Gnur 238 exam #2
1. THE NURSING PROCESS <Ans> PART 1 AND 2 ASSESSMENT AND DIAGNOSIS
<Ans>
2. ADPIE <Ans>
3. 1) assessment <Ans> Collect data (subjective and objective)
Physical Exam
health history INTERVIEW
Therapeutic relationship
INSPECTION
4. 2) Diagnosis <Ans>
Actual Risk
Health Promotion
5. 3) PLanning <Ans> Prioritize nursing
diagnoses Personalize care plans
-SHORT TERM goals
-LONG TERM goals
Outcome indentification
,-NOC
6. 4) Implementation <Ans> Interventions
-Independent
-Dependent
-Collaborative
-Direct/Indirect
7. 5) Evaluation <Ans> Care plan evaluation
-patient GOAL/OUTCOME attainment
-continue?
8. NURSING DIAGNOSIS <Ans> Assessment leads to FORMATION of nursing
diagnosis PROBLEMS NURSES IDENTIFY AND TREAT**
Taxonomy to categorize client problems or needs is referred to as the NANDA list
(North American Nursing Diagnosis Association)
9. Medical vs. Nursing Diagnosis <Ans>
10. Medical <Ans> defines disease
process ex. MI
11. Nursing <Ans> Impaired
Nutrition Highly anxious-->
anxiety Knowledge of
medication regime
,12. HEALTH TEAM MEMBERS <Ans> Social
Workers Pharmacists
Dietitians
OT and PT
Chaplains
Physicians
Unlicensed assistive personnel
Environmental services
Maintenance department staff
13. TYPES OF NURSING DIAGNOSES <Ans>
14. Actual <Ans> Problem exists RIGHT NOW
15. Risk <Ans> at risk for FURTHER problems/impaired health, related to condition
but no evidence yet
16. Health Promotion <Ans> change LIFESTYLE, enhanced readiness
17. PES METHOD <Ans>
18. Problem <Ans> DIAGNOSIS label
The diagnosis label is a CONCISE term or phrase that represents a pattern of relate
clustered data
19. Etiology <Ans> Related factors/risks
Related factors are the underlying CAUSE or etiology of a patient's problem
20. Symptoms <Ans> Defining CHARACTERISTICS
cues or clusters of related assessment data that are SIGNS, SYMPTOMS, or
, indications of an actual or health-promotion nursing diagnosis
21. Actual - PES <Ans> Diagnosis Label
Related Factors
Characteristics
22. Risk - PE <Ans> Diagnosis Label
Related Factors
23. Health Promotion- PS <Ans> Diagnosis Label
Related Factors
24. Example <Ans> <Ans> Problem <Ans> Acute pain R/T post operative surgical
procedure AMB 9 on pain rating scale.
Etiology <Ans> related to (R/T) condition, experience, chief complaint (cannot be
medical diagnosis)
1. THE NURSING PROCESS <Ans> PART 1 AND 2 ASSESSMENT AND DIAGNOSIS
<Ans>
2. ADPIE <Ans>
3. 1) assessment <Ans> Collect data (subjective and objective)
Physical Exam
health history INTERVIEW
Therapeutic relationship
INSPECTION
4. 2) Diagnosis <Ans>
Actual Risk
Health Promotion
5. 3) PLanning <Ans> Prioritize nursing
diagnoses Personalize care plans
-SHORT TERM goals
-LONG TERM goals
Outcome indentification
,-NOC
6. 4) Implementation <Ans> Interventions
-Independent
-Dependent
-Collaborative
-Direct/Indirect
7. 5) Evaluation <Ans> Care plan evaluation
-patient GOAL/OUTCOME attainment
-continue?
8. NURSING DIAGNOSIS <Ans> Assessment leads to FORMATION of nursing
diagnosis PROBLEMS NURSES IDENTIFY AND TREAT**
Taxonomy to categorize client problems or needs is referred to as the NANDA list
(North American Nursing Diagnosis Association)
9. Medical vs. Nursing Diagnosis <Ans>
10. Medical <Ans> defines disease
process ex. MI
11. Nursing <Ans> Impaired
Nutrition Highly anxious-->
anxiety Knowledge of
medication regime
,12. HEALTH TEAM MEMBERS <Ans> Social
Workers Pharmacists
Dietitians
OT and PT
Chaplains
Physicians
Unlicensed assistive personnel
Environmental services
Maintenance department staff
13. TYPES OF NURSING DIAGNOSES <Ans>
14. Actual <Ans> Problem exists RIGHT NOW
15. Risk <Ans> at risk for FURTHER problems/impaired health, related to condition
but no evidence yet
16. Health Promotion <Ans> change LIFESTYLE, enhanced readiness
17. PES METHOD <Ans>
18. Problem <Ans> DIAGNOSIS label
The diagnosis label is a CONCISE term or phrase that represents a pattern of relate
clustered data
19. Etiology <Ans> Related factors/risks
Related factors are the underlying CAUSE or etiology of a patient's problem
20. Symptoms <Ans> Defining CHARACTERISTICS
cues or clusters of related assessment data that are SIGNS, SYMPTOMS, or
, indications of an actual or health-promotion nursing diagnosis
21. Actual - PES <Ans> Diagnosis Label
Related Factors
Characteristics
22. Risk - PE <Ans> Diagnosis Label
Related Factors
23. Health Promotion- PS <Ans> Diagnosis Label
Related Factors
24. Example <Ans> <Ans> Problem <Ans> Acute pain R/T post operative surgical
procedure AMB 9 on pain rating scale.
Etiology <Ans> related to (R/T) condition, experience, chief complaint (cannot be
medical diagnosis)
