructions usually on a nursing care plan that describes when and how nursing interventions are to be implemented. different than goals.
What are the components of a Nursing Order? Date: date that the order was written Subject: Should always be the nurse. Do not need to to write "the nurse" but it should be understood. Action verb: tells the nurse what action to take.
Nursing order continued... Times and Limits: state when, how, where, frequency, duration. Should be structured around patient. Signature: the nurse writing the order should sign.
What is delegating? is the process of directing another person to perform a task or activity and maintaining accountability.
What are the 5 rights of delegation? Can I delegate this task? Right Task, Right Circumstances, Right Person, Right Communication, Right Supervision
Evaluation is... ? the final step of the nursing process. It is ongoing, planned, and systematic activity. Evaluate the patients progress towards goals, effectiveness of care plan, quality of nursing care in the health care setting.
What does a nurse need during Implementation stage? Cognitive, Interpersonal, and Psycho motor skills
What is the order of nursing diagnosis in Maslow's Hierarchy of Needs? 1. Physiological 2. Safety and security 3.Love and Belonging 4. Self Esteem 5. Self Actualization
5 Steps of objective evaluation 1.Identify evaluative criteria and standards 2.Collect Data 3.Interpret and summarize findings 4.Document findings 5.Terminate, continue, or revise the care plan
Created by: MCCGroup5