Exam 1 Study Guide
Nursing Process
Follow ADPIE! (Assess before implementation, etc.)
1. Assessment: Gather data and collect information from the patient
Subjective- patient
Objective- what the nurse observes
Consider verbal and nonverbal communication
Listen, and observe and ask open ended questions, when you assess
you, data collect, gather all the information you can to really assess the
client and allows you provide the best care for them.
2. Diagnosis- Diagnosis the client based on the data you gathered in the
assessment
3. Plan- Plan what are going to do for the client,
Set patient centered goals and expected outcomes
As the patient needs changes the goals and outcomes should change
and it should
Involve the family and health care team in the planning process.
Short- and Long-term goals
Independent nursing intervention- initiates a nursing diagnosis
without supervision
Dependent nursing intervention- requires an order from the health
care provider
Interdependent Intervention- Therapies that require the combined
knowledge, skill, and expertise of multiple healthcare provides.
4. Implementation – putting your nursing care plan into action
Direct nursing intervention- treatment performed through interactions
with the patient
Indirect nursing intervention- actions performed away from the
patient on their behalf such as documentation and advocating for the
patient
5. Evaluation- final stage that requires critical thinking in whether the outcomes
and goals were met, if they were not then you need to reevaluate and then
start the process again
, Goals – Client centered, not the nursing interventions. Use SMART goals.
Specific- precise, who, what, when, where, and why
Measurable- able to be reached, how will you know if you’ve accomplished
the goal
Attainable- able to be reached, patient agrees and motivated
Realistic- realistic and achievable, patient condition, ability, and willingness
Timely- when do you expect the goal to be met, have a set target date
Prioritizing care
1st level: Airway Breathing Circulation
2nd level then pain **unless it is chest pain!
3rd level: sleep, long term problems
Delegation
5 rights of delegation
Right Task
Right Circumstance
Right Person
Right Direction
Right Supervision
Roles of RN, CNA, LPN
RN: administer an NG tube feeding for a client, and perform suctioning
LPN: An LPN can monitor client findings for an RN's assessment, reinforcing client
teaching from a care plan, performing tracheostomy care and suctioning,
uncomplicated wound care, check NG tube patency, administering enteral
feedings, inserting a urinary catheter, and administering some medications.
Remember to delegate VS only when the client is stable.
Legal/Ethical
Ethical dilemmas
When can a minor sign a consent form? (pg. 313)
18 or older
Nursing Process
Follow ADPIE! (Assess before implementation, etc.)
1. Assessment: Gather data and collect information from the patient
Subjective- patient
Objective- what the nurse observes
Consider verbal and nonverbal communication
Listen, and observe and ask open ended questions, when you assess
you, data collect, gather all the information you can to really assess the
client and allows you provide the best care for them.
2. Diagnosis- Diagnosis the client based on the data you gathered in the
assessment
3. Plan- Plan what are going to do for the client,
Set patient centered goals and expected outcomes
As the patient needs changes the goals and outcomes should change
and it should
Involve the family and health care team in the planning process.
Short- and Long-term goals
Independent nursing intervention- initiates a nursing diagnosis
without supervision
Dependent nursing intervention- requires an order from the health
care provider
Interdependent Intervention- Therapies that require the combined
knowledge, skill, and expertise of multiple healthcare provides.
4. Implementation – putting your nursing care plan into action
Direct nursing intervention- treatment performed through interactions
with the patient
Indirect nursing intervention- actions performed away from the
patient on their behalf such as documentation and advocating for the
patient
5. Evaluation- final stage that requires critical thinking in whether the outcomes
and goals were met, if they were not then you need to reevaluate and then
start the process again
, Goals – Client centered, not the nursing interventions. Use SMART goals.
Specific- precise, who, what, when, where, and why
Measurable- able to be reached, how will you know if you’ve accomplished
the goal
Attainable- able to be reached, patient agrees and motivated
Realistic- realistic and achievable, patient condition, ability, and willingness
Timely- when do you expect the goal to be met, have a set target date
Prioritizing care
1st level: Airway Breathing Circulation
2nd level then pain **unless it is chest pain!
3rd level: sleep, long term problems
Delegation
5 rights of delegation
Right Task
Right Circumstance
Right Person
Right Direction
Right Supervision
Roles of RN, CNA, LPN
RN: administer an NG tube feeding for a client, and perform suctioning
LPN: An LPN can monitor client findings for an RN's assessment, reinforcing client
teaching from a care plan, performing tracheostomy care and suctioning,
uncomplicated wound care, check NG tube patency, administering enteral
feedings, inserting a urinary catheter, and administering some medications.
Remember to delegate VS only when the client is stable.
Legal/Ethical
Ethical dilemmas
When can a minor sign a consent form? (pg. 313)
18 or older
