the diagnosis and treatment of human responses to actual or potential health problems
systematic problrm solving method that has five steps
Assessment, Nursing, diagnoses, planning, implementation, evaluation
the process of collecting, calidation, and clustering data
involves identifying and prioritizing actual or potential health problems or responses.
Actual nursing diagnosis
occuring health problem for you patient
potential nursing diagnosis
identifies a high risk health problem that most likely will occur unless preventive measures are taken
possible nursing diagnosis
is one that needs further data to support
is a potential medical complication that warrants both medical and nursing interventions
The Nursing Process Steps:
setting goals and outcomes ounce prioritized your diagnoses
carrying our your plan to achieve goals and out comes
involves determiong the effectiveness of your plan.
is a process of sharing information and meaning, of sending and recieving messages
Non Verbal Behavior
vocal cues or paralinguistics, action cues, kinetics, object cues, personal space and touch
describe the quality of uour voice and its inflections, tone, intensity, and speed when speaking.
are body movements that convey messages. Posture, arm position....
is the territory surrounding a person that she or he perceives as provate of the physical distance that needs to be maintained for ther person
is a means of communication.
Patient Interview Communication Techniques
Affirmation/Facilitation; Silence; Clarifying; Restating; Actice listenting; Braod or General Openings; Reflection; Humor; Informing; Redirecting; focusing; sharing perceptions; identifying themes; sequencing events; suggesting; presenting reality; summarizing
Purpose of Assessment
is to collect data pertinent to the patients health status to identify deviations from normal to sidcover the patients strengths and coping resources to pinpoint actual problems
are needed for critical thinking creative thinking and clinical decision making.
is a complex thinking process (Reflective,reasonable thinking)
is automatic, without conscuous deliberation and comes with experience.
trial and error approach
include both verbal and nonverbal communication skills
Primary Preventive Care
focuses on health promotion and guards against health problems
Secondary preventive care
focuses on early detection, prompt intervention, and health maintenance for patients with health problems
tertiary preventive care
deals with rehabilitative or extended care
(rehab, hospice, home care, long term
examines the patients overall health status
problem oriented and may be the initial assessment or an ongoing assessment
are regerred to as symptoms
referred to as signs (physical examinations)
are structured with specific quesitons and are controlled by the nurse.
controlled by the patient, although the nurse often needs to summarize and clarify the data.
yes or no (Do you have pain)
perceptions (What brought you to the hospital)
is the time to introduce yourself to your patient
is often where data collection occurs (longest phase)
to end the interview.... summarize and restate your findings= clarify data
entails deliberate use ofyour senses of sight, smell and hearing, to collect data.
provides the objective database. helpt assess your patients health status and identify actual pr potential problems.
look at paitent compare appearance.
use light touch to assess surface characteristics to put your patient at ease.
use direct indirect and fist percussion to assess organ size and areas of tenderness
listen to your patient directly and indirectly to hear sounds produced by the body.
Source oriented documentaiton
easily identifies each discipline, but it tends to fragment the data making it difficult to follow the squencing of events
problem oriented medical records
everyone involved in the care of the parient charts on the same form.