307 ADPIE (Nursing Process)

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Critical Thinking
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A reasoning process used to reflect on and analyze thoughts, actions, and knowledge Requires a desire to grow intellectually Requires the use of nursing process to make nursing care decisions An active, organized, cognitive process used to carefully examine ones thinking and the thinking of others Recognizing an issue exists, analyzing information, evaluating information, and making conclusions
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Thinking and Learning
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Intellectual and emotional growth involves learning new knowledge, as well as refining the ability to think, solve problems, and make judgements
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Develop Critical thinking
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Reflective journaling – A tool used to clarify concepts through reflection by thinking back or recalling situations Concept mapping – A visual representation of client problems and interventions that illustrates an interrelationship
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Nursing process
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assess, diagnosis, planning, intervention, evaluation
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Assess
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Assess patient to determine need for nursing care Collection and verification of data Analysis of data Interview patient – stop loved ones if they answer for him or her Info from primary care physician, medical history, patient records, reports from other nurses, labs, EKG, family, pharmacy
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Diagnosis
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determine for actual and potential health problems clinical judgement about the client in response to an actual or potential health problem. you can do something about – help a fever, dry skin, dehydration, airway clearance, bed sores. a diagnosis will ensure that you select relevant and appropriate nursing interventions.
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Actual Nursing diagnosis
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Describe human responses to levels of wellness that have a readiness for enhancement. a big girl who has a bed sore
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Risk Nursing diagnosis
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Describes human responses to health conditions/life processes that may develop. Patient is at risk for – doesn’t have it yet but will (bed sore)
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Planning
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Helps nurses to anticipate and sequence nursing interventions. short term goals – response expected within hours to a week long term goals – response expected within weeks or months Goals have to be timed and measurable. ex. by 2:15pm on 2/14/14 will ambulate 5 yards.
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Interventions/implementation
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What you do to reach your goals. reassessing the client actions planned are carried out utilizes evidence based interventions and treatments nurses coordinates and documents the care uses health promotion and health teaching methods
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Evaluation
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did the patient reach the goal? identify evaluative criteria and standards collect data interpret and summarize findings document findings and clinical judgements terminate, continue, or revise the care plan

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