Adult Health 1 (Crtcl Thnking)

ADPIE

Assessment: recognize & analyze clues

Diagnoses: prioritize hypothesis

Planning: generating solutions

Implementation: taking action

Evaluation: outcomes

The Nursing Process

1. Assess

2. Develop a NDX based on the cues provided

3. Develop Goals & Outcomes for the pt

4. Provide nursing actions to assist in relieving the primary, secondary, tertiary nursing diagnoses

5. what are the outcomes? re-evaluate the patient?

NCSBN’s 6 Functions of Clinical Judgement

1. recognize cues - what matters most?

2. analyze cues - what does it mean?

3. prioritize hypothesis - where do i start?

4. generate solutions - what can i do?

5. take action - what will i do?

6. evaluate outcomes - did it help?

Encourage - 1st step of clinical judgement

the data from patients is not limited to the physical assessment

• look at the entire assessment

• sights, smell, interviews, medications, labs, hobbies, sensation

Assessment

focused on analyzing the patient’s response to both actual and potential health problems

first step of the nursing process

systematic (the whole), continuous, non stagnant (always changing)

requires trending data

subjective + objective

Types of Assessment

Initial - first evaluation when pt enters facility

Focused - targeted evaluation that addresses specific complaint

Emergency - done during crisis to address life-threatening issue

Time-lapsed - scheduled repeat check done after treatment has been initiated

Patient-centered - approach that prioritizes patient needs, values, preferences

Sources of Data Collection

Primary Data: gathers firsthand information from patient through surveys, interviews, & questionnaires

Secondary Data: (not the patient) utilizes patient family, existing records, & studies such as medical records, hospital databases & government health statistics

BOTH are essential for a comprehensive understanding of a patient’s health status

Data Analysis

• trends

• unexpected norms

• population deviations

• non-productive behaviors

• developmental lags or dysfunctions

• unexplained occurrences

• data cluster - cues & data

Nursing Diagnosis

Identifies

• potential patient health problems

• factors contribute to the patients health problem

• patient data dupporting the health problem

NDX are written with RT (related to) and AEB (as evidenced by statements) and prioritized

• SAFETY met FIRST

• never a medical dx

Prioritizing Nursing Diagnosis

• MASLOW’s

• airway, breathing, & circulation (met first)

• predict & prevent complications

• proactive

• risk evidence

• safety

Development of NDX

Contains:

• NANDA Stem

• Related to: etiology (cause)

• AEB: the support statements that support the NDX

Risk for Statements:

DO NOT CONTAIN AEB STATEMENTS

• are not primary NDX

• represent a potential NDX as it lacks AEB statements

SMART Goals

Specific:

Measurable: allows for progress tracking

Achievable: realistic + attainable

Relevant: align w/ broader objectives

Time-bound: defined deadline to create urgency + accountability

Implementation of Care

the purpose is to reduce or eliminate factors related to the ndx

(BRAINSTORMING WAYS TO ADDRESS NDX)

actions include:

• medical treatment

• non-pharm

• promote patient autonomy

• evidence-based practice

• education

• organized care: patient, visitors, equipment, environment & assistive personnel

Delegation during Implementation

a nurse can delegate duties to other non-licensesd professional or assistive personnel

• Right Task

• Right Circumstance

• Right Person

• Right Supervision

• Right Direction & Communication

Evaluation

determine achievement of goals + outcomes:

“Goal Not/Met, Continue with Goal”

Triple Aim in Healthcare

1. Improve patient experience of care

2. Improve health of population

3. Reduce cost of healthcare per capita