Ch 13. Assessment, Diagnosis, Planning Flashcards
Nursing Process
ADPIE Assessment Diagnosis -Nursing diagnosis Planning -Outcomes identification Implementation Evaluation
Assessment
The deliberate and systematic collection of data from a primary source and secondary sources
Determines a client’s current and past health status, and functional status
Determines a client’s current and past coping patterns
Establishes an individualized database
Cue
info nurse can gain from their senses. Ex. Urine sample that smells foul that’s a cue. Swollen red picc line, adventitious sounds
Inference
making judgements or interpretations based off the cue. Ie. Foul urine may be due to a UTI
Primary Source
Client
Secondary sources
Family and significant others
Health care team
Medical records
Tertiary sources
Literature
Nurse’s experience
Interview
An organized conversation with the client Open-ended questions Closed-ended questions Orientation phase Working phase Termination phase
Nursing Health History
Identifying data Source of history Reason for health history interview Current state of health Developmental variables Psychological variables Spiritual variables Sociocultural variables Physiological variables
Physical Exam
Observation of client’s behaviour
Diagnostic and laboratory data
Interpreting assessment data and making nursing judgements
Steps in Data Analysis
Recognize pattern or trend by cues.
Compare with normal standards.
Make a reasoned decision.
Data Documentation
Documentation is the nurse’s legal and professional responsibility.
Anything heard, seen, felt, or smelled should be reported accurately.
Subjective client information should be placed in quotation marks.
Accurate terminology and abbreviations must be used.
Nursing Diagnosis
Pre-written
A nursing diagnosis focuses on a client’s actual or potential response to a health problem rather than on the physiological event, complication, or disease
E.g., Deficient knowledge regarding postoperative routines
Medical Diagnosis
identification of a disease condition on the basis of specific evaluation of signs and symptoms
NANDA
Means of translating nursing observations and assessments into standard conclusions in a common nomenclature
Provides a precise definition of the client’s needs
Gives all members of the health care team a common language to use
