Chapter 8

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  1. The Nursing Process 5 Steps:
    • ADPIE
    • Assessment
    • Diagnosis
    • Planning and goal setting
    • Intervention
    • Evaluation
  2. Nursing Process:
    Is a professional nurses approach to identifying, diagnosis, and treating human responses to health and illness.
  3. Assessment:
    Its an ongoing process- you're never done!

    The focus of assessment to establish a data base of information about the patients response to his health conditions to enable the nurse to determine care needs.
  4. Nursing Assessment- What's in the data base?
    • Health history
    • Physical examination findings
    • Lab results
    • Information from other members of the health care
  5. Types of data:
    • 1.) Objective
    • 2.) Subjective
  6. Where does the data come from?
    The patient, family, other members of the health care team, the medical record, and literature.
  7. How do we get the data?
    • 1. Observation
    • 2. Interviewing
    • 3. Examining
  8. Diagnosis: (after you have all the data and put it together)
    The statement of an actual or potential alteration in health status of a patient.
  9. Nursing Diagnosis:
    • 1. describes an indiviual response
    • 2. oriented to the patient
    • 3. changes as the pt response changes
    • 4. Guides nursing activities
    • 5. Compliementary to the medical diagnosis
    • 2-3 part statement
  10. Nursing Diagnosis contains:
    • 1. statement of the problem......"PAIN" (NAME)
    • 2. etiology.......surgical incision (WHATS THE CAUSE)
    • 3. rates his incisional pain as an "8" (WHATS THE PROBLEM)
    • Alteration in skin integrity
    • R/T surgical inervention
    • AEB 7cm abdominal incision
  12. Planning:
    • 1. Set priorities (what deserves atention 1st)
    • 2. Establish patient goals (a desired outcomeor chg in behavior the goal should reflect"resoultion" of the problem goals must be measureable)
    • 3. Plan the nursing strategies ( what might work?)
    • 4. Communicate the plan
  13. Implementation:
    • (put the plan in action)
    • Interventions
  14. Evaluation:
    Collect the data R/T the goal
  15. Opened ended questions:
    Prompts patients to describe a situation in more than one or two words.
  16. Closed ended questions:
    Limit the patients answers to one or two words such as "yes" or "no".
  17. Medical Diagnosis:
    Is the identification f a disease condition bease on an evaluation of physical signs, symptoms, history, and diagnostic tests and procedures made by physicians.
  18. NANDA Iternational defines nursing diagnosis into 5 steps:
    • Actual
    • Health promotion
    • Risk
    • Syndrome
    • Wellness
Card Set:
Chapter 8
2011-10-02 04:30:57
Basic Nursing

Nursing Process
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