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Protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of ind, families, communities and populations
Nurse process 6 phases
assessment, diagnosis, outcome identification, planning, implementation and evaluation
the RN identifies expected outcomes for a plan individualized to the patient or situation
the RN develops a plan that prescribes strategies and alternatives to attain expected outcomes
systemic, dynamic process by which the nurse through interaction with the client analyzes data about the client
occurs when related cues are grouped together, also assists in identification of nursing diagnosis
identify the type and cause of a health condition; clinical judgment about the client's response to actual or potential health conditions or needs
guidelines to help nurse identify the cues
1. deviations from population norms. 2. any change in the patient's usual health status. 3. developmental delays. 4. dysfunctional behavior. 5. changes in usual behavior
Four Components of Nursing Diagnosis
1. nursing diagnosis title/label. 2. definition of the title/label. 3. contributing/etiologic/related factors and 4. defining characteristics
clincal cues, signs and symptoms that furnish evidence that the problem exists
actual nursing diagnosis
human responses to health condition/life processes that exist in an ind, family, or community; three part statement, words "related to" links the first and second parts of the statement. "manifested by" joins the second and third parts of the diagnostic statement ex. constipation related to insuff fluid intake manifested by abdominal distention, no bowel movement for 5 days and straining at stool
risk nursing diagnosis
human responses to health conditions/life processes that may develop in a vulnerable ind, family or community; two part statement connected by words "related to" ex. risk for impaired skin integrity related to mechanical forces
syndrome nursing diagnosis
used when a cluster of actual or risk nursing diagnoses are predicted to be present in certain circumstances; one part statement ex. rape-trauma syndrome has the etiology provided in the label itself
wellness nursing diagnosis
juman responses to levels of wellness in an ind, family or community that have a readiness for enhancement; written as a one part statement. Words "readiness for enhanced" are used ex. readiness for enhanced nutrition
certain physiologic complications that nurses monitor to detect onset or changes in status. ex. potential complication: hypoglycemia
identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, lab test and procedures; physicians make these diagnoses. ex. congestive heart failure
statement about the purpose to which an effort is directed. Exm. the nurse might want to prevent constipation or promote activity
states the behaviors that the patient will be able to perform rather than what the nurse will do.
nursing establishes priorities of care, selects and converts nursing interventions into nursing orders and communicates the plan of care using standardized languages or recognized terminology to document the plan
those activities that should promote the achievement of the desired patient outcome
those actions ordered by a physician for a nurse or other health care professional to perform
nursing orders should include:
date, signature of nurse responsible for the care plan; subject action verb; qualifying details
established plan is put into action to promote outcome achievement includes ongoing activities of data collection, prioritization, performance of nursing interventions and documentation
structured vocabulary that provides nurses with a common means of communication
the results of outcomes of nursing interventions. These outcomes or indicators are influenced by nursing and can be used to judge effectiveness of care and determine best practices
a health care system that involves adminstrative control over primary health care services in a medical group practice. Redundant facilities and services are eliminated and costs are reduced. Health education and preventive medicine are emphasized
multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high risk, high volume, high cost types of cases
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