Funda ADP QUIZ

• Nursing process


  A systematic, cyclical approach to nursing care that involves assessment, diagnosis, planning, implementation, and evaluation
• Purposes of nursing process

  • Identify client's health problem
  • Establish plans
  • Deliver specific nursing intervention to meet this needs
• Phases of nursing process (ADPIE)

  • Assessing
  • Diagnosing
  • Planning
  • Implementing
  • Evaluating
• Assessing

  • Cyclic & dynamic
  • Client centered
  • An adaptation of problem solving process
  • Decision making is involved in every phase
  • Interpersonal & collaborative
  • Universal
  • Use of critical thinking
• NP was introduced by LYDIA HALL

• JOHNSON, ORLANDO, & WIEDENBACH

  were the first to use the nursing process in 1963
• Assessing


  1. Gather subjective & objective data

  2. Identify the client's chief complaint
• Diagnosing


  1. Based on the data collected, identify a nursing diagnosis

  2. Consult evidence-based practice literature
• Planning


  1. Goal development

  2. Recall nursing & health related knowledge

  3. Consult w/ the primary care provider & client

  4. Review outcomes of prior clinical situations
• Implementing


  Identify & implement interventions to assist in the attainment of goals & resolution of the nursing diagnosis
• Evaluating


  Evaluate the client's response to the care provided
• Assessment


  Systematic & continuous collection, organization, validation, & documenting data
• Assessment activities (COVD)

  • Collecting data
  • Organizing data
  • Validating data
  • Documenting data
• Types of assessment

  • Initial Comprehensive Assessment (ICA)
  • Problem-Focused Assessment (PFA)
  • Emergency Assessment (EA)
  • Time-Lapsed Assessment (TLA)
• Data collection


  Process of gathering info. about a client's health status
• Database


  • Nursing Health History
  • Physical Assessment
  • Results of Laboratory and Diagnostic Examination
  • Material contributed by other health personnel
  • Past History & Current Problems
• Implementation


  Carrying out your plan to achieve goals and documenting the planned nursing interventions
• Evaluation


  Measuring the degree to which goals or outcomes have been achieved and identifying factors that positively of negatively influence goal achievement
• Diagnosis


  Analyze the data you collected then identify the actual & potential health problems or responses to life processes
• Planning


  Involves setting goals & outcomes, determining outcome criteria & developing a plan
• SMART goals


  • Specific
  • Measurable
  • Attainable
  • Realistic
  • Time bounded
• Components of a nursing health history

  • Biographic Data
  • Chief Complaint / Reason for Visit
  • Past History of Illness
  • Family History of Illness
  • Lifestyle
  • Social Data
  • Psychologic Data
  • Patterns of Healthcare

  
• Types of data


  • Subjective data / Covert
  • Objective data / Overt
• Sources of data


  • Primary (client)
  • Secondary (family members, other support persons, other health professionals, records and reports, laboratory and diagnostic analyses, relevant literature)
• Observation


  A conscious, deliberate skill that is developed through effort and with an organized approach to gather data by using the senses
• Using the senses to observe client data

  • Vision (overall appearance, signs of discomfort or distress, facial and body gestures, skin color and lesions, abnormalities of movement, nonverbal demeanor)
  • Smell (body / breath odors)
  • Hearing (lung and heart sounds, bowel sounds, ability to communicate, language spoken, ability to initiate conversation)
  • Touch (skin temp. and moisture, muscle strength, pulse rate, rhythm, and volume, palpatory lesions)
• Interview


  A planned communication / conversation with a purpose to get / give info, identify problems of mutual concerns, evaluate
• Approaches to interviewing

  • Directive (highly structured, elicit specific info, controls the interview, client have a limited opportunities to ask questions / discuss concerns)
  • Non-directive (rapport-building, nurse allows the client to control the purpose, subject matter, and pacing)
• Types of interview questions

  • Open-ended (non-directive, invite client to explore)
  • Closed-questions (directive, restrictive, "yes" or "no" or short factual answer)
• Open-ended questions


  • Advantages (let the interviewee do the talking, interviewer able to listen and observe, reveal what the interviewee thinks is important, can provide info. the interviewee may not ask for)
  • Disadvantages (takes more time, only brief answers may be given, valuable info. may be withheld, often elicit more info.)
• Close-ended questions


  • Advantages (question and answers can be controlled more effectively, they require less effort from the interviewee, takes less time, responses are easily documented)
  • Disadvantages (may provide too little info. and require follow-up questions, may not reveal how the interviewer feels, the interviewer may dominate the interview with questions)
• Types of questions


  • Leading-closed ended (use in directive interviews and thus, directs the clients answers, gives client less opportunity to decide whether the answer is true or not, the result may lead to inaccurate data)
  • Neutral (a question that the client can answer without direction or pursue from the nurse, open-ended, non-directive)
• Planning the interview


  1. Review available info. about the client's current illness

  2. Time of the interview (client is physically comfortable and free of pain, minimal interruptions)

  3. Place (a well-lit, well-ventilated room, free of noise, movement, and distractions, others cannot overhear or see the client)

  4. Seating arrangement (when the client is in bed - the nurse sits at a 45-degree angle to the bed, nurse and patient sit on 2 chairs placed at right angles to a desk or table)

  5. Distance (neither too small nor too great)

  6. Language (Nurses must convert complex medical terms into common English, often requiring interpreters or translators if the client and nurse do not speak the same language or dialect)
• Stages of an interview

  • The Opening (sets the tone, establish rapport, orient the interviewee)
  • Body (client communicate what he/she thinks, feels, knows, and perceived)
  • Closing (Nurse terminates the interview when the needed info, has been obtained)
• Cephalocaudal assessment


  Head to toe assessment
• Examining functional heath patterns

  • Health perception and health management
  • Nutritional-metabolic
  • Elimination
  • Activity-exercise
  • Cognitive-perceptual
  • Roles-relationships
  • Self-perception or self-concept
  • Coping-stress
  • Value-belief
• Validating data


  Act of "double checking" or verifying data to confirm that it is accurate and factual
• Cues vs. inferences


  Cues - directly observed by the nurse

  Inferences - nurse's interpretation or conclusions made based on the cues
• Documenting data


  Records the clients data
• Diagnosing

  A. Actual nursing diagnosis (a client problem that is present at the time of nursing assessment)

  B. Health promotion diagnosis / wellness diagnosis (client's preparedness to implement behaviors to improve their health condition, willingness to learn about their health maintenance or willingness to change health practices)

  C. Risk nursing diagnosis (problem does not exist yet but the client is at high risk of developing it)