Nursing process - correct answer ✔✔ How nurses think, identify, and respond
Problem solving process
AAPIE - correct answer ✔✔ Assessment, analysis, planning, implementation, evaluation
Assessment - correct answer ✔✔ The evaluation of your client through subjective (from client;
ex-pain, itching, headache) and objective (what you observe; ex-vital signs) data
1-initial 2-focus 3-time-lapsed 4-emergency
Client is BEST source
Documentation of assessment must be: - correct answer ✔✔ Concise, thorough, and accurate
Primary source - correct answer ✔✔ Patient
Secondary source - correct answer ✔✔ Anything NOT rom patients mouth
Family, friends, caregivers, other healthcare workers, medical records
Analysis - correct answer ✔✔ Recognize patterns/trends in data, compare with expected
standards or reference ranges, arrive at conclusions, focus on facts
Planning - correct answer ✔✔ Establish priorities, identify goals and outcomes, identify actions
and interventions, prioritize hypotheses, generate solutions
, 3 types of planning- Comprehensive, Ongoing (still planning throughout), Discharge
(anticipating)
Goals of planning must be SMART - correct answer ✔✔ S- singular and specific
M- measureable
A- attainable (can reach this point)
R- realistic
T- time (timeframe)
Implementaion - correct answer ✔✔ Problem solving, clinical thinking and judgement to
implement best solution to restore health
What do nurses do during implementation? - correct answer ✔✔ Perform actions, delegate
tasks, supervise other staff, and document
Delegation rights (5) - correct answer ✔✔ Right task, right circumstance, right person, right
direction, and right supervision
DO NOT delegate: - correct answer ✔✔ Unstable patient, initial assessment, teaching or
educating patient
Evaluation - correct answer ✔✔ Nurse evaluates patient response, determine effectiveness of
care plan, form clinical judgement
What factors lead to lack of goal achievement? - correct answer ✔✔ -incomplete database
-unrealistic client outcomes
-nonspecific nursing interventions
-inadequate time for client to reach goal