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14 Cards in this Set
- Front
- Back
What are the phases of the nursing process?
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Assessment
Diagnosis (Nursing Diagnosis) Planning Implementation Evaluation (AD PIE) |
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What is involved with the assessment step of the nursing process?
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data collection (vital signs) weight etc.
MAR (medical record) Physical Assessment Interview OTC meds- supplements, vitamins, recreational drugs etc. Allergy assessment Health history (surgeries, fractures) Family history (genetic disease info) Subjective and Objective Data Environment- home/work life |
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Subjective Data
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feelings, opinions, expressions (feedback from patient)
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Objective Data
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what we can see, touch, evaluate (measurable)
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What is involved with Nursing Diagnosis?
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General survey- 60 sec check(color, speech, mobility, LOC)
Data analysis Clustering information Determine strengths, determine unmet needs Nurses Diagnosis (NANDA nursing diagnosis) Physical Exam (objective data) - Types, techniques (palpation & osculation) equipment Diagnostic Statements PES (S is first) |
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What is involved with the Planning phase of the Nursing Process?
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Outcomes, Goals, Interventions
Priority setting- Patient’s greatest concern (safety need vs. physical need) Measurable |
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What is involved in the implementation phase of the Nursing Process?
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activation of the plan
Should be patient centered and individualized Measurability- what specific outcomes do we expect? Delegation |
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Describe the evaluation phase of the Nursing Process
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It's Continuous
Was it realistic to the specific patent? Was the outcome or goal met? |
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Describe the components of the PES model in nursing diagnostic statements.
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"S"is first Signs & Symptoms (assessment, verbalization)
P-Problem E- Etiology (manifestation source of problem) Connect problem to etiology Connect the etiology to the signs and symptoms |
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Actual Nursing Diagnosis
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related to patient condition or disease process, identified through data collection, using PES
Ex- diabetic, low blood sugar levels |
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Potential Nursing Diagnosis
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may occur based on patient condition, intervention, or disease process
Only identifies problem & etiology Ex- risk of infection from a surgical procedure (etiology) |
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Describe guidelines for writing an outcome statement
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Planning should be a collaborative effort between nurse and client (patient). The setting of more specific outcomes is necessary for systematic measurement of the patient’s progress. The nurse may write patient outcomes by describing/desired, realistic, measurable patient behaviors to be accomplished by a specific date
Ex- short term outcomes, the patient will maintain normal vital signs in response to activity in two days |
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What to do if interventions have been effective
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What actually happened? Do we need to continue therapy? Is therapy ongoing?
If goal was met, what’s next? Revisit problem. |
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What to do if interventions have been ineffective
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Revisit Problem, Go through Nursing Process with further research and detail
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