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what is the nursing process
ADPIE
assessing
collecting, validating, and communicating patient data
Diagnosing
analyzing patient data to identify patient strengths and problems
Outcome Identification/Planning:
specifying patient outcomes and related nursing interventions
implementing
: carrying out the care plan
evaluation
: measuring the extent to which patient achieved outcomes
types of nursing assessments
Initial problem focused emergency time lasped
what in initial in the nursing assessment
stablish a complete database and provides reference base for problem identification, reference, and future comparison
what in problem focused in the nursing assessment
ongoing process to determine the status of a specific problem identified in an earlier assessment; short focused prioritized assessment; "flag" risks
what is emergency in the nursing assessment
occurs during physiologic or psychological crisis to identify life threatening problem and identify new or overlooked problems
What is a time-lapsed assessment?
occurs weeks to months after the initial assessment and compares current status to baseline to reassess health status
what is the assessment checklist
preparing for data collection collecting data identifying cues and making inferences validating data clustering related data and identifying patterns reporting and recording data
objective data
observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them
what is subjective data
information perceived by the affected person
what is objective data examples
directly or indirectly observed through measurement inspection palpation percussion auscultation respiration in 16 per min bp apical pulse irregular or reg Xray film
what is some example for sub data
data elicited from pt pt fam client records other health care proff. client interview caring ability and empathy listening skills
i have a head ache
it frightens me
nursing diagnosis parts
diagnosis problem Nausea/vomiting/diarrhea
3 liquid stools in 24 hours, 250 ml of green emesis, dry mucous membranes
Types of Nursing Diagnoses
problem focused risk diagnosis health promotion diagnosis
Nursing adpie planning purpose
design a plan of care with and for the patient that results in prevention, reduction, or resolution of the health problem and attainment of the patient's health expectations
what is the Nursing adpie planning method
Develop goals & outcomes then design interventions to accomplish them
what is the outcome identification and planning
establish priorities identify expected pt outcomes select evidence-based nursing interventions
planning what are the steps to care planning 1
Collect and assess data • Diagnose problems and potential problems• - Decide on outcome - an expected conclusion to a patient health problem determined after data interpretation• --Outcomes and plans are determined by the nurse AND the patient/family (short term and long-term goals)• -Develop interventions to achieve goals• -Implement and evaluate interventions • Revise and repeat steps as needed
what is goals
are what you want the patient to do or accomplish - not what you are going to do!
what is interventions
must relate to the goals you set which must relate to the problems you diagnosed.
Outcomes To be measurable, outcomes should have the following:
-Subject - the patient or some part of the patient• -Verb - the action the patient will perform• -Conditions - the particular circumstances in or by which the outcome is to be achieved • -Performance criteria - The expected patient behavior or other manifestation in observable, measurable terms• -Target time - when the patient is expected to be able to achieve the outcome• -Examples:• "During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL."• --"At the next visit, 12/23/20, the patient will correctly demonstrate relaxation exercises (4-7-8 breathing and progressive muscle relaxation)."
The Nursing Interventions Classification (NIC) project
defines a nursing intervention as "any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes"
what are the 3 types of intervention
independent dependent collaborative
what is the independent intervention
-Nurse initiated interventions â—‹In realm of independent nursing practice â—‹No MD order required
what is the dependent interventions
Physician initiated interventions â—‹Require MD orders
what is the collaborative interventions
Coordination of multiple professional
evaluation is what
is a form of assessment - instead of assessing the patient, you are assessing how well they have met their goals. If they aren't meeting their goals, you are assessing why. You may need to modify your goals or your interventions if they are not appropriate.
what is critical thinking
Purposeful, goal-directed thinking based on scientific knowledge â—ŹIt involves seeking and weighing alternatives and selecting the best one to meet the desired outcome â—ŹUses a logical process to gather information, analyze it, and take purposeful action based on the evaluation â—ŹNurses need to think critically to make complex decisions, adapt to new situations, and continually update their knowledge and skills.
Cognitively skilled nurses are critical thinkers.
why do nurses think critically
â—ŹTo solve complex patient problems in a logical and clear manner (being thinkers, not just doers) â—ŹTo provide safe, competent, and skillful nursing care to meet the needs of patients, families, and communities â—ŹTo make reliable observations, draw sound conclusions, create new information, evaluate lines of reasoning, improve self-knowledge â—ŹIt is mandated for accreditation of schools of nursing (the profession believes it is essential)
NCBSN operational definition
Clinical judgment is defined as the observed outcome of critical thinking and decision-making. It is an iterative process that uses nursing knowledge to observe and assess presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care.
NCBSN developed a clinical judgement model that
builds on and expands the nursing process. The evidence-based Clinical Judgment Measurement Model (NCJMM) identifies cognitive skills needed to make appropriate clinical judgments and will be the basis for the Next-Generation NCLEX-RN.
Cognitive skills needed for appropriate clinical judgements:
Recognize cues â—ŹAnalyze Cues â—ŹPrioritize hypotheses â—ŹGenerate solutions â—Źtake action â—ŹEvaluate outcomes
novice nurses thinking pattern
Knowledge is organized as separate facts â—ŹFocus too much on actions, forgetting to assess before acting â—ŹNeed clear cut rules â—ŹUnaware of resources â—ŹHindered by anxiety and lack of self-confidence â—ŹRely on step-by-step procedures (focus on procedures rather than the patient's response to the procedures) â—ŹUncomfortable if patient's needs alter the performance of activities â—ŹQuestion and collect data more superficially â—ŹFollow standards and policies as written â—ŹLearn best when partnered with a supportive mentor or preceptor
what is the mnemonic for prioritization
•A-Airway •B-Breathing •C-Circulation (any issue, heart, blood, brain, tissue) •D-Diagnoses (consider issues with diagnoses)
•P-Pain •L-Lab issues •M-Medication Issues •T-Teaching •F-Fall precautions/Safety •D-Drains and tubes (IV, foley, wound drain)
Note 
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