Test 1

a distinct entity among the healthcare professions and also delineated specific steps in a process approach to nursing ADPIE

• assessment
• diagnosis
• outcome indentification & planning
• implementation
• evaluation

nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals,, families, communitites and populations

a systematic method that directs the nurse and the patient, as together they accomplish the 5 steps (adpie)

• systematic
• dynamic
• interpersonal
• outcome oriented
• &
• universally applicable

• is a basic life skill:
• identifying a problem and then taking the steps to resolve it

• ADPIE
• assessing
• diagnosing
• outcome identification & planning
• implementing
• evaluating
• documenting communication
• hand-off communication SBAR
• S ituation
• B ackground
• A ssessment
• R ecomendations

• when collecting and recording data nurses should be
• purposeful
• complete
• accurate
• factual
• relevant

observation--the conscious and deliberate use of the five senses to gather data.

interview--is a planned communication

physical assessment--the examination of the patient for objective data

• profile-name,age,sex etc
• reason for seeking healthcare
• normal health habits and patterns
• cultural considerations -relation to diet,decision making
• current state of health
• current meds, allergies & immunizations
• perception of health status
• developmental, family,environment & psychosocial history
• patient and familys expectations
• patient and familys ability and willingness to follow care planned
• patients and familys educational needs
• whether or not an advance directives exists
• patients personal resources (strenghts) and deficits
• patients potential for injury

• subjective
• and
• objective

information perceived only by the affected person, these data cannot be verfied or perceived by another

are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them

is the process of confirming or verifying

• there are discrepancies
• and
• when they lack objectivity

denotes significant data or data that influence an analysis

• recognizing significant data
• recognizing patterns and clusters
• indentifying strengths and problems
• identifying potential complications
• reaching conclusions
• partnering with patient

is a norm, or a generally accepted rule in the same class or category

is a grouping of patient data or cues that points to the existence of a patient health problem

a cluster of significant data

• no problem
• possible problem
• actual or potential nursing diagnosis
• clinical problem other than nursing diagnosis

• no response indicated
• reinforce patients health habits and patterns
• initiate health promotion activities to prevent disease or illness or to promote higher level of wellness
• wellness diagnosis might be indicated

collect more data to confirm or disprove suspected probloem

• begin planning, implementing, and evaluating care designed to prevent, reduce, or resolve problem
• if unable to treat problem b/c patient denies and refuses treatment, make patient aware of possible outcomes for this stance

• consult with approriate healthcare professional and work collaboratively on problem
• refer to medicine or other services

medical diagnosis: identify diseases.pysician diagnoses and directs for treatment. remains the same as long as the disease remains

nursing diagnosis: focus on unhealthy response to health and illness, can change from day to day

• -actual
• -risk
• -possible
• -wellness
• -syndrome

represent a problem that has been validated by the presence of major defining characteristics

are clinical judgements that an individual, family, or community is more vulnerable to develope the problem

are statements describing a suspected problem for which additional data are needed

are clinical judgements about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness

comprise a cluster of actual or risk nursing dianoses that are predicted to be present b/c of a certain event or situation

• problem
• etiology
• defining characteristics

describes the health state or health problem of the patient as clearly and concisely as possible

identifies the physiologic, psychologincal, sociologic, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor

is the subjective or objective datat that signal the existence of the actual or potential health problem.

realize beforehand, foresee

damaged, made vulnerable

lessened in size, amount or degree

insufficient, inadequate

late, slow or postponed

limited, handicapped

not properly arranged

too large or too small in comparison with the norm

agitated,interrupted, interfered with

not operating normally

producing the inteded or desired result

greater than necessary or desirable

out of proportion or balance

damaged or weakend

not producing the inteded or desired effect

having its continuity broken

below norm

properly arranged or controlled

observed through the senses

in a suitable state for an activity or situation

related to a particular circumstance

significant info that is helpful in making decisions

actual or potential health problems that may occer from complications from disease

information

anyalysis of a patient

study of the cause of disease

to rate or assess

to carry out the plan of care

statement about a specific disease process using terminology from a well developed classification

actual or potential health problem that a nursing intervention can prevent

assessment of the patient by interviewing the patient

• ADPIE
• assessing
• diagnosing
• organizing and planning
• implementing
• evaluating

percievable by the senses

written guide that directs the efforts of the nursing team to meet health goals

written plan that describes nurses activities

clear, concise, specific, accurate, relevant, plausible, consistent

info perceived only by the affected patient