Term
| Define the concept of nursing process. |
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Definition
ADPIE
A) Assessment- subjective data (what pt tells you) objective data (measurable & observable)
B) Diagnoses- identify patients problems, WHERE TO FIND? NANDA
C) Planning- Nurses set priorities, determine client outcomes, and select specific nursing interventions> 3 types of planning: comprehensive planning(on admission to a health care facility), ongoing planning (throughout the provision of care), discharge planning (must begin during admission)
> end product= NURSING CARE PLAN “NCP- identify probs, outcomes, interventions, to implement
D) Implementation- care is based on assessment data, analyses. Use of problem-solving, critical thinking, clinical judgment, therapeutic communication & technical skills, EBP. DURING= delegate tasks, supervise other health care staff, document the care
E) Evaluation- determine if goals met? IF NOT THEN YOU REASSESS! Nursing interventions effective? Modify outcomes interventions?
GOALS= S M A R T |
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Term
List three client and three nursing benefits of using the nursing process correctly. |
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Definition
PT BENEFITS:
- Scientifically based, holistic, individualized care
-The opportunity to work collaboratively with
nurses
-Continuity of care
YOU:
Able to identify the patients past and presence health status
Establish a plan that the pt need
To improve nursing intervention that meets the patients needs |
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Term
Describe the four basic competencies essential to professional nursing practice.
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Definition
COGNITIVE, INTERPERSONAL, TECHNICAL SKILLS, ATTITUDE
-Clinical decision making requires critical thinking.
-Clinical decision-making skills separate professional nurses from technical and ancillary staff.
-Patients often have problems for which no textbook answers exist.
-Nurses need to seek knowledge, act quickly, and make sound clinical decisions. |
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Term
Describe how the nurse utilizes critical thinking when making clinical judgments and decisions.
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Definition
-observes for changes in patients
-recognizes potential problems
-identifies new problems as they arise
-takes immediate action when a patient’s condition worsens
clinical decision: read things over, do things systematically
based decision on data gathered from prior |
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Term
Describe the purpose of a nursing assessment and distinguish it from a medical assessment. |
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Definition
A nursing assessment is holistic and focuses on client responses to disease, pathology, and other stressors.
A medical assessment focuses on disease and pathology.
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Term
Distinguish between objective and subjective data. |
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Definition
OBJECTIVE DATE: MEASURABLE AND OBSERVABLE. signs during physical exam: how they feel, see, hear, and smell. DATA from fam, nurse, friends, medical records, literature review
SUBJECTIVE: direct quotes from patients “my shoulder is really, really sore” |
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Term
Describe the techniques used in a physical examination. |
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Definition
Collect data.
Cluster cues, make inferences, and identify patterns and problem areas.
Critically anticipate.
Be sure to have supporting cues before making an inference.
Knowing how to probe and frame questions is a skill that grows with experience. |
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Term
Describe the term nursing diagnosis, distinguishing it from a medical diagnosis. |
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Definition
Nursing diagnosis: clinical judgment about the patient in response to an actual or potential health problems
Medical diagnosis: identification of a disease condition based on specific evaluation of signs and symptoms |
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