Phases of nursing process (ADPIE)
Assessment, Diagnosis, planning, Implementation, Evaluation
Nursing Process: assessment
-collect data
-review of clinical record
-health history
-physical exam
-function assessment
-risk assessment
-use EBP
-document relevant data
Nursing process: diagnosis
-compare clinical findings with normal and abnormal variation
-interpret data
-ID clusters of cues
-make hypothesis
,-test hypothesis
-derive dx
-validate dx
-document dx
Nursing process: planning
-establish priorities
-developmental outcomes/goals (SMART goals)
-identify nursing interventions
-document plan of care
SMART goals
Specific, Measurable, Attainable, Realistic, Timely
Nursing Process: Implementation
-implement the plan in a safe and timely manner
-use EBP interventions
-collaborate with colleagues
-coordinate care delivery
-provide teaching and health promotion
, -document implementation and modifications
Nursing process: Evaluate
-progress towards goals/outcomes
-conduct systematic, ongoing, criterion based evaluation
-include patient and significant others
-use ongoing assessment to revise diagnosis, outcome, plan
-disseminate results to patient and family
Close/direct questions
-elicit a one or two word response
-help you elicit specific information
-helpful in filling in any details originally left out
-highly stressed people and people with difficulty hearing will find these easier
Open-ended questions
-unbiased
-associated with non-directive interview
-invite clients to discover, explore, elaborate, clarify, or illustrate a thought or feeling