Summary NR 302 FINAL EXAM STUDY GUIDE.pdf

Nurses’ role in health assessment o ADPIE o Assessment – collection of data from multiple sources ▪ Review of clinical record; interview; health history; physical examination; functional assessment; cultural/spiritual assessment; consultation; review of literature o Diagnosis – interpretation of data by identifying clusters of cues so as to make inferences ▪ Compare clusters of cues with definitions and defining characteristics ▪ Validation on inferences based on findings ▪ Identify related factors ▪ Document the diagnosis o Planning – establish priorities based on meeting identified patient care goals ▪ Develop outcomes and set time frames for meeting proposed outcomes ▪ Identify relevant interventions and utilize interdisciplinary health care team members in the care planning process for the patient ▪ Document plan of care o Implementation – determine patient readiness and involve patient in health care process ▪ Review planned interventions with interdisciplinary health care team members to facilitate collaborative effort ▪ Utilize principles of delegation, being mindful of supervision and evaluation ▪ Counsel person and significant others ▪ Refer to continuing care ▪ Document care provided