NUR 155 Exam 1 - study guide Fundamental of Nursing (Galen College of Nursing) Questions and answers latest update

Nursing ProcessADPIE: Assessment- info gathered (subjective/objective data) • Primary data – Patient interview • Secondary data - Medical record/close relative • Subjective data - Symptoms/health history • Objective data – Signs/physical examination/lab results/diagnostic test results • Recognize cues Diagnosis – Analyze cues/cluster related data/identify nursing diagnosis • List supporting data: o Etiology (cause or origin of disease) o Signs/symptoms Planning- prioritize hypotheses and nursing diagnoses/generate nursing care plans o Long term goals o Short term goals • Outcome identification Implementation- take oaded_by • Interventions: o Independent o Dependent o Collaborative care o Direct o Indirect • Documentation: o Care plans o Clinical pathways o Standing orders Evaluation- care plan evaluation • Patient/group goal/outcome attainment? • Continue? • Revise/adapt? • Discontinue? FOR GOALS SHORT/LONG TERM LOOK FOR SOMETHING THAT CAN BE MEASURED AND A TIME FRAME!!!oaded_by SMART S- Specific M- Measurable A - Attainable R- Realistic T- Time frame YOU HAVE TO THINK AND REASON BEFORE YOU JUDGE • Clinical Reasoning- Ability to focus/filter clinical data to recognize what is the most important and what is the least important so that the nurse can identify if there is actual a problem present • Clinical thinking- application of knowledge and experience to identify patient problems and direct clinical judgments and actions o Thinking ahead: anticipate any challenges/be prepared o Thinking – in – action: knowledge and practical experience to be more most effective (think about multiple options and safely acting) o Thinking back: take time to reflect back on what interventions worked and where care could have been improved • Clinical judgment- outcome of critical thinking/decision oaded_by - Intuition: “gut feeling” SBAR (for giving report to nurses/calling doctors): S- Situation; state purpose for call/conversation B- Background; tell story of pt A – Assessment; what is going on/what you gathered R- Recommendation; what needs to be done