Block One Nursing Process
Study online at [Link]/_1yqnjt
1.
ADPIE
Assessment
Diagnosis
Planning
Implementation
Evaluation
Applied discipline, on-going, constantly
overlapping process used for patient care.
11.
Risk
nursing
diagnosis
(two parts)
A clinical judgment about human
experience/responses to health conditions/life
processes that have a high probability of
developing any vulnerable individual, family
group or community. Related factors are not
available because there are no problems yet,
though they are likely to develop.
12.
Syndrome
nursing
diagnosis
Clinical judgment describing a specific cluster of
nursing diagnoses that occur together, and are
best addressed together and through similar
interventions. Have both defining characteristics
and related factors.
13.
SMART
Outcomes
Specific
Measurable
Attainable
Realistic
Timed
2.
Assess
Perform a nursing assessment
collect data to be used in your diagnosis
focuses on the client's response to illness
3.
Diagnose
NANDA
Make a nursing diagnosis
Analyze the data collected from the
Assessment stage
4.
Plan
NOC
Formulate and right outcome/goal statements
and determine appropriate nursing
interventions based on evidence (research)
5.
Implementation
NIC
Put care plan into action
14.
Maslow's
1st Need
Physiological needs
(A,B,C) then anything else physiological
6.
Evaluation
Evaluate the outcomes in the nursing care
that has been implemented. Make necessary
revisions and care as needed.
15.
Maslow's
2nd Need
Security & Safety
16.
Maslow's
3rd Need
Love & Belonging
17.
Maslow's
4th Need
Self-Esteem
18.
Maslow's
5th Need
Self-Actualization
19.
NANDA
The Problem
This specific NURSING diagnosis that begins
your diagnosis statement.
Stands for North American Nursing Diagnosis
Association
20.
R/T or
"related to"
The Cause
Etiology
Part of you diagnosis statement, follows NANDA
diagnosis
21.
As
Evidenced
By (AEB)
Signs, symptoms, characteristics
The last part of your diagnosis statement
Subjective and Objective
Put together into clustered Cues.
22.
Prioritizing
problems
You do this after you have put together your
nursing diagnosis statement as part of the
planning phase.
Keep in mind Maslow's Hierarchy of Needs for
anything g physiological remember the ABC's
23.
Goals of
the
planning
phase
priorities
ID and write expected patient outcomes (NOC)
Select evidence based nursing interventions
(NIC)
Communicate the plan of care
7.
PES System
(Three part
nursing
diagnosis)
Problem- The nursing diagnosis label: a
concise term or phrase that represents a
pattern of related cues. The nursing
diagnosis is taken from the official NANDA-I
list
Etiology- "related to" (r/t) phrase or etiology:
related cause or contributor to the problem
Symptoms (AEB) - "as evidenced by"defining characteristics phrase: symptoms
that the nurse identified in the assessment.
8.
9.
10.
Two part
nursing
diagnosis (risk
statement)
Consist of the nursing diagnosis in the
"related to" (r/t) statement
Actual nursing
diagnosis
Describes human responses to health
conditions/life processes that exist in an
individual family or group, or community.
Supported by defining characteristics and
related factors.
Health
promotion
nursing
diagnoses
A clinical judgment about a person's family's,
group's or community's motivation and desire
to increase well being and actualize human
health potential as expressed in the
readiness to enhance specific health
behaviors and which can be used in any
health state. Outcomes and intervention
should be focused on enhancing health.
24.
NOC
Nursing Outcome Classification
33.
Steps to
Implementing
Check your knowledge and orders
get organized
assess PT rediness
explain what you are doing
promote client participation
34.
Purpose of
Implementation
assist patient in achieving valued health
outcomes
promote and restore health and prevent
disease
promote self-care (optimum level of function)
facilitate coping with altered function
35.
Documentation
final step of implementation
records nursing activities and client
response
communicate between shifts and disciplines
imperative for continuity of care
Specific statements of desired goal or
outcome
describes the changes in health status you
hope to achieve
25.
2 phases of
planning
Initial:
done by admission nurse, starts with first
client contact
On-going:
changes made as you evaluate the
patient's responses to care
26.
Nursing Care
Plans
Comprehensive , central source of
information needed to efficiently, safely and
effectively care for a patient.
what I did - how the patient responded
Ensures communication, addresses
individual needs
27.
2 types of Goals
(Planning)
Short term: within a few hours or days,
positive reinforcement for patient
36.
How do I
evaluate client
progress?
review outcomes, collect reassessment
data, judge goal achievement, record the
evaluative statement.
37.
Evaluative
statement
decide how well outcome was met
Met, partially met, not met
list patient data or behaviors that support
this decision
Long-term: weeks, months or years to
achieve the optimum level of functioning.
Attained after discharge most of the time.
28.
29.
Components of a
Goal Statement
This statement contains:
Subject = always the patient!
Action= what will they do? (concrete)
Performance Criteria = How? (be specific)
Target Time = When?
Special Conditions = special resources if
needed
Goals/Outcomes
must be...
specific, observable, measurable, patient
centered, time limited and realistic
Derived directly from the nursing diagnosis
State the opposite of the NANADA
diagnosis (problem)
30.
NIC
Nursing Interventions Classification
Consists of a label, a definition, and a list
of specific activities
linked to NANDAs and Outcomes
Include interventions applicable to all
settings
31.
Nursing
Interventions
Must be...
Safe
Within the legal scope of nursing practice
Compatible with medical orders
Specific and realistic
32.
Implementation
Doing or delegating
remember the "rights" of delegation
Revise plan of care if goals were not met
38.
revisions to
the plan of
care
delete or modify the nursing diagnosis
make the outcome statement more realistic
adjust the criteria in the outcome statement
change the nursing interventions