Term
| "actual nursing diagnosis" |
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Definition
| a problem response that exists at the time of the assessment |
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Term
| "possible nursing diagnosis" |
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Definition
| when your intuition and experience direct you to suspect a diagnosis is present but lack data to support it. |
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Term
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Definition
| a problem response that is likely to develop in a vulnerable pt if the nurse does not intervene to prevent it. |
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Term
| "syndrome nursing diagnosis" |
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Definition
| a collection of N diagnoses that usually occur together. |
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Term
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Definition
| subject is transition from one level of wellness to a higher one. Describes status, not problems. |
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Term
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Definition
A - Assess (what data is collected?)
D - Diagnose (what is the problem?)
P - Planning Outcomes -
P - Planning Interventions(how to manage the problem)
I - Implement (putting plan into action)
E - Evaluate (did the plan work?) |
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Term
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Definition
Planning: Prioritize problems/diagnoses, formulate goals/desired outcomes, select nursing interventions
1. Establish Priorities
- Use Maslow's hierarchy of needs - physiological needs come first
2. Guidelines for writing goals/desired outcomes
- Write in terms of client responses ("The client will")
- Be sure it is realistic for client
- Ensure it is compatible with therapies of other professionals
- Each goal is derived from only one nursing diagnosis
- use observable, measurable terms
- make sure client considers goal important
3. Plan individualized care - specific to each client |
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Term
| COMPREHENSIVE NURSING CARE PLAN |
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Definition
| Doc or docs that are the central source of info needed to guide holistic, goal-oriented care to address each pt's unique needs |
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Term
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Definition
Diagnosing: Analyze data, identify health problems, risks, and strengths, formulate diagnostic statements
1. components of nursing diagnosis (NANDA)
- problem and definition -> activity intolerance: insufficient energy for ADLs
- related factors/etiology -> bed rest
- defining characteristics -> verbal report of fatigue
What's the problem, what's causing it to occur, what did we assess?
2. Types of nursing diagnoses
- Actual - client problem that is present at the time of assessment
- Health Promotion - relates to client's readiness to implement behaviors to improve
- Risk - Clinical judgement that problem risk factors are present
- Wellness - describe human responses to levels of wellness |
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Term
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Definition
| the cause or origin of a disease |
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Term
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Definition
Implementing: reassessing the client, determining the nurse's need for assistance, implementing the nursing interventions, supervising the delegated care, documenting nursing activities
1. process of choosing nursing interventions
- not only driven by goal statement, but also etiology of problem
-BASE INTERVENTION ON SCIENTIFIC KNOWLEDGE, CLEARLY UNDERSTAND the intervention, ADAPT ACTIVITIES to the individual client, implement SAFE CARE, provide teaching, support, and comfort, be holistic, respect dignity of client, encourage active participation of client |
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Term
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Definition
Problem;
Etiology; factors that cause, contribute to
Connecting phrase (related to) |
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Term
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Definition
Implementing: reassessing the client, determining the nurse's need for assistance, implementing the nursing interventions, supervising the delegated care, documenting nursing activities
1. process of choosing nursing interventions
- not only driven by goal statement, but also etiology of problem
-BASE INTERVENTION ON SCIENTIFIC KNOWLEDGE, CLEARLY UNDERSTAND the intervention, ADAPT ACTIVITIES to the individual client, implement SAFE CARE, provide teaching, support, and comfort, be holistic, respect dignity of client, encourage active participation of client |
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Term
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Definition
| describes a disease, illness, or injury. Used to identify a disease process or pathology so that appropriate treatment can be given. |
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Term
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Definition
| (Nursing Interventions Classification) |
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Term
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Definition
| NURSING OUTCOMES CLASSIFICATION |
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Term
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Definition
| statement of client health status that nurses can identify, prevent, or treat independently. |
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Term
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Definition
Assessing: Collect data, organize data, validate data, document
1. Differentiate types of data
- subjective - symptoms or covert data (itching, pain, feelings)
- objective - signs or overt data (measurable - can be seen, heard, felt or smelled)
2. Methods of data collection
- Observe - gather data by using senses: notice data and interpret data
- Interview - planned communication with purpo9se i.e. health history
- physical assessment - uses observation to detect health problems
- diagnostic and lab reports (reading)
3. Aspects of an interview
-Influenced by time, place, seating, distance, language
- 3 stages: orientation/intro, body/development, closing |
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Term
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Definition
| A systematic, rational method of planning and providing individualized nursing care. It is cyclic and dynamic, client centered, interpersonal and collaborative, universally applicable, and focuses on problem solving and decision making. |
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Term
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Definition
| subjective or objective data that the client provides and the nurse observes through five senses and interview |
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Term
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Definition
| Data obtained through caregivers or other health professionals objectively or subjectively |
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