Nurs 207 - Nursing Process Flashcards
Identify the 5 steps of the nursing process
ADPIE
Assessment Diagnosis Plan Implementation Evaluation
Assessment
Uses objective, subjective, biographical, historical data
Requires you to cluster data, identify the relevance of data
Diagnosis
Focus on nursing problems
- nurses cannot fix medical problems
Starts with analyzing assessment data
Create an evaluative judgement about clients health status
Plan
Involves the clients input to create goals/outcomes
Formulate and write outcome/goal statements (SMART) and determine the appropriate nursing interventions based on the clients reality and evidence (research)
Provides your “why” - rationale for your actions
Implementation
Initiation of care plan
“Carrying out” the specific, individualized intervetions in the plan of care
Assessing effectiveness - ensure intervention is appropriate for client - know the rational for all interventions
Documentation
Evaluate
Actually occurs throughout the nursing process
Involve client and family
Revisit the outcomes to ensure they were SMART
May need to change interventions to meet dynamic client needs
Document and report
3-part diagnosis statement
P - Problem Statement (from NANDA)
- a concise term or phrase that represents a pattern of related cues
E - Etiology (cause, why is this a problem)
- “Related to” or r/t phrase
S - Signs and Symptoms (what data supports the diagnosis)
- symptoms identified by nurse in assessment
- “as evidenced by”
3 types of Diagnoses
Actual - contains all 3 parts (PES)
Risk - contains 2 parts (PE)
Wellness or health-promoting - contains 2 parts (PS)
Actual Diagnosis
This is actually happening at this time aka problem focused
Risk Diagnosis
There is an issue but it is not happening yet (potential)
Wellness or health-promoting diagnosis
Aimed at preventing the problem from even beginning
