Editing Fundamentals of Nursing – RN Flashcards (section)

== Nursing process and clinical judgment ==

;What are the five steps of the nursing process, in order?
:Assessment, diagnosis or analysis, planning, implementation, and evaluation (ADPIE). The process is cyclical, so evaluation feeds back into reassessment.

;How does a nursing diagnosis differ from a medical diagnosis?
:A medical diagnosis names a disease and is treated by the provider. A nursing diagnosis names a human response to an actual or potential health problem that nurses are licensed to treat independently, and it changes as the patient's response changes.

;What are the three parts of an actual nursing diagnosis?
:Problem, etiology (related to), and defining characteristics (as evidenced by). A risk diagnosis has only the problem and the risk factors, because the problem has not yet occurred and there are no signs and symptoms.

;What are the characteristics of a correctly written expected outcome?
:Patient centered, specific, measurable, attainable, realistic, and time limited. It states the patient's behavior with the conditions and a deadline, not the nurse's action.

;What priority frameworks does the registered nurse use, and in what order?
:Airway, breathing, and circulation first. Then Maslow's hierarchy, with physiologic needs before safety and psychosocial needs. Then acute before chronic, unstable before stable, and unexpected before expected.

;When should the nurse assess before intervening, and when not?
:Assess first in almost every situation. Act first only when an emergency demands an immediate, obvious action, such as an obstructed airway, an unwitnessed collapse, or a patient found lying flat during tube feeding.

;What does the nurse do when an expected outcome is only partially met?
:Return to assessment, identify the barrier, and revise the diagnosis, outcome, or interventions. Do not document the outcome as met, and do not abandon a realistic goal.