Nursing Process & Approach to Assessment | Quizlet

nursing process steps

ADPIE

Assessment

Diagnosis

Planning

Implementation

Evaluation

nursing process: assessment (noticing)

nurse collects & analyzes patient info

SODA:

Subjective: what the patient says (current complaint, history, meds, pain scale)

Objective: what you can see/measure (VS, intake & output of fluids, height/weight, grimacing,...)

Diagnostic: labs, imaging (x-ray, CT,...)

Assessment: your physical assessment (head to toe)

nursing process: diagnosis (interpreting)

RN's clinical judgement about actual or potential health problems to help prioritize plan & care

nursing diagnosis statement: problem, related to (r/t) (usually medical diagnosis), as evidenced by (AEB) (S&S)

nursing diagnosis (ND): client's response to disorder or condition

medical diagnosis (MD): made by provider about disorder or condition

NANDA list: a list of nursing diagnosis phrases

nursing process: planning (responding)

goals & outcomes formulated, personalized to individual's unique needs (client care conference held sometimes)

prioritizing problems (ABCs, safety, actual ND, risk for ND)

SMART goal (specific, measurable, achievable, relevant, time-bound)

nursing process: implementation (responding)

performing planned interventions

assist patient to meet SMART goal

have rationale for actions (why this will help the patient)

actions!!!: educating, administering medication, assessing/monitoring, changing dressings,...

nursing process: evaluation (reflecting)

effectiveness of nursing care plan is measured & evaluated -> determine if progress is satisfactory

was the SMART goal accomplished? -> change/adapt care plan if needed

how will you determine if they met this goal? -> assess/reassess

planning: prioritizing order

1.) ABCs (airway, breathing, circulation)

2.) safety

3.) risk vs. actual

planning: prioritizing order: Maslow's Hierarchy of Needs

Bottom/most important/foundation (goes along with ABCs): physiological needs: oxygen, nutrition, fluids, body temp, elimination, shelter, sex (healthcare providers)

2nd level from bottom: safety & security: physical safety, psychological safety (healthcare providers)

middle level: love & belonging needs (family & friends, healthcare providers)

2nd level from top: self-esteem (to boost: encourage daily activities & personal care)

top level: self-actualization

Maslow's Hierarchy of Needs practice: put in the right order (bottom level has 5 needs):

social isolation

disturbed body image

impaired urinary elimination

risk for falls

acute pain

decreased cardiac output

medication non-compliance

spiritual distress

impaired skin integrity

hopelessness

caregiver role strain

disturbed sensory perception

ineffective coping

ineffective airway clearance

impaired home maintenance

AIDET

Acknowledge: greet patient by name (verify name & DOB)

Introduce: introduce yourself by name and job title

Duration: give a time for how long the certain process will take

Explanation: explain what you are going to do; answer questions

Thank you: after you're done, thank patient & family

stethoscope diaphragm uses

used for high-frequency/high-pitched sounds (ex: bowel or lung sounds)

stethoscope bell uses

used for low-frequency/low-pitched sounds (ex: heart sounds)

place it lightly on the skin (using too much pressure doesn't pick up the low frequencies)

penlight uses

uses focused light to enhance inspection

assess PERRLA: are

Pupils equal,

Round,

Reactive to light, and do they have

Accommodation?

also used to closely visualize certain structures: eyes, ears, nose, mouth, throat, lesions, or skin changes

tape measure uses

to measure certain parts of body (ex: circumference of swollen extremities, fundal height of pregnant patients, circumference of infant's head, dimensions of a wound,...)

types of assessment: comprehensive/complete assessment

full head-to-toe (HTT) assessment (all body systems)

tells info about general health status

for general wellness visit, during hospital admissions, & during shift change

types of assessment: focussed assessment

depends on the situation; based on patient's presenting symptoms

used for certain medications, new problem/complaint (C/O), evaluation of intervention effectiveness, status change, in the ED

ex: abdominal pain -> assess GI system

ex: difficulty breathing -> assess respiratory system, skin, VS, level of consciousness

techniques of assessment: inspection

eyes

general inspection: gender, height & weight, race(s), age, signs of distress, body type, posture, gait, movements, hygiene, dress, mood, speech, signs of abuse, substance abuse

use adequate lighting

inspect each area for size, shape, color, symmetry, position, and abnormality

position and expose body parts as needed for viewing but respect privacy

validate findings with the patient (talk to patient about what you find)

techniques of assessment: palpation

touch

uses touch to gather info (pain, swelling, temp, texture,...)

use different part of hands to detect different characteristics

hands should be warm, fingernails short

start with light palpation (press down 1 cm to asses texture, temp, pulsations); end with deep palpation (press down 4 cm to asses internal structures & their size, shape, mobility)

techniques of assessment: palpation: bimanual palpation

2 hands

top hand applies pressure & bottom hand feels underlying structure

often used for kidney exam or if client is obese

techniques of assessment: percussion

percuss

tap finger on skin with fingertips to vibrate underlying tissues & organs

sound determines location, size, & density of structures (the denser the tissue, the quieter the sound)

*being replaced by imaging nowadays

techniques of assessment: auscultation

listen

listen for sounds produced by body -> stethoscope or hear for respiratory stridor (high-pitched, whistling or crowing sound when airway is narrowed)

order of assessment techniques: non-abdominal

IPPA

Inspection

Palpation

Percussion

Auscultation

order of assessment techniques: abdominal

IAPP

Inspection

Auscultation

Percussion

Palpation

(percussing and palpating might change abdomen sounds, so you do those after auscultation)

(think "listen first" -> but obviously you look with your eyes/inspect first in any situation duh)