Steps of the nursing process

0.0(0)
studied byStudied by 0 people
GameKnowt Play
learnLearn
examPractice Test
spaced repetitionSpaced Repetition
heart puzzleMatch
flashcardsFlashcards
Card Sorting

1/27

encourage image

There's no tags or description

Looks like no tags are added yet.

Study Analytics
Name
Mastery
Learn
Test
Matching
Spaced

No study sessions yet.

28 Terms

1
New cards

nursing process

what is a five step problem solving process that nurses use to guide their professional actions and results in an individualized, comprehensive, client-centered plan of care

2
New cards

ADPIE

what is the five step nursing process

3
New cards

assessment

gathering data about the patient and their health status

puzzle pieces, collecting data

4
New cards

diagnosis

analyzing data to identify patterns to help draw conclusions about the patient's health status

putting puzzle pieces together

5
New cards

planning

identifying goals and outcomes, choosing interventions. Steps of carrying out the plan

6
New cards

evaluation

last step of the process, involves making judgements about the patient's progress toward desired outcomes, the effectiveness of the care plan and the quality of nursing care

figuring out if they reached desired outcome

7
New cards

collecting data

step in assessment process

from the clients medical record, observation, interview with client/caregivers, medical history, physical assessment diagnostic/lab reports, and from other interprofessional team members

8
New cards

using a systemic and ongoing process

step in assessment process

allows you to stay organized and not miss data, ____ refers to the process being constantly changing as new info is revealed

9
New cards

subjective

what kind of data is when the client tells the nurse others can provide but their accuracy may be questionable

10
New cards

objective

what kind of data can be observed or measured gathered through physical assessment and lab or diagnostic tests can be measured or observed by the nurse or other hcp

11
New cards

primary

what kind of data obtained directly from the client by what they state or what the nurse observes can be subjective or objective

12
New cards

secondary

what kind of data is obtained secondhand through the medical record or another person "they told me their shoulder is very sore this morning"

13
New cards

comprehensive

what kind of assessment is head to toe

14
New cards

focused

what kind of assessment is for a specific body part

15
New cards

medical

what kind of assessment focuses on disease and pathology

16
New cards

nursing

what kind of assessment focuses on the client's responses to illness will initiate changes in the plan of care

17
New cards

validating

what process includes double checking data obtained, not all data needs validation

18
New cards

when should the nurse validate data

when the subjective/objective data do not agree or make sense

client's statement's differ at different times in the interview, when data are far out outside normal range, and when factors are present that interfere with accurate measurement

19
New cards

guidelines for documenting data

document asap

write neatly, legibly, and in black ink or record data

document electronically

use proper spelling and grammar

use acronyms sparingly

write the pts owns words, when possible

record only the most important pt words

use concrete, specific information

record cues, not inferences

20
New cards

reflecting on the assessment

When should you ask

is my data complete, accurate and validated

did i record data not conclusions

did i follow up with special needs assessment if indicated

think about the client interview

review the physical assessment , observation and examination

21
New cards

nursing

what kind of diagnosis is the statement of client health that the nurse can identify, treat, independently, stated based on the client's reactions to the disease processes

biological

emotional

interpersonal

social

spiritual

problem or strength

22
New cards

medical

what kind of diagnosis describes a disease, illness, or injury, helps identify the patho so appropriate treatment can be given, and nurses cannot legally diagnose or treat these problems

23
New cards

health problem

what kind of diagnosis is from physiological complications of diseases, medical treatments or diagnostic studies, clients with certain diseases or treatments are at risk for developing the same complications, always a potential problem

24
New cards

prioritizing problems

Places problems in order of importance

Does not mean that you must resolve one problem before attending to another

Determined by the theoretical framework you use

**Maslow's hierarchy of needs is commonly used to prioritize nursing problems

25
New cards

patient care plan

this is the central source of info needed to

ensure care is complete

provide continuity of care

promote efficient use of nursing efforts

provide a guide for assessing and charting

meet requirements of accrediting agencies

establish GOALS and OUTCOMES

26
New cards

airway clearance impairment

related to thick secretions and decreased chest expansion secondary to dehydration and pain

27
New cards

bathing, dressing, feeding, toileting deficit

relayed to fatigue, secondary to heart failure

28
New cards

5 rights

RIght task

Right circumstance

right person

right direction/communication

right supervision/evaluation