Block One Nursing Process

Study online at quizlet.com/_1yqnjt

1.

ADPIE

Assessment
Diagnosis
Planning
Implementation
Evaluation
Applied discipline, on-going, constantly
overlapping process used for patient care.

11.

Risk
nursing
diagnosis
(two parts)

A clinical judgment about human

experience/responses to health conditions/life
processes that have a high probability of
developing any vulnerable individual, family
group or community. Related factors are not
available because there are no problems yet,
though they are likely to develop.

12.

Syndrome
nursing
diagnosis

Clinical judgment describing a specific cluster of

nursing diagnoses that occur together, and are
best addressed together and through similar
interventions. Have both defining characteristics
and related factors.

13.

SMART
Outcomes

Specific
Measurable
Attainable
Realistic
Timed

2.

Assess

Perform a nursing assessment

collect data to be used in your diagnosis
focuses on the client's response to illness

3.

Diagnose
NANDA

Make a nursing diagnosis

Analyze the data collected from the
Assessment stage

4.

Plan
NOC

Formulate and right outcome/goal statements

and determine appropriate nursing
interventions based on evidence (research)

5.

Implementation
NIC

Put care plan into action

14.

Maslow's
1st Need

Physiological needs
(A,B,C) then anything else physiological

6.

Evaluation

Evaluate the outcomes in the nursing care

that has been implemented. Make necessary
revisions and care as needed.

15.

Maslow's
2nd Need

Security & Safety

16.

Maslow's
3rd Need

Love & Belonging

17.

Maslow's
4th Need

Self-Esteem

18.

Maslow's
5th Need

Self-Actualization

19.

NANDA

The Problem
This specific NURSING diagnosis that begins
your diagnosis statement.
Stands for North American Nursing Diagnosis
Association

20.

R/T or
"related to"

The Cause
Etiology
Part of you diagnosis statement, follows NANDA
diagnosis

21.

As
Evidenced
By (AEB)

Signs, symptoms, characteristics

The last part of your diagnosis statement
Subjective and Objective
Put together into clustered Cues.

22.

Prioritizing
problems

You do this after you have put together your

nursing diagnosis statement as part of the
planning phase.
Keep in mind Maslow's Hierarchy of Needs for
anything g physiological remember the ABC's

23.

Goals of
the
planning
phase

priorities
ID and write expected patient outcomes (NOC)
Select evidence based nursing interventions
(NIC)
Communicate the plan of care

7.

PES System
(Three part
nursing
diagnosis)

Problem- The nursing diagnosis label: a

concise term or phrase that represents a
pattern of related cues. The nursing
diagnosis is taken from the official NANDA-I
list
Etiology- "related to" (r/t) phrase or etiology:
related cause or contributor to the problem
Symptoms (AEB) - "as evidenced by"defining characteristics phrase: symptoms
that the nurse identified in the assessment.

8.

9.

10.

Two part
nursing
diagnosis (risk
statement)

Consist of the nursing diagnosis in the

"related to" (r/t) statement

Actual nursing
diagnosis

Describes human responses to health

conditions/life processes that exist in an
individual family or group, or community.
Supported by defining characteristics and
related factors.

Health
promotion
nursing
diagnoses

A clinical judgment about a person's family's,

group's or community's motivation and desire
to increase well being and actualize human
health potential as expressed in the
readiness to enhance specific health
behaviors and which can be used in any
health state. Outcomes and intervention
should be focused on enhancing health.

24.

NOC

Nursing Outcome Classification

33.

Steps to
Implementing

Check your knowledge and orders

get organized
assess PT rediness
explain what you are doing
promote client participation

34.

Purpose of
Implementation

assist patient in achieving valued health

outcomes
promote and restore health and prevent
disease
promote self-care (optimum level of function)
facilitate coping with altered function

35.

Documentation

final step of implementation

records nursing activities and client
response
communicate between shifts and disciplines
imperative for continuity of care

Specific statements of desired goal or

outcome
describes the changes in health status you
hope to achieve
25.

2 phases of
planning

Initial:
done by admission nurse, starts with first
client contact
On-going:
changes made as you evaluate the
patient's responses to care

26.

Nursing Care
Plans

Comprehensive , central source of

information needed to efficiently, safely and
effectively care for a patient.

what I did - how the patient responded

Ensures communication, addresses
individual needs
27.

2 types of Goals
(Planning)

Short term: within a few hours or days,

positive reinforcement for patient

36.

How do I
evaluate client
progress?

review outcomes, collect reassessment

data, judge goal achievement, record the
evaluative statement.

37.

Evaluative
statement

decide how well outcome was met

Met, partially met, not met
list patient data or behaviors that support
this decision

Long-term: weeks, months or years to

achieve the optimum level of functioning.
Attained after discharge most of the time.
28.

29.

Components of a
Goal Statement

This statement contains:

Subject = always the patient!
Action= what will they do? (concrete)
Performance Criteria = How? (be specific)
Target Time = When?
Special Conditions = special resources if
needed

Goals/Outcomes
must be...

specific, observable, measurable, patient

centered, time limited and realistic
Derived directly from the nursing diagnosis
State the opposite of the NANADA
diagnosis (problem)

30.

NIC

Nursing Interventions Classification

Consists of a label, a definition, and a list
of specific activities
linked to NANDAs and Outcomes
Include interventions applicable to all
settings

31.

Nursing
Interventions
Must be...

Safe
Within the legal scope of nursing practice
Compatible with medical orders
Specific and realistic

32.

Implementation

Doing or delegating
remember the "rights" of delegation

Revise plan of care if goals were not met

38.

revisions to
the plan of
care

delete or modify the nursing diagnosis

make the outcome statement more realistic
adjust the criteria in the outcome statement
change the nursing interventions