NUR 155 Exam 1 Study Guide: Nursing Process Overview & Techniques galen college of nursing Questions and answers latest update

NUR 155 UNIT 1 THE NURSING PROCESS Nursing process is the foundation of professional nursing practice, framework within which provide care to patients in an organized and effective manner, requires critical thinking. 5 STAGES: ADPIE ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTAION EVALUATION 1.ASSESSMENT • PURPOSE: to collect data • BEST SOURCE OF DATA: PRIMAY patient/SECONDARY family member • 2 TYPES OF DATA: - 1. Subjective: what the pt says (headache, nausea, health history) - 2. Objective: observe and measured (vital signs, lab results, diagnostic tests) • 3 METHODS OF DATA COLLECTION: - Observation (no touch), Intervention, Physical exam 2. NURSING DIAGNOSIS • WHERE DOES THIS COME FROM: NANDA • 3 TYPES OF NURSING DIAGNOSES: - 1. Actual - 2. Risk - 3. Health promotion • 3 PARTS TO AN ACTUAL NURSING DIAGNOSIS: - 1. Problem - 2. Etiology - 3. Defining characteristics (signs/symptoms)oaded_by Ex: Ineffective breathing pattern related to anxiety as evidenced by hyperventilation. YOU CAN NEVER INCLUDE A MEDICAL DIAGNOSIS IN A NURSING DIAGNOSIS. 3. PLANNING • 4 STEPS IN THE PLANNING PROCESS: 1. Set priorities 2. To write goals 3. To select nursing intervention 4. To write nursing interventions • WHAT DO WE USE TO PRIORITIZE: ABC, AIRWAY BREATHING CIRCULATION, Maslow’s hierarchy of needs • GOAL SETTING CRITERIA: remember goals must be patient centered, every goal: PATIENT WILL…. EX: patient will demonstrate the ability to perform controlled breathing within 48 oaded_by SMART Specific Measurable Attainable Realistic Timeframe • WHAT IS A NURSING INTERVENTION: Nursing action • 3 TYPES OF INTERVENTION 1. INDEPENDENT (WITHOUT DOCTOR ORDER) 2. DEPENDENT (WITH DOCTOR ORDER) 3. COLLABRATIVE (WORKING WITH TEAM MEMBERS) EX: Teach the patient how to breathe in and out of a paper bag as tolerated. 4 IMPLEMENTATION • Putting the plan into action • First, make sure you reassess your patient to make sure their status has not changed. • This is where RN can delegate • Delegation is assigning a task to someone else • Who can the RN delegate to: UAP (UNLICENSED ASSISSTIVE PERSONNEL), LPN, What are some tasks you can delegate: 1. Vital signs 2. Feeding 3. Bathing 4. Ambulation