Term
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Definition
is systematic & continuous collection, validation, analysis and communication of pt. data.
-collect & analyze data
-interview pt./ take HX
-physical exam HTT
-review diagnostic test & Lab
-med record, family, literature is considered |
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Definition
| a sign something may be wrong |
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Definition
| inc; all pertinent patient information collected by H/C professional |
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Key terms
emergency assessment |
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Definition
| identify a life threatening problem. |
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Key terms
focused assessment |
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Definition
| nurse gathers data about a specific problem that has already been identified. |
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Definition
| judgment you reach about the cue |
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Key terms
initial assessment |
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| performed shortly after the patient is admitted to H/C facility. |
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Key terms
minimum data set |
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| specifies the info that must be collected from every patient & use a structured assessment form to organize or cluster this data. |
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Definition
| identifies the patient's health status, strengths, health problems, health risk and need for nursing care. Also do a physical exam. |
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observable, measurable, can be seen, heard or felt by someone other than the person experiencing them.
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Definition
conscious/deliberate use of all 5 senses to gather data.
-pupils, V/S, scratching, pulse.
-Can be felt, seen by someone else. |
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Key terms
physical assessment |
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Definition
| exam of pt. for objective data that may define pt's condition & help the nurse in planning care. |
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Key terms
review of system ROS |
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Definition
| nursing physical assessment involves the examination of all body systems. Do a Head to toes assessment. |
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Definition
perceived only by the affected person. can not be verified by another person.
-difficult to measure
-What the pt. says. Use clients words. "tender sinuses", "rebound tenderness" "Nausea", "itching", "headache" |
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Key terms
time lapsed assessment |
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Definition
| scheduled to compare a pt. current status baseline data obtained earlier |
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Definition
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Asking family about
-med record, family HX, literature is considered? |
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Definition
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| Who is the primary source for information? |
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Definition
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Definition
-focus on unhealthy response to health & illness
-describes problems treated
-may change from day to day as pt. response to change.
Ex; ineffective airway clearance |
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Definition
-identify disease
-describes problem
-remains the same as long as disease is present |
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| Where can I get a NANDA from, what resources? |
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Definition
-Nursing Diagnosis Handbook "Ackley/Ladwig"
-Fundamentals of Nursing textbook by Taylor pg 252
-Capenito Nursing Nanda book |
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Term
ANA definition of Nursing Process?
(basis for nursing diagnoses (NANDA) |
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Definition
Processed used to identify, diagnose, treat human responses to health & illness (ANA 2003)
-enables organization of care
-integrated critical thinking
protecting, promoting health, prevent injury, alleviate suffering
-Gives us a system, guidelines to follow so we don't miss things. Always incorporated thinking. |
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NANDA definition?
What is the focus?
What is the purpose? |
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Definition
North American Nursing Diagnoses Association
Diagnoses, group of nursed that get together and evaluate and revamp and change them.
Increases the visibility of nursing contribution to pt. care by continuing to develop, refine & classify phenomena of concerns to nurses |
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Term
Once we have the information and assessment is finished it's now time for the data analysis.
What are the three area of data analysis? |
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Definition
-validate data
-interpret data
-cluster data |
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Term
data analysis
validate data |
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Definition
| that is unclear, unsure or that needs to be proved |
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data analysis
interpret data |
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Definition
-pattern of behavior, is something wrong.
-Does something need to be addressed
-Compare with normal standards
-Make a conclusion |
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data analysis
cluster data |
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Definition
-by system, is their a relationship between information.
-lump it all together
Ex; info that proves person has a bowel problem. |
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Term
dyspnea
Is this subjective or objective?
When would it be objective? |
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Definition
difficult, painful, labored breathing.
Subjective
When a COPD pt. looks fine and all # are good. RR, O2 sat, but they are saying "I can't breath". I need a fan. Pt. has a complaint but all my objective data shows no resp. distress, no nasal flaring, O2 sat <95%. |
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| Problems(bad/good with data collection? |
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Definition
-not organized/be organized
-omission, missing data/ don't leave info out.
-poor data, irrelevant, duplicate, erroneous/ be careful, don't skip anything
-failure to establish rapport/trustworthy
-record an interpretation/chart facts
-failure to update database/update, do assessment often, could have allergy changes.
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Term
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Definition
Problem that has been validated by major defining characteristics.
-data to support OBJECTIVE & SUBJECTIVE/NEED EVIDENCE & PROOF
/validated
-label
-definition
-defining characteristics
-related factors
Ex: Nutrition problem
NANDA=imbalanced nutrition than body requirements.
Where do I go looking for evidence?
BMI, H/W, Labs, food intake |
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Term
Types of diagnoses
Risk (potential) |
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Definition
Clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation.
-not a problem yet, but going to soon.
-Don't have to prove, symptoms leading that way.
-NO EVIDENCE |
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Term
Types of diagnoses
Possible |
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Definition
suspected problem for which additional data is needed. Additional data used to confirm or rule out the suspected problem.
-think, no evidence to support it. |
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Types of diagnoses
Wellness |
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Definition
Healthy pt. already take to a higher level of wellness.
Two cues present;
1. a desire for higher level of wellness
2. an effective present status or function. |
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Term
Types of diagnoses
syndrome |
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Definition
Comprise a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event, situation.
Ex: Rape Trauma Syndrome or Post trauma syndrome
-multiple problems at the same time. |
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Term
| What three part must be included in a NANDA? |
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Definition
1. problem=label=NANDA
2. Etilogy=cause=related factors(r/t)
3. Defining characteristics =evidence/proof with subjective & objective info.
Ex; honey booboo |
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Term
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Definition
group of pt. data or cues that points to the existence of a health problem.
-Nursing diagnoses should always be derived from cluster of significant data rather than from a single cue. |
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Nursing diagnoses should always be derived from cluster of significant data rather than from a single cue.
This is called? |
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Definition
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Goals & Expected Outcomes
S.M.A.R.T. stands for? |
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Definition
specific
measureable
attainable
relistic
time frame |
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