DETAILED ANSWERS
,THE NURSING PROCESS: PART 1 AND 2 ASSESSMENT AND DIAGNOSIS -
ANSWER
ADPIE - ANSWER
1) assessment - ANSWERCollect data (subjective and objective)
Physical Exam
health history INTERVIEW
Therapeutic relationship
INSPECTION
2) Diagnosis - ANSWERActual
Risk
Health Promotion
3) PLanning - ANSWERPrioritize nursing diagnoses
Personalize care plans
-SHORT TERM goals
-LONG TERM goals
Outcome indentification
-NOC
4) Implementation - ANSWERInterventions
-Independent
-Dependent
-Collaborative
-Direct/Indirect
5) Evaluation - ANSWERCare plan evaluation
-patient GOAL/OUTCOME attainment
-continue?
NURSING DIAGNOSIS - ANSWERAssessment 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)
Medical vs. Nursing Diagnosis - ANSWER
Medical - ANSWERdefines disease process
ex. MI
, Nursing - ANSWERImpaired Nutrition
Highly anxious--> anxiety
Knowledge of medication regime
HEALTH TEAM MEMBERS - ANSWERSocial Workers
Pharmacists
Dietitians
OT and PT
Chaplains
Physicians
Unlicensed assistive personnel
Environmental services
Maintenance department staff
TYPES OF NURSING DIAGNOSES - ANSWER
Actual - ANSWERProblem exists RIGHT NOW
Risk - ANSWERat risk for FURTHER problems/impaired health, related to condition but
no evidence yet
Health Promotion - ANSWERchange LIFESTYLE, enhanced readiness
PES METHOD - ANSWER
Problem - ANSWERDIAGNOSIS label
The diagnosis label is a CONCISE term or phrase that represents a pattern of related,
clustered data
Etiology - ANSWERRelated factors/risks
Related factors are the underlying CAUSE or etiology of a patient's problem
Symptoms - ANSWERDefining CHARACTERISTICS
cues or clusters of related assessment data that are SIGNS, SYMPTOMS, or
indications of an actual or health-promotion nursing diagnosis
Actual - PES - ANSWERDiagnosis Label
Related Factors
Characteristics
Risk - PE - ANSWERDiagnosis Label
Related Factors