Nursing 400 Exam 1 – Questions With Reviewed
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Terms in this set (128)
Nursing Process ADPIE
Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment is the collection, organization, and documentation of
data. When documenting data stick to the facts, no
opinions. Make sure to validate data before
documenting. Can use the facility database to collect
data on patients.
Data sources: Patient, Family members, Facility
Database
What are the 4 goals of the 1. Established during admission
Assessment?
2. Identifies the client's strengths and health
problems that can be prevented or resolved
3. Develop a list for nursing and collaborative
problems.
4. Develop an individualized care plan that is client
specific in order for pt to meet the desired goal,
promote wellness, restore health, and facilitate
coping with altered functioning
,Types of Health assessments comprehensive
ongoing partial
focused
emergency
comprehensive assessment Conducted upon admission to healthcare facility
ongoing partial assessment conducted at regular intervals
focused assessment gathers data about a specific problem that has
already been identified.
emergency assessment identify life-threatening problems
Diagnosis Must use NANDA for nursing diagnosis. Match
objective and subjective data with diagnosis from
NANDA. Can use medical diagnosis to help with
nursing diagnosis.
EX: Patient has pneumonia and difficulty breathing,
your diagnosis would be they have ineffective
breathing.nses to levels of wellness in an individual,
family, or community
Syndrome Diagnosis
Diagnosis that is associated with a cluster of other dx
Types of Nursing Diagnosis' Actual Nursing Dx
Possible Nursing Dx
Wellness Dx
Syndrome Dx
Actual Nursing Dx Problem present during the initial nursing assessment
, Risk Nursing Dx Using clinical judgement and considering the risk
factors to develop a potential problem
Possible Nursing Dx Evidence about health problems is incomplete or
unclear
Additional data are used to confirm or rule out the
suspected problem
Wellness Dx Describes human responses to levels of wellness in
an individual, family, or community
Syndrome Dx Dx that is associated with a cluster of other dx
Planning Is about how you are going to achieve your goal.
Discharge planning starts as soon as the patient is
admitted. Always have rationale behind your
plan/intervention. Keep in mind how the longer a
patient is bed ridden, the longer it will take for them
to get better. Implement the nursing process in a
goal directed manner. Initial planning addresses
problems and identifies patient goals. Ongoing is
when you note health improvements and risk factors.
Update the diagnosis when necessary. Discharge
nursing also plans for outpatient care if necessary
Intervention Are health promoting techniques to improve health,
function, and quality of life.
Independent intervention is when the nurse handles the intervention EX: Telling
patients to adjust diet or have them perform a range
of motion exercises.
Dependent intervention is when a doctor is needed to approve an order EX:
Thinking a patient should be on oxygen. When
implementing a nursing intervention keep in mind the
patient's skill such as cognitive, interpersonal and
technical skills.
Solutions
Save
Terms in this set (128)
Nursing Process ADPIE
Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment is the collection, organization, and documentation of
data. When documenting data stick to the facts, no
opinions. Make sure to validate data before
documenting. Can use the facility database to collect
data on patients.
Data sources: Patient, Family members, Facility
Database
What are the 4 goals of the 1. Established during admission
Assessment?
2. Identifies the client's strengths and health
problems that can be prevented or resolved
3. Develop a list for nursing and collaborative
problems.
4. Develop an individualized care plan that is client
specific in order for pt to meet the desired goal,
promote wellness, restore health, and facilitate
coping with altered functioning
,Types of Health assessments comprehensive
ongoing partial
focused
emergency
comprehensive assessment Conducted upon admission to healthcare facility
ongoing partial assessment conducted at regular intervals
focused assessment gathers data about a specific problem that has
already been identified.
emergency assessment identify life-threatening problems
Diagnosis Must use NANDA for nursing diagnosis. Match
objective and subjective data with diagnosis from
NANDA. Can use medical diagnosis to help with
nursing diagnosis.
EX: Patient has pneumonia and difficulty breathing,
your diagnosis would be they have ineffective
breathing.nses to levels of wellness in an individual,
family, or community
Syndrome Diagnosis
Diagnosis that is associated with a cluster of other dx
Types of Nursing Diagnosis' Actual Nursing Dx
Possible Nursing Dx
Wellness Dx
Syndrome Dx
Actual Nursing Dx Problem present during the initial nursing assessment
, Risk Nursing Dx Using clinical judgement and considering the risk
factors to develop a potential problem
Possible Nursing Dx Evidence about health problems is incomplete or
unclear
Additional data are used to confirm or rule out the
suspected problem
Wellness Dx Describes human responses to levels of wellness in
an individual, family, or community
Syndrome Dx Dx that is associated with a cluster of other dx
Planning Is about how you are going to achieve your goal.
Discharge planning starts as soon as the patient is
admitted. Always have rationale behind your
plan/intervention. Keep in mind how the longer a
patient is bed ridden, the longer it will take for them
to get better. Implement the nursing process in a
goal directed manner. Initial planning addresses
problems and identifies patient goals. Ongoing is
when you note health improvements and risk factors.
Update the diagnosis when necessary. Discharge
nursing also plans for outpatient care if necessary
Intervention Are health promoting techniques to improve health,
function, and quality of life.
Independent intervention is when the nurse handles the intervention EX: Telling
patients to adjust diet or have them perform a range
of motion exercises.
Dependent intervention is when a doctor is needed to approve an order EX:
Thinking a patient should be on oxygen. When
implementing a nursing intervention keep in mind the
patient's skill such as cognitive, interpersonal and
technical skills.
