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NUR 126 > Wk 2 Nursing process > Flashcards

Wk 2 Nursing process Flashcards

1
Q

Define ADPIE

A 
Assessment
Diagnosis
Plan
Implement
Evaluate
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2
Q

Define Assessment

A

Deliberate and systematic
Gathering info from patient or other sources (friends, family, medical record, health professionals),
Analysis of information
Establishes a database

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3
Q

Define Diagnosis

A

Nursing diagnosis is a clinical judgment about an individual, family, or community response to actual or potential health problems or life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.” (NANDA, 2008)

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4
Q

Interviewing techniques

A 
Observation
Open-ended questions
Leading questions
Back channeling
Probing
Direct Closed-Ended Questions
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5
Q

Assessment documentation

A

Document all information collected during health history and physical examination

Clear, concise, appropriate terminology

Used as a baseline

Data Clusters-
Provides a way to organize data
Organized by actual or potential problems

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6
Q

Types of Nursing Diagnosis (3)

A

Problem-Focused Nursing Diagnosis
Risk
Health Promotion Nursing Diagnosis

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7
Q

Problem-Focused Nursing Diagnosis described

A

Problem-Focused
clinical judgment concerning undesirable human response to health condition/life process that exists

Related Factor- etiological or causative factor

Defining Characteristics- observable assessment cues that support Dx

Example: Impaired physical mobility related to obesity as evidence by impaired ability to reposition in bed.

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8
Q

Risk diagnosis described

A

Risk
clinical judgment concerning the vulnerability of client for developing an undesirable human response

Has only Risk Factors; No related factors or defining characteristics

Example: Risk for falls as evidence by history of falls and 67 years old

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9
Q

Health Promotion Nursing Diagnosis described

A

Health Promotion Nursing Diagnosis
clinical judgment concerning motivation & desire to increase well-being & actualize human health potential

Has only defining characteristics

Example: Readiness for enhanced nutrition as evidence by expressed knowledge of healthy food choices

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10
Q

Formulating a Nursing Diagnostic Statement

5

A 
Label
Definition
Related Factors
Defining characteristics
Risk factors
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11
Q

Formulating a Nursing Diagnostic Statement

LABEL

A

Label
Name of the nursing diagnosis as approved by NANDA-I
Describes essence of patient’s response to health conditions in as few words as possible

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12
Q

Formulating a Nursing Diagnostic Statement

DEFINITION

A

Definition
Describes the characteristics of human response
Assists in identifying a patient’s correct diagnosis

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13
Q

Formulating a Nursing Diagnostic Statement

RELATED FACTORS

A

Related factors
Contributing factors that influence the change in health status
Can be pathophysiologic (biologic, or psychosocial); treatment-related; situational (environment or personal) or maturational

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14
Q

Formulating a Nursing Diagnostic Statement

DEFINING CHARACTERISTICS

A

Defining Characteristics
Observable assessment cues that support diagnostic judgement
Used with Problem-Focused and Health Promotion Nursing Dx

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15
Q

Formulating a Nursing Diagnostic Statement

RISK FACTORS

A

Risk factors
Situations which increase vulnerability for a patient or group
Environmental, physiological, psychological, genetic, or chemical elements that place client at risk for health problem.
Only used in Risk Nursing Dx

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16
Q

Define Plan

A

Goals must be patient-centered- A patient’s highest possible level of wellness and independence in function, based on patient needs, abilities, and resources

Use SMART acronym for writing goals and expected outcomes

Specific
Measurable
Attainable
Realistic
Timed
17
Q

Goals/Outcomes (2 types)

A

Short term

Long term

18
Q

Goals/Outcomes

SHORT TERM

A

Immediate problems

Achieved in short time frame, hours to less than a week

Client will have relief of pain as evidenced by stating pain less than 3 on scale of 0-10 before end of shift.

19
Q

Goals/Outcomes

LONG TERM

A

May take weeks or months

Prevention or rehabilitation

Client will improve ambulation as evidenced by ambulating without walker within 6 weeks of discharge

20
Q

Define Implementation

A

The nurse initiates interventions to help the patient achieve their goals and outcomes

NOT a doctor’s order

21
Q

Define Evaluation

A

Did your patient meet his or her desired outcome?

Possible outcomes
Goal met
Goal partially met
Goal not met

What would you change about this plan, based upon your evaluation?

NUR 126 (23 decks)

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