Nursing 101 Exam 2

ADPIE

Assessment Diagnosis Planning Implementation Evaluation

Direct care

ADL's instrumental ADL's physical care techiques counseling teaching control of adverse reactions preventive measures involves direct contact with the patients

Emergent assessment

AMPLE= Allergies, Medications, Past Medical History, Last Meal, Events Leading to Injury

ABCSDEF

Airway breathing circulation safety discomfort education feelings

Diagnosis

analyze data to identify actual or potential health problems and client strengths/ needs types- actual, risk, wellness Steps- NANDA, etiology- RT/ secondary to

internal variables

are a patient's perception of symptoms and the nature of the illness, coping skills, locus of control

Implementation/ interventions

carry out proposed interventions, nurse-initiated/independent interventions, provider- initiated/ dependent interventions Collaborative interventions

types of implementation skills

cognitive, technical, interpersonal, ethical/ logical

assessment

collection, validate, and communicate client health data

Indirect care

communication nursing interventions delegating, supervising, and evaluating the work of other staff members behind the scenes work that involves the patient

evaluation

compare client response to expected outcomes- were goals met. if not, what do you do?

Diagnostic reasoning

data combined with critical thinking

closed vs. open communication

focus on point listen attentively ask about main problem first use good communication skills may use multiple types of questions: open-ended, validating, clarifying, sequencing, reflective, directing

Problem oriented approach

identify an undesirable human response to existing problems or concerns of a patient. ex include chronic pain or urinary retention

medical diagnosis

is by the care physician or doctor remains in place until a cure is found or the patient is no longer symptomatic focuses on the illness, injury or disease process only

clinical decision

making separates professional nurses from technical personnel, a continuous process characterized by open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant

analyze data to identify actual or potential health problems and client strengths/ needs

not a medical diagnosis NANDA types: actual, risk, wellness Steps: NANDA, etiology-rt/ secondary to defining characteristics- as evidence by

Nursing diagnosis

o is a precise statement describing the patients present status and factors contributing to it? o Looks at the patient's response to illness or changes in the patient's ADL's o We can also PREVENT potential problems (risk for infection) before they occur w/ nursing diagnosis.

objective data

our assessment, data the nurse collects, ex. friends, family caregivers, health care professionals, literature review, medical records

Planning

outcome identification (GOALS) can be considered 2 steps: identify outcomes and then develop plan to attain outcomes

subjective data

patients response, what others tell the nurse, what the client has told them

the nursing diagnosis

problem ____RT/ Secondary to____ as evidenced by______

Data validation

validate the information you have collected to avoid making incorrect inferences. validation of assessment data is the comparison of data with another source to determine accuracy.

Steps of scientific method

· 1. Make an observation. · 2. Ask a question. · 3. Form a hypothesis, or testable explanation. · 4. Make a prediction based on the hypothesis. · 5. Test the prediction. · 6, Iterate: use the results to make new hypotheses or predictions.

Nursing process

· A systematic, rational method of planning and providing individualized nursing care to patients. · The nursing process provides a framework for problem-solving, a means to define the nurses' role in caregiving, and a method to communicate with other nurses and healthcare providers

writing measurable outcomes/goals

· BASED ON THE NURSING DIAGNOSIS · Individualization of patient care · Create a plan of care (care plan) · Identifies/ sets/ communicates priorities · Promotes continuity of care · Establish goals or outcomes that are INDIVIDUAL to the patient and MEASURABLE! · Select appropriate nursing measures and to evaluate the response to care · THIS IS WHAT WE DO FOR THE PATIENT!

implementation skills

· Nursing measures that help the patient to achieve the goal. · Individualized to meet the needs and values of the patient. · Realistic to what the patient can ACTUALLY do. · Based on scientific rational / evidenced based practice. · Compatible with the patient's beliefs. · Able to be communicated to nursing staff... Including nursing assistants. · Protect client safety. · Promote client participation and self-care. · Need to be specific... NOT VAGUE! Need to state HOW OFTEN they need to be done

Complete Nursing diagnosis

· is a precise statement describing the patients present status and factors contributing to it? · Looks at the patient's response to illness or changes in the patient's ADL's · We can also PREVENT potential problems (risk for infection) before they occur w/ nursing diagnosis.

external variables

Visibility of symptoms, social group, cultural background, economics, and accessibility to health care system, social support