Planning (Adpie)

Front 1

Planning:
Assessment+Dx =Plan

Back 1

systematic phase of the nursing process: decision making and problem solving

Front 2

Types of Planning:

Back 2

Initial
Ongoing
Discharge

Front 3

Initial

Back 3

Admission Assessment RN creates initial plan of care

Front 4

Ongoing

Back 4

All RN's:
determine change in status
priorities for shift
prioritize problems to focus on
coordinate all RN's to address multiple problems

Front 5

Discharge

Back 5

process of anticipating and planning needs for discharge

Front 6

informal RN plan of care

Back 6

strategy for action
i.e. Mrs Phan is tired. I will need to reinforce her need for sleep

Front 7

formal RN plan of care

Back 7

written or computerized guide that organizes continuity of care

Front 8

standardized care plan

Back 8

formal plan that specifies care for groups of client needs
i.e. MI

Front 9

individualized care plan

Back 9

tailored to meet need of specific client

Front 10

Care Plan:
PGIE

Back 10

P roblem
G oal/outcome
I ntervention
E valuate

Front 11

Planning:
Assessment+Dx =Plan

Back 11

systematic phase of the nursing process: decision making and problem solving

Front 12

Types of Planning:

Back 12

Initial
Ongoing
Discharge

Front 13

Initial

Back 13

Admission Assessment RN creates initial plan of care

Front 14

Ongoing

Back 14

All RN's:
determine change in status
priorities for shift
prioritize problems to focus on
coordinate all RN's to address multiple problems

Front 15

Discharge

Back 15

process of anticipating and planning needs for discharge

Front 16

informal RN plan of care

Back 16

strategy for action
i.e. Mrs Phan is tired. I will need to reinforce her need for sleep

Front 17

formal RN plan of care

Back 17

written or computerized guide that organizes continuity of care

Front 18

standardized care plan

Back 18

formal plan that specifies care for groups of client needs
i.e. MI

Front 19

individualized care plan

Back 19

tailored to meet need of specific client

Front 20

Care Plan:
PGIE

Back 20

P roblem
G oal/outcome
I ntervention
E valuate

Front 21

Protocols

Back 21

preprinted physician orders
i.e sliding scale for insulin

Front 22

Policies and Procedures

Back 22

hospital manual for guidelines

Front 23

Standing order

Back 23

written document: allows RNs to intervene under circumstances when MD is not present

Front 24

Multidisciplinary (collarborative) Care Plan

Back 24

standardized plan that outlines the care required for clients

Front 25

Guidelines for Care Plan

Back 25

Date/ Sign
Category Headings: RN Dx, Goal
Medical terminology
Be specific
refer to resource rather than list
Tailor plan
Preventative
Interventions
coordinate activites
discharge plan

Front 26

Priorities

Back 26

Poop vs Pretty

Front 27

Goals/Outcomes

Back 27

observable response within a project time frame
i.e. Goal: Gain 5 lbs by Apr 25

Front 28

Long term

Back 28

fixes problem

Front 29

Short term

Back 29

steps to fix problem

Front 30

Guidelines for writing Goal/Outcome

Back 30

"The Client will..."
realistic
derived from diagnosis
observable/measurable
i.e "The client will ambulate with an assistive device to the end of the hall by end of shift

Front 31

Types of Interventions

Back 31

Independent
Dependent
Collaborative

Front 32

Independent

Back 32

RN is licensed to do

Front 33

Dependent

Back 33

carried out under MD orders

Front 34

Collaborative

Back 34

actions carried out with other members: PT, OT, Social Work