Nursing 111 Exam 1
Phases of the nursing process
(ADPIE) Assessment, Diagnosis, Planning Outcome, Implementation, & Evaluation
ANA Code of Ethics
1. Be accountable and competent 2. Use informed judgment 3. Maintain employment conditions conducive to quality patient care 4. Protect the client from misinformation 5. Collaborate with other healthcare members to provide the best care.
Role and responsibility of the nurse according to the NC Nurse Practice Act
1. Professional standards of care that incorporate the nursing process 1. Professional performance standards that identify the various role functions of the nurse in direct patient care 1. Practice guidelines for the various specialty areas that are developed by professional organization
Identify how clustering of data cues aid in identifying a client or clinical problem
1. identify patterns that will assist with identification of the nursing process 2. helps get a better explanation of what is going on with the pt.
Nurses role in each process
Assessment: Collect data Diagnosis: develop theory Planning Outcome: develop a plan Implementation: putting plan into action Evaluation: evaluate the success of the care plan
Focus Charting
Data - Subjective and Objective Actions - Intervention Response - Pts response to interventions
How does clinical decision making impact the quality of client care and outcomes
Ensures continuity of care and safety of the pt.
How does critical thinking impact clinical decision-making
It allows us to make sound decisions, ensure safety of the pt., and achieve the best possible outcome for the pt.
Steps to processing a dilemma
Massage the dilemma Outline the options Resolve the dilemma Act by applying the chosen options Look back & evaluate
Maslow's Hierarchy of Needs
Most Important 1st Physiological: food, air, water, temp (basic needs) Safety & Security Love & Belonging Self Esteem Cognitive (knowledge, understanding, exploration) Aesthetic (order, beaut) Self Actualization (personal growth) Transcendence of self
PIE Charting
Problem Intervention Evaluation
SBAR for Reporting
Situation - What's going on with the client? Background - What background information is pertinent to the situation? Assessment - What did you find? Recommendation - What action/recommendation is needed to correct the problem? What do you want to happen for this client.
SOAP Charting
Subjective Objective Assessment Plan
Define critical thinking
the ability to think in a systematic and logical manner with openness & objectiveness to form a judgment.
