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Assessment
Diagnosis
Plan
Implement
Evaluate
100
GATHERING information about the patient's condition
What is Assessment
100
Identify the patient's problems
What is Diagnosis
100
Set goals of care, desired outcomes, identify appropriate nursing actions
What is Plan
100
To Perform the nursing action identified in planning
What is Implement
100
Determine if goals & expected outcomes are achieved
What is Evaluate
200
A ___ is information that you obtain through use of the senses. An _______ is your judgement or interpretation of these (ex. A patient crying possibly implies fear or sadness)
What is CUE & INFERENCE
200
A set of signs or symptoms gathered during assessment that you group together in a logical way.
What is Data Clustering
200
-NURSE initiated - Independent (action that a nurse initiates) -PHYSICIAN initiated - Dependant (require an order from a physician or other health care professional) -COLLABORATIVE - Interdependent (require combined knowledge, skill, & expertise of multiple health care professionals.
What is Types of Interventions
200
-COGNITIVE Skills (critical thinking) -INTERPERSONAL Skills (trust, caring, communication) -PSYCHOMOTOR Skills (cognitive & motor)
What is Implementation Skills
200
Ongoing process
What is Evaluation
300
1. Collection & Verification of (data) 2. Analysis of (data)
What is Two Stages of Assessment
300
Clinical judgement about the patient in response to an actual or potential health problem
What is Nursing Diagnosis
300
-HIGH (emergent) -INTERMEDIATE (non-emergent/non-life threatening) -LOW (affect patient's future well being)
What is Classification of priorities:
300
Any treatment based on clinical judgement and knowledge that a nurse performs to enhance patient outcomes. - includes direct & indirect care measures aimed at individuals, families, and/or the community.
What is Nursing Intervention
300
Nursing care helps patients: RESOLVE actual health problems, PREVENT potential problems, MAINTAIN a healthy state
What is Standards for Evaluation
400
*Patient-centered interview = An organized conversation with the patient. -SET THE STAGE (preparation, environment, greeting) -SET THE AGENDA (gather info about pt. concerns) -COLLECT the Assessment or nursing health history -TERMINATE the interview
What is Methods of Data Collection
400
PES Format: Problem, Etiology, Symptoms (or defining characteristics). REMEMBER: Problem-r/t-evidence by
What is Components of a Nursing Diagnosis
400
Ordering of nursing diagnosis or patient problems using determinations of urgency and/or importance to establish a preferential order for nursing actions.
What is Priority Setting
400
Reassessing the patient->Reviewing & revising the existing nursing care plan->Organizing resources and care delivery ->Anticipating & preventing complications.
What is Implementation Process
400
Defines Standards for Evaluation
What is (ANA) American Nurses Association
500
*OPEN-ENDED (patient's own words) *CLOSED-ENDED (yes/no) *BACK-CHANNELING (shows interest to the patient, by active listening prompt "all right" "go on" "uh huh") *PROBING (furthering open-ended questions by asking "Is there anything else you can tell me?" or "What else is bothering you?"
What is Interview Techniques
500
The Diagnostic Reasoning process involves using the assessment data you gather about a patient to logically explain a clinical judgement or a nursing diagnosis.
What is Critical Thinking and the Nursing Diagnostic Process
500
(1) Involves setting priorities, (2) Identifying patient-centered goals and expected outcomes, (3) prescribing individualized nursing interventions
What is Planning
500
Clinical practice guidelines & protocols. Standing orders. NIC interventions. ANA Standards of Professional Practice.
What is Standard Nursing Interventions
500
the Physiological, Emotional, and Behavioral responses that are a Patient's goals and Expected outcomes.
What is Criterion-based Standards for Evaluation