The Nursing Process Correct Answer-a process we use for evaluating
patients and forming a plan
Steps of the Nursing Process Correct Answer-ADPIE
Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment Correct Answer-collect data (physical exam)
organize data (make a list of findings)
validate data (labs)
document relevant data
Diagnosis Correct Answer-analyze data (compare findings with normal)
interpret data (what is the problem?)
document diagnosis/problem statement
Planning Correct Answer-what do we want to see happen?
prioritize problem
set timeline for outcomes (SMART goals)
, identify nursing interventions
evidence based trends
document plan of care
Implementation Correct Answer-implement interventions
safe and timely manner
collaborate with colleagues
provide teaching
document the implementation
Evaluation Correct Answer-evaluate progress toward outcomes
conduct systemic, ongoing, criterion based eval
may need to extend due date
writing evaluation (date, time, conclusion of goal, supporting statement
if patient didn't meet goal)
Head to toe assessment Correct Answer-done at annual physical, with a
new patient, or a new hospital admission
update biological data
source of history
reason for seeking care
history of present illness (location, severity, timing, setting)
past health history
family health history