Decision Making In Nursing

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Nursing process provides a framework for clinical decision-making, which helps to guide care and promote critical thinking. Improvements patients participation in care by promoting patient autonomy and individualized care. ADPIE is an acronym that is used to help nurses remember the steps in order: Assessment, Diagnosis, Planning, Implementation, and Evaluation. In the assessment phase, nurses collect subjective and objective data about the patient in a systematic way through observations, interview questions, and physical examinations. Data is collected, organized, verified, and recorded. Subjective data is reported by the patient that cannot be objectively measured. This constitutes verbal descriptions of health. Objective data is measurable…show more content…
Next priorities proceed up the hierarchy of needs from there. Once priority diagnoses are identified, patient-centered outcomes are established. Outcomes are patient-specific, able to be measured, Attainable by the patient, realistic and time-limited. These patient-centered outcomes provide direction for the assortment of nursing interventions. Once these are developed the care plan is communicated to health care team to set the plan into motion. During the evaluation, assessment if nursing interventions have been effective or helpful in meeting desired outcomes. The patient presented this week is an adolescent at the outpatient clinic that has been diagnosed with a sexually transmitted infection (STI). The nursing process begins with the collection of comprehensive patient-centered data. Including health history, prior surgical history, secondary diagnoses, family history, number of recent sexual partners, allergies and current medication regimen. This patients priority needs further teaching about STIs and safe sex practices. The combination of data guides the nurse to the appropriate nursing…show more content…
Expected Patient Outcome: The patient will verbalize 3 resources that can support with increasing knowledge of disease process by the end of teaching secession. Nursing Interventions: 1) Assess patients knowledge base of STI 2) Teach patient ways to prevent transmission of STI to others 3) Provide informational brochures or websites to obtain information such as CDC 4) Observe patients ability and readiness to learn 5) Establish an environment of mutual trust and respect to enhance learning 6) Provide sufficient time during teaching to allow the adolescent to ask questions. 6) Document teaching in patients medical record Scientific Rationales: 1) This provides an important starting point in education. 2) Sexual abstinence is indicated during the communicable phase of the disease. 3) Some may prefer written over visual materials, or they may prefer group versus individual instruction. Matching the learner's preferred style with the educational method will facilitate success in mastery of knowledge. 4) Cognitive impairments need to be identified so an appropriate teaching plan can be designed. 5) This is especially important when providing education to adolescent patients who look to peers for guidance during this segment of the
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