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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
ADPIE
what is the five step nursing process
assessment
gathering data about the patient and their health status
puzzle pieces, collecting data
diagnosis
analyzing data to identify patterns to help draw conclusions about the patient's health status
putting puzzle pieces together
planning
identifying goals and outcomes, choosing interventions. Steps of carrying out the plan
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
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
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
subjective
what kind of data is when the client tells the nurse others can provide but their accuracy may be questionable
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
primary
what kind of data obtained directly from the client by what they state or what the nurse observes can be subjective or objective
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"
comprehensive
what kind of assessment is head to toe
focused
what kind of assessment is for a specific body part
medical
what kind of assessment focuses on disease and pathology
nursing
what kind of assessment focuses on the client's responses to illness will initiate changes in the plan of care
validating
what process includes double checking data obtained, not all data needs validation
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
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
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
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
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
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
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
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
airway clearance impairment
related to thick secretions and decreased chest expansion secondary to dehydration and pain
bathing, dressing, feeding, toileting deficit
relayed to fatigue, secondary to heart failure
5 rights
RIght task
Right circumstance
right person
right direction/communication
right supervision/evaluation