Nursing Process Chapter 11-16 Fundamentals (Freshman)
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| ASSESSING, DIAGNOSING, PLANNING, IMPLEMENTING, EVALUATING | ADPIE
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| Systematic, continious collection, validation, communication of client data | Assessing
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| All pertinent information collected by the nurse and others during the assessment | Database
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| What depends on complete and accurate data during assessment | All other pieces of the nursing process
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| Client responses to health problems are the | Data focus
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| Perceived by the senses, signs overt data, can be verified by another | Objective Data
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| Comes from the client, can not be verified, symptoms | Subjective Data
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| Observation, nursing history (interview, verify by asking), physical assessment are the components of | What are the components of data collection?
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| The assessment must be | Complete, Factual, Accurate, Relevant information
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| Client, Support systems (family), client record, other professionals, literature | What are the sources of data in assessment?
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| Data must always be | Validated, Communicated, Documented (if not, it did not happen)
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| Diagnosing | Identifies the causes of the problem
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| Diagnosing | Identifies actual and potential problems
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| Nursing diagnoses | We look at actual or potential health problems that can be prevented or resolved by independent nursing interventions when writing this
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| 5 steps to nursing diagnoses | Interpret data, Cluster data, Determine problem areas, and write the _______
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| To cluster data in diagnoses a nurse needs to make the conclusion | No problem, possible problem, actual problem, wellness issue
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| Actual problem | Problem is present (diagnosis)
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| Risk for problem | Patient is vulnerable to developing the problem (diagnoses)
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| Possible problem | More data needs to be established (diagnoses)
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| Patient already working on the problem and desires to do even better (diagnoses) | Wellness issue
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| Need, due to, neglence, healthy, mediacal diagnosis, permanent, poor, inadequate, abnormal, unhealthy are all | Unacceptable terms for diagnoses
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| Problem-->related to-->etiology (cause)-->as evidenced by (characteristics) | Format of a written nursing diagnoses
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| Nursing diagnosis, how is the problem written? | NANDA terms
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| What are the defining characteristics of the nursing diagnoses? | As evidenced by or as manifested by: (subjective and objective data that signal the existence of the problem... the CUES that reflect the existence of the problem.
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| How is the nursing diagnosis prioritized? | Maslow's hierarchy, Client problems, Anticipation of future problems
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| Identify goals (outcomes) with the client | Planning
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| When we identify interventions to help we are in the ____ process | Planning
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| Complete care plan is a | Formal Plan
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| Moment by moment planning is | Informal plan
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| Initial (on admission), ongoing (reformed from new data), Discharge (begins on admission) are the phases of | Planning
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| Discharge planning is a phase of planning that should include | Teaching, counceling to prepare for home/self care
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| How many goals/outcomes per nursing diagnosis should there be? | At least 1 (The patient will ...)
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| Writing the goals/outcomes can be written in | Short term or Long term
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| What should the goals/outcomes of planning include? | Cognitive, Psychomotor, Affective (feelings beliefs and attitudes.. hard to measure)
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| Cognitive is (goal/outcome) | Thought (ability to explain)
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| Psychomotor is (goal/outcome) | Ability to demonstrate
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| Does the nursing goals/outcomes in planning have to be measurable? | Yes
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| This has a Subject(client), Verb (Action), Condition (how it will be achieved.. not always included), performance criteria (observable, measurable terms), target time (when patient is expected to achieve the ______) | Parts of the goal or outcome in planning... how to write the measurable outcomes
ex. During the next 24-hour period the patient's fluid intake will total at least 2,000 mL. OR AT the next visit, 12/23/09, the patient will correctly demonstrate exercise
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| When I say: "The client will... What do I mean? | I am establishing the goals/outcome in planning
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| If a goal is well written, then we will know that we have formed a base to be able to | Evaluate whether the patient's problem has been solved
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| Contains goals/outcomes, Contains nursing orders that establishes specific nursing care to be done for the client to assist in resolving the problem | Planning
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| When I carry out the nursing orders I am | Implementing
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| Another term for implementing | Interventions
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| When I assist the client to achieve health goals or outcomes I am | Implementing the nursing orders
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| What are the 5 types of orders to be implemented? | Independent, Dependent, Collaborative, Protocols, Standing
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| If the nurse follows nursing orders | Independent interventions
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| When the nurse carries out orders by the physician | Dependent Interventions
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| If the physician has the nurse consult the social worker then the nurse carries out the orders | Collaborative intervention
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| Nurse initaited interventions that are written plans that detail the nursing activities to be executed in specific situations | Protocols (admission and discharge)
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| A protocol that empowers a nurse, it initaites certain actions that usually requires an order or supervision of the doctor (emergency situations like bowel interventions, narcotic OD, reverse respiratiory depression) | Standing orders (interventions)
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| A measure of how well a client has achieved goals/outcomes | Evaluation
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| Identifies factors contributing to client's success or failure | Evaluating
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| On evaluation what do we do if we find that the goal is unmet or partially met? | Modify, collect more data, delete diagnoses, make goal more realistic, adjust time, change interventions
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| On evaluation, what are the options? | Goal met, Goal partially met, Goal not met
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| Prepared care plans that ID Diagnosis, outcomes, Interventions common to a specific population | Standarized care plans
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| On admission a nursing history and physical assessment are obtained | Initial planning
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| When a nurse perfects, changes, or updates a care plan prn | Ongoing planning
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| Begins at admission and involves home care, community resources etc. | discharge planning
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| Intial planning, Ongoing planning, and discharge planning are | Comprehensive care planning, needs to be kept up to date
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| Within 1 day of teaching, the patient will list 3 benefits of continuing to apply moist compresses to leg ulcer after discharge (what is this) | Outcome cognitive (knowlege increased)
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| By 6/12/09, the patient will correctly demonstrate application of wet to dry dressing on leg ulcer | Outcomes/goals of planning, psychomotor (achievement of new skills)
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| By 6/12/09, the patient will verbalize valuing health sufficiency to practice new health behaviors to prevent recurrence of leg ulcer | Outcome/goals of planning, Affective (changes in value, belief)
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| Health state, LOS, Growth/development level, values/cultural, other therapies, human/financial resources, Risks/benefits, scientific evidence, changes is stats=need for modification | How we determine patient centered outcomes
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| Thought that is disiplined comprehensive, based on intellectual standards and as a result well reasoned; a systematic way to form and shape ones thinking that funcitons purposefull and exactingly | Critical thinking
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| Promotes critical thinking and self directed learning "critical thinking approach to care plan" | Concept mapping
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| We get baseline data that enables the nurse to make a judgement about the patiens health status, ability to manage (h)is own health care and need for nursing to plan individualized care | Initial assessment
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| Assessment conducted to assess a specific problem; focuses on pertinent history and body regions | focused assessment
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| rapid focused assessment conducted to determine potentially fatal situations | emergency assessment
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| An assessmsent that is scheduled to compare a patiens current status to baseline data obtained earlier | Time lapsed assessment
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| Act of confirming or verifying | Validation (objective data)
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| Condition of health relating to health requiring intervention if disease or illness is to be prevented or resolved and coping and wellness are to be promoted | Health problem
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| An aim or an end. In outcome and planning | Goal
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| Ongoing evaluation program designed and implemented to secure the excellence of healthcare; may involve an assessment of structure, process and outcome standards | Quality assurance program
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| Finding deficient workers and removing them | Quality inspection (of quality assurance program)
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| finding opportunities of improvement (team building) | quality as opportunity (of quality assurance program)
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| Case management plan that is detailed, standardized plan of care developed for a patient population with a disignated diagnosis, or procedure; it includes expected outcomes, list of interventions to be performed and the sequence and timing of intervention | Critical/Collaborative Pathway
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| Method of evaluating the oucomes of nursing care or the process by which of these outcomes are achieved using a review of patient records. | Nursing Audit!!
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| An approved list of running diagnosis | NANDA
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| Maslows heirarcy of needs is used to prioritize the | diagnoses (physiological high priority then goes down from there)
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| What part of ADPIE requires the most documentation due to legalities (if you dont document, it didnt happen) | Implementation
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