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    1 - Adpie I

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    Ryan haze Samson
    The nursing process involves five steps: assessment, diagnosis, planning, implementation, and evaluation. 1) Assessment involves gathering both objective and subjective data about a client's condition through various means such as physical exams, vital signs, symptoms, and lab results. 2) Diagnosis identifies actual or potential health problems based on the assessment. Nursing diagnoses address both physical and psychological needs based on Maslow's hierarchy, prioritizing life-threatening issues. 3) Planning develops goals and desired outcomes for an action plan, which should be specific, measurable, attainable, realistic, and timely. The plan is discussed with the client to ensure their needs are met.

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    1 - Adpie I

    Uploaded by

    Ryan haze Samson
    364 views1 page
    The nursing process involves five steps: assessment, diagnosis, planning, implementation, and evaluation. 1) Assessment involves gathering both objective and subjective data about a client's condition through various means such as physical exams, vital signs, symptoms, and lab results. 2) Diagnosis identifies actual or potential health problems based on the assessment. Nursing diagnoses address both physical and psychological needs based on Maslow's hierarchy, prioritizing life-threatening issues. 3) Planning develops goals and desired outcomes for an action plan, which should be specific, measurable, attainable, realistic, and timely. The plan is discussed with the client to ensure their needs are met.

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    1 - ADPIE I

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    The nursing process involves five steps: assessment, diagnosis, planning, implementation, and evaluation. 1) Assessment involves gathering both objective and subjective data about a client's condition through various means such as physical exams, vital signs, symptoms, and lab results. 2) Diagnosis identifies actual or potential health problems based on the assessment. Nursing diagnoses address both physical and psychological needs based on Maslow's hierarchy, prioritizing life-threatening issues. 3) Planning develops goals and desired outcomes for an action plan, which should be specific, measurable, attainable, realistic, and timely. The plan is discussed with the client to ensure their needs are met.

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    364 views1 page

    1 - Adpie I

    Uploaded by

    Ryan haze Samson
    The nursing process involves five steps: assessment, diagnosis, planning, implementation, and evaluation. 1) Assessment involves gathering both objective and subjective data about a client's condition through various means such as physical exams, vital signs, symptoms, and lab results. 2) Diagnosis identifies actual or potential health problems based on the assessment. Nursing diagnoses address both physical and psychological needs based on Maslow's hierarchy, prioritizing life-threatening issues. 3) Planning develops goals and desired outcomes for an action plan, which should be specific, measurable, attainable, realistic, and timely. The plan is discussed with the client to ensure their needs are met.

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    of 1

    Nursing Process I

    Fundamentals of Nursing

    Contraindication

    Nursing process:
    The systematic approach used to guide client care. A D P I E

    A Assessment
    → Gather info & review history
    1st Chest pain

    Objective Data → Observed


    Headache

    Stomach ache

    Example: physical exam, vitals signs, ASSESSMENTS

    signs & symptoms, labs, etc

    Subjective Data → what the client Says (reports)


    Nausea

    Example: stomach ache, chest pain,


    headache, nausea, etc)

    D Diagnosis: Nursing Diagnosis Maslow’s ATI Questions


    → Identify problems Q1: Client with pneumonia … oxygen sat. 89% …
    most appropriate nursing diagnosis?
    Using the assessment data collected, the goal is to
    address both actual or potential health problems Impaired gas exchange
    for the client.

    It is mainly used to help shape clinical judgment about a client’s ATI Questions
    physical & psychological status, but may also include the client’s social
    Q2: Client with Crohn's disease … feels overwhelmed
    factors, family, or community experiences. & has not had any outside support since her recent
    divorce. Which nursing diagnoses are best for the
    Physical needs always come before psychological needs, as outlined plan of care? (SATA)
    by the Maslow’s hierarchy of needs.
    Hopelessness
    For example: We are always going to prioritize an airway issue before Risk of deficient fluid volume
    we treat an emotional one. Just think what is going to kill your client Ineffective coping
    the fastest & that should help guide which nursing diagnosis to place Imbalanced nutrition
    first on your care plans.

    P
    Develop an action plan with specific goals & desired OUTCOME of
    Planning: Plan of Care the plan & always discuss this plan with the client to assess that
    → Goals, outcomes, & action plan
    perceived needs are being met. Don’t forget about the patient’s
    opinion here, but make sure patient’s desire is realistic, obviously.
    S - Specific goals
    M - Measurable goals ATI Question
    A - Attainable goals … MOST appropriate way to assess if the plan of
    care correlates with the client's perceived needs?
    R - Realistic goals
    Discuss the plan of care with the client
    T - Timely goals
    Poorly written outcome:
    “Client will walk without dizziness.”
    SMART outcome:
    “Client will demonstrate improved activity
    tolerance as evidenced by walking 20 feet
    without dizziness by day 3 of hospitalization.”

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