Term
| Medical Diagnosis vs. Nursing Diagnosis |
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Definition
Nurses bring you PEPSiD, doctors give you an ostomy
Physical
Emotional
Psychosocial
Spiritual
Developmental |
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Term
| Nursing Process (in order) |
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Definition
ADPIE
Assess: SOA (no P)
Diagnose: PEPSiD
Plan: the P in SOAP, what ARRRR ya doin'?
Implement: Do it
Evaluate: how'd you do? |
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Term
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Definition
Charts
History
Subjective/Objective
Labs |
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Term
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Definition
assess based on their FITE
Focused: specific, detailed
Initial: superficial, basic
Time Lapsed: check the same thing multiple different times to assess change (pain after meds)
Emergency: focused, less detailed, only concerned with priority involvement |
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Term
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Definition
| Descriptions of actual health problems, potential health problems, and healthy responses thereto |
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Term
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Definition
Problem, Etiology, Support
Pt presents w/ PROBLEM r/t ETIOLOGY aeb SUPPORT
(ex: SOB; lung occlusion; no improvement in spite of hyperventilation) |
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Term
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Definition
Set priorities
sets client outcome (goal) and develops evaluative strategy
selects interventions
communicates plan |
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Term
| Methods of Prioritization |
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Definition
Include but are not limited to:
Maslow's
CAB
triage |
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Term
| 3 types and 3 time-frames of outcomes |
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Definition
cognitive, psychomotor, and affective
short-term, long-term, and health promoting |
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Term
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Definition
Subject, Verb, Conditions, Criteria, Time frame (SMART)
Pt (sub) will reach (verb) a pO2 (criterion) of 80 or higher (condition) in 48 hours (time) |
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Term
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Definition
Independent: a nurse can do it on their own
Dependent: a nurse must rely on another discipline to initiate this intervention
Collaborative: this intervention requires the action of several disciplines |
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Term
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Definition
| carrying out of care plan, documenting actions and results |
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Term
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Definition
Met: outcome was reached by care plan
Partially met: care plan is working, but outcome has not been reached (extend time frame)
Unmet: care plan is not working |
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