Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
58 Cards in this Set
- Front
- Back
|
ADPIE
|
Assessment
Diagnosis Planning Implementation Evaluation |
|
|
AAPIE
|
Assessment
Analysis Planning Implementation Evaluation |
|
|
Assessment
|
a systematic, dynamic process by which the nurse, thru interaction w/the pt., significant other, and health care providers, collects info and analyzes data about pt.
|
|
|
Components of Assessments
|
Cognitive, psychosocial, emotional, cultural, and spiritual
|
|
|
Focused assessment is advised when...
|
pt. is critically ill, disoriented, or unable to respond
|
|
|
Subjective Assessment
|
Verbal statements provided by the pt. Example: the pt. states they are having trouble breathing
|
|
|
Objective Assessment
|
Observable and measurable signs, can be recorded, example: pt. breath sounds are diminished bilaterally thru the bases
|
|
|
Primary & most accurate source of data
|
the patient
|
|
|
Secondary source of data
|
family members, significant other, medical records, diagnostic procedures, and nursing literature; when pt. is unable to supply info, these sources are used
|
|
|
2 methods of data collection
|
1. interview
2. physical exam |
|
|
Data collected during interview:
|
1. biographical data
2. reason pt. is seeking health care 3. history of present illness 4. past health history 5. environmental history 6. psychosocial history |
|
|
2 types of physical exams
|
1. head-to-toe format
2. focused assessment |
|
|
Data clustering
|
related cues grouped together, attention is focused on health concerns that need support and assistance, this assists in the identification of nursing dx
|
|
|
Diagnosing
|
ID the type and cause of a health condition; ANA defines as "A clinical judgement about the patients response to actual or potential health conditions or needs; this provides the basis for determination of a plan of care to achieve expected outcome
|
|
|
Who may observe and collect data?
|
the LPN or RN may both observe and collect data
|
|
|
Problem
|
Any health care condition that requires diagnostic, therapeutic, or educational actions, deviations from the pop. norms, any chg in the pts. usual health status, any dysfunctional behavior
|
|
|
Nursing Diagnosis
|
a clinical judgement about an individual, family, or community response to actual or potential health problems or life processes; provides basis for selection of nursing interventions
|
|
|
Nurses can legally...
|
identify and prescribe the primary interventions to treat or prevent problems that are nursing diagnoses
|
|
|
Components of Nursing Diagnosis
|
1. Nursing diagnosis title/label
2. Definition 3. Contributing / Etiologic / Related factors and risk factors 4. defining characteristics |
|
|
Nursing Diagnosis Title/Label
|
provides a concise name for the identified health problem; adjectives add meaning to the nursing diagnosis - imbalanced, impaired, etc.
|
|
|
Definition
|
Presents clear, precise description of the problem; helps to identify the difference between similar diagnoses
|
|
|
contributing / etiologic / related factors and risk factors
|
conditions that might be involved in the development of a problem and are found in the nursing diagnosis; may become focus for nursing interventions; written as "related to"
|
|
|
Risk Factors
|
those that increase the susceptibility of a patient to a problem
|
|
|
Defining characteristics
|
cues that tell how the diagnosis is manifested; clinical cues, signs, and symptoms that furnish evidence that a problem exists; written as "manifested by".
|
|
|
Risk Nursing Diagnosis
|
a clinical judgement that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation; 2 part statement (label & risk factor)
|
|
|
Possible Nursing Diagnosis
|
used when a problem is considered feasible; add'l data must be gathered to confirm or rule out the prob; written in 2 part statement (label & cont. etilogic risk factor)
|
|
|
Syndrome Nursing Diagnosis
|
used when a cluster of actual or risk nursing diagnoses are predicted to be present in certain circumstances ( 1 part statement)
|
|
|
Current syndrome diagnoses:
|
post-trauma syndrome, rape-trauma syndrome, risk for disuse syndrome, impaired environmental interpretation syndrome, and relocation stress syndrome
|
|
|
Wellness Nursing Diagnosis
|
a clinical judgement about an individual, family, or community in transition from a specific level of wellness to a higher level of wellness; written in 1 part statement (readiness for enhanced...)
|
|
|
Collaborative Problems
|
certain physiologic complications that nurses monitor to detect onset or changes in staus; nurses manage problems using md-prescribed and nurse-prescribed interventions to minimize the complications
|
|
|
Medical Diagnosis
|
the identification of a disease or condition through a scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures
|
|
|
Planning
|
nurse est. priorities of care, writes desired pt. outcome, selects and converts nursing interventions into nursing orders, & communicates the plan of care
|
|
|
Priority Setting
|
nursing diagnoses are ranked in order of importance for the pts. life and health; physiologic needs come 1st; actual problems may be ranked before risk problems
|
|
|
ABC's
|
Airway
Breathing Circulation |
|
|
Maslow's Hierarchy of Needs
|
1. physiological needs
2. security and safety 3. love and belonging 4. self-esteem 5. self-actualizaiton |
|
|
Why include pt. in planning?
|
validates his/her importance as an individual and motivates him to participate in their health care and adhere to care plan; gives them greater sense of control
|
|
|
Est. desired pt. outcomes
|
nurse predicts the condition of the pt. following nursing interventions; expressed in a statement that indicates degree of wellness desired, expected, or possible for pt. to achieve
|
|
|
Outcome
|
a statement provides a description of the specific, measurable behavior that the pt. will be able to exhibit in a given time frame following the intervention
|
|
|
Goal
|
a statement about the purpose to which an effort is directed
|
|
|
A well-written patient-centered goal / desired outcome statement achieves teh following:
|
1. uses the word "patient"as the subject of the statement
2. uses a measurable verb 3. is specific for the pt. and the pts. problem 4. is realistic for the pt. and the pts. problem 5. includes a time frame for pt. reevalution |
|
|
Four elements of Outcome Statement:
|
1. B (Behavior) desired behavior
2. M (measure) criteria for measuring behavior 3. C (conditions) condition in which behavior shld occur 4. T (time frame) when the behavior shld occur |
|
|
Physician prescribed interventions
|
actions ordered by physician for a nurse or other health care provider to perform; meds, wound care, dx tests; nursing judgement still used; assessing, teaching, & validating safety of phys. orders expected of nursing practice
|
|
|
Nurse-prescribed intervention
|
actions the nurse can legally order or begin independently; providing a back massage, turning pt. q2h, etc.
|
|
|
Nursing orders should include:
|
1. date
2. signature of the nurse responsible for the plan of care 3. subject (who will carry out order) 4. action verb 5. qualifying details |
|
|
Implementation
|
phase of nursing process in which established plan is put into action to promote achievement of the outcome
|
|
|
A vital component of the implementation phase is...
|
documentation; if it was not charted, it was not done!
|
|
|
Implementation - expect to perform the following:
|
routine assessment & monitoring, therapeutic interventions, offering comfort, providing nourishment, helping w/ADL's, supporting resp. & elimination functions, providing skin care, emotional support, pt. teaching & counseling, communication w/other interdisciplinary team members
|
|
|
Evalution
|
a determination is made about the extent to which the established outcomes have been achieved
|
|
|
3 judgements of evaluation:
|
1. The outcome was achieved
2. The outcome was not achieved 3. The outcome was partially achieved |
|
|
Managed Care
|
a health care system whose aim is to enhance specific clinical and financial outcomes within a specific time frame
|
|
|
Case Management
|
a certified nursing specialty; refers to the assignment of a health care provider to a pt. so that the care of that pt. is overseen by one individual; assists the pt. and family to receive required svc's, coordinates these services, and evaluates the adequacy of these svc's.
|
|
|
Clinical Pathways
|
multidisciplinary plan that schedules clinical intervention over an anticipated time frame for high-risk, high-volume, high-cost types of cases
|
|
|
Role of LPN
|
provided direct bedside nursing care, closely observe, prioritize, intervene, and evaluate the care provided to and for the pt.
|
|
|
Role of LPN in assessment
|
observe and report significant cues to the charge nurse or phys.
|
|
|
Role of LPN in diagnosis
|
assist with the determination of accurate nursing diagnoses; gather data to confirm or eliminate problems
|
|
|
Role of LPN in planning
|
assist w/ setting priorities, suggest interventions, assist w/ the development of realistic pt-centered desired pt. outcomes
|
|
|
Role of LPN in implementation
|
assist with the establishment of priorities, carry out phys. and nursing orders, evaluate the effectiveness of nursing activities
|
|
|
Role of LPN in evaluation
|
assist with reevaluation of the pts. health state after nursing interventions, suggest alternative nursing interventions when necessary
|
