Assessment, Diagnosis, Planning, Implementation, Evaluation – Flashcards

Flat on back, most relaxed (raise HOB is patient becomes SOB)

Laying on stomach with hands above head. (not good for patients with respiratory difficulties)

laying on left side, helps to listen to heart and hear murmurs (not good for patients with resp difficulties)

HOB 45-60 degrees elevated with legs slightly elevated.

patient is laid supine and bed is tilted to have head above feet by about 15-30 degrees

A methodical way of solving problems 1. identify the problem 2. Collect data 3.Formulate a question or hypothesis 4. Test the question or hypothesis

Journal writing is a tool for developing critical thought and reflections by clarifying concepts. Express clinical experiences in your own words. Record notes after a clinical experience. Journaling improves your observation and descriptive skills and ultimately your clinical decision making.

Caring for patients with multiple nursing diagnoses or collaborative problems, a concept map is a visual representation of patient problem and interventions that shows their relationship to one another. Concept maps help you learn to organize or connect information in a unique way so the diverse information that you have about a patient begins to forms meaningful patterns and concepts.

Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE).

An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well. For example, a nurse's assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient's response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain mediation 1. Collection of information from a primary source (patient) and secondary source (family, etc.) 2. Interpretation and validation of data to ensure a complete database.

Observation: looking at the patient's non-verbal communication (eye contact, body language, tone of voice) Open-ended questions: Used to try to find out information, in the patient's own words, about health goals, or any health concerns or problems. (tell me more about, what are your concerns, tell me how you're feeling) Leading questions: Most risky type of question because of possibility of limiting the information provided by the patient. "it seems to me this is bothering you quite a bit, is that true?" Back channeling: reinforces your interest in the patient's story. Uses " uh huh, go on, tell me more" indicating you have heard what the patient said and would like them to continue. Probing: As a patient tells you their story encourage full description without trying to control the story. "Is there anything else you can tell me?, What else is bothering you?" Direct/closed ended questions: Simple yes or no, simple answers. How long have you had diarrhea?, Do you have cramping or pain?"

Keep is short and simple. Do not try to interpret results with "good, bad, etc"

In the patient's own words "I feel like I didn't sleep well last night"

Airway, Breathing, Circulation

Used when assessing the present illness or health concern P-Provokes: what causes the symptom, what makes it better or worse, are there any activities that make it worse? Q- Quality: What does the symptom feel like? Sharp, dull, burning, etc. R-Radiate: Where is the symptom located? Does it radiate to another location? S-Severity: Ask the patient to rate the severity of a symptom on a scale of 0-10 T- Time: Assess the onset and duration of symptom. When did it start? Does it come and go?

North American Nursing Diagnosis Association International NANDA-I NANDA-I nursing diagnoses include 3 types, problem focused, risk, and health promotion.

A diagnostic label with a related factor ex: Acute pain r/t trauma of surgical incision, Impaired physical mobility r/t incisional pain

Medical diagnoses are based upon a physician's identification of a disease.

The nursing diagnosis is the nurse's clinical judgment about the client's response to actual or potential health conditions or needs. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications—for example, respiratory infection is a potential hazard to an immobilized patient. The diagnosis is the basis for the nurse's care plan.

Nurses make diagnostic conclusions using nursing diagnosis to form clinical decisions necessary for safe and effective nursing practice.

Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-range goals for this patient that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the patient's care plan so that nurses as well as other health professionals caring for the patient have access to it

A measurable change that must be achieved to reach a goal. "Patient identifies S&S of wound infection before discharge from hospital"

Writing a goal: use SMART S-Specific goal M- Measurable A- Attainable R-Realistic T-Timed So a good goal would be "patient will achieve pain relief by day of discharge"

A goal you expect the patient to achieve in a short time, usually less than a week. Usually used in the acute care setting.

A goal you expect the patient to achieve in a longer period of time, usually several days, weeks, or months. "Patient will be tobacco free in 60 days"

Actions that the nurse initiates without supervision or direction from others. Do not require an order. Mostly pertain to ADLs, health education, an counseling. Ex: Positioning patients, instructing patients of side effects of meds, providing skin care to ostomy site.

Actions that require an order from a HCP. The interventions are based on the HCP's response to treating or managing a medical diagnosis. Ex: administering medications, implementing an invasive procedure (foley), prepping a patient for a diagnostic test.

AKA Interdependent Nursing Interventions are therapies that require the combined knowledge, skill, and expertise of multiple HCPs.

Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient's record.

Both the patient's status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.

To evaluate whether, after application of the first four steps of the nursing process, a patient's condition or well-being improves.

Reassess