Nur 111 Unit 1 (The Nursing Process & Professional Nursing Practice)
Nur 111 Unit 1 (The Nursing Process & Professional Nursing Practice)
Study online at https://quizlet.com/_62hht2
1. The Nurs- *ADPIE*
ing Process • Assessment
(Overview) • Diagnosis
• Planning
• Implementation
• Evaluation
2. The Nursing Step One: Assessment
Process • ANA Standard of Practice 1
Step Two: Diagnosis
• ANA Standard of Practice 2
Step Three: Planning
• ANA Standard of Practice 3
• ANA Standard of Practice 4
Step 4: Implementation
• ANA Standard of Practice 5
Step 5: Evaluation
• ANA Standard of Practice 6
3. Using the Nurs- • Organize & prioritize care
ing Process helps • Maintain a focus on patients, their problems & attainment of goals
nurses • Think critically
• Give competent care - ANA Standards of Practice
4. ANA Standard of The registered nurse collects comprehensive data pertinent to the patients health
Practice 1- *As- or the situation
sessment*
5. Initial Assess- • Admission within 24 hours of client entering healthcare system
ment Purpose: Obtain data related to persons reason for seeking medical assistance
• Data provides guidance for care & determines the need for further assesment
6.
Page 1 of 12
, Nur 111 Unit 1 (The Nursing Process & Professional Nursing Practice)
Nur 111 Unit 1 (The Nursing Process & Professional Nursing Practice)
Study online at https://quizlet.com/_62hht2
Ongoing Asses- • Performed as needed, any time after the Initial Assessment in completed
ment • Reflects the dynamic state of the client
Purpose: Used to identify or to follow up on previously identified problems
7. Comprehensive Provides holistic information about the client's overall health status
Assessment
8. Focused Assess- • Performed to obtain data about an actual, potential, or possible problem that has
ment been identified or is suspected
*Special Needs:* Provides in-depth information about a particular area of client
functioning and often involves using a specially designed form
9. Data Collection • Interview
Methods • Physical Examination
10. Directive Inter- Used to obtain factual, easily categorized information
view • Closed-ended questions
11. Nondirective In- Allows the patient to control the subject matter
terview • Promotes communication, builds relationships
• Helps patient to express feelings
• Open-ended questions
12. Sources of Data a. Primary data: Client
b. Secondary data: Family members, co-workers, patients clinical record
c. Tertiary data: Textbooks, journals etc..
13. Types of Data 1. Subjective "symptoms" can only be described by the person experiencing it
2. Objective "signs" can be detected by observer
14. Physical Assess- *Inspection:* Observation & visual examination of the client, as well as use of
ment (IPPA) equipment such as an otoscope or ophalmoscope (ear exam)
*Palpation:* Light touch, progressing to deeper touch, using the pads of the
fingers
Page 2 of 12
Nur 111 Unit 1 (The Nursing Process & Professional Nursing Practice)
Study online at https://quizlet.com/_62hht2
1. The Nurs- *ADPIE*
ing Process • Assessment
(Overview) • Diagnosis
• Planning
• Implementation
• Evaluation
2. The Nursing Step One: Assessment
Process • ANA Standard of Practice 1
Step Two: Diagnosis
• ANA Standard of Practice 2
Step Three: Planning
• ANA Standard of Practice 3
• ANA Standard of Practice 4
Step 4: Implementation
• ANA Standard of Practice 5
Step 5: Evaluation
• ANA Standard of Practice 6
3. Using the Nurs- • Organize & prioritize care
ing Process helps • Maintain a focus on patients, their problems & attainment of goals
nurses • Think critically
• Give competent care - ANA Standards of Practice
4. ANA Standard of The registered nurse collects comprehensive data pertinent to the patients health
Practice 1- *As- or the situation
sessment*
5. Initial Assess- • Admission within 24 hours of client entering healthcare system
ment Purpose: Obtain data related to persons reason for seeking medical assistance
• Data provides guidance for care & determines the need for further assesment
6.
Page 1 of 12
, Nur 111 Unit 1 (The Nursing Process & Professional Nursing Practice)
Nur 111 Unit 1 (The Nursing Process & Professional Nursing Practice)
Study online at https://quizlet.com/_62hht2
Ongoing Asses- • Performed as needed, any time after the Initial Assessment in completed
ment • Reflects the dynamic state of the client
Purpose: Used to identify or to follow up on previously identified problems
7. Comprehensive Provides holistic information about the client's overall health status
Assessment
8. Focused Assess- • Performed to obtain data about an actual, potential, or possible problem that has
ment been identified or is suspected
*Special Needs:* Provides in-depth information about a particular area of client
functioning and often involves using a specially designed form
9. Data Collection • Interview
Methods • Physical Examination
10. Directive Inter- Used to obtain factual, easily categorized information
view • Closed-ended questions
11. Nondirective In- Allows the patient to control the subject matter
terview • Promotes communication, builds relationships
• Helps patient to express feelings
• Open-ended questions
12. Sources of Data a. Primary data: Client
b. Secondary data: Family members, co-workers, patients clinical record
c. Tertiary data: Textbooks, journals etc..
13. Types of Data 1. Subjective "symptoms" can only be described by the person experiencing it
2. Objective "signs" can be detected by observer
14. Physical Assess- *Inspection:* Observation & visual examination of the client, as well as use of
ment (IPPA) equipment such as an otoscope or ophalmoscope (ear exam)
*Palpation:* Light touch, progressing to deeper touch, using the pads of the
fingers
Page 2 of 12
