1.
3 steps to writing a nursing diagnosis: 1. problem- describes the health state or health problem of patient using NANDA quantifiers
2. Etiology- identifies the physiologic, psychological, sociologic, spiritual and environmental factors related to the problem as either a cause or a contributing factor
3. Manifestation- data that signal the existence of the actual or potential problem
2.
4 steps in planning: 1. prioritize problems
2. set outcome goals with patient
3. identify interventions that will address patient's health problems and achieve goals
4. document the care plan
3.
4 steps to assessment: 1. collect data
2. organize data
3. validate data
4. document data
4.
1950: nursing diagnosis first introduced
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1953: Fry proposed the formulation of nursing diagnosis
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1973: first national conference was held
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1982: North American Nursing Diagnosis Association (NANDA) founded
8.
actual nursing diagnosis: describes human responses to health conditions or life processes
9.
assessment begins with: patient presenting an initial health problem
*then you observe behavior
*listen for cues
10.
characteristics of a nursing process: 1. patient centered (actions relate to patient, not nurse)
2. emphasizes feedback
3. facilitates creativity
4. fundamental to all nurses
11.
collaborative problem: an actual or potential complication that nurses monitor to detect a change in client status
ex: after surgery
12.
components of a nursing diagnosis: 1. diagnostic label: NANDA approved
2. etiology
3. risk factors
4. related factors
5. definition: NANDA approved
6. support of the diagnosis
13.
data: information about the patient
14.
deffinition of assessment: te process of systematically collecting, organizing, validating and documenting data relevent to the health status of patient (indevidual, family, group, community)
15.
deffinition of diagnosis: process that results in formulating a nursing diagnosis and creation or design of a care plan
16.
deffinition of planning: a deliberate, systematic process that involves decision making and problem solving
17.
Diagnosis: (analysis)
1. involves critical analysis and interpretation of assessment data
2. identifies health problems, risks, and strengths
3. provides a basis for selecting nursing interventions to achieve outcomes
18.
etiology: assessment data
19.
evaluation: was the goal reached?
on the basis of the evaluation, the care plan is either continued, modified, or terminated
20.
evaluation may be: 1. ongoing- throughout a shift (hourly, quarterly, daily)
2. intermittent- (weekly, monthly)
3. terminal- (ending, once the wound is healed the dressings stop)
21.
how to express etiology in nursing diagnosis: express it in ways that can change
22.
implementation: "intervention"
consists of carrying out the intervention or delegating nursing interventions, and specific strategies designed to achieve outcome goals
23.
medical diagnosis: a clinical judgement about the client in response to an actual or potential health problem
24.
no not include in your nursing diagnostic statement: the medical diagnosis
25.
nursing diagnosis: the identification of a disease condition based on specific evaluation of signs and symptoms
26.
nursing diagnosis: a statement representing a clinical judgement about the patient's responses to actual or potential health problems or state of wellness
27.
purpose of assessment: to establish a database
*must be accurate
28.
risk nursing diagnosis: describes human responses to health conditions/life processes that may develop
29.
sources of errors in nursing diagnosis: 1. data collection
2. interpretation and analysis of data
3. data clustering in insuficient amounts
4. wrong label on diagnostic statement
5. poor varification for documentation
30.
wellness nursing diagnosis: describe human responses to levels of wellness that have a readiness for enhancement
31.
when does planning for discharge begin?: at the time of admission
32.
why do we need to make care plans: so we can comunicate our plans to other health care professionals
33.
why is accuracy important in assessment: *all other phases of the nursing process rely on accurate and complete data
34.
writing nursing diagnosis: two or three part statements
(risk diagnosis only two steps)
