Chapter 12-14 Nursing Process Flashcards
Purpose of the NANDA
Define, refine and promote a taxonomy of nursing terminology of the general use to professional nurses
Components of nursing diagnosis
- The problem and its definition
- The etiology (related factors)
- The defining characteristics (as evidence by)
Nursing process vs Medical process
Nursing- holistic focus, teach for independence, involved with family individuals and groups.
Medical- disease focus, consults with nursing for planning ADLs.
Describe the components of diagnosing
-refers to the reasoning process
-diagnosis is the statement or conclusion regarding the nature of a phenomenon
-standardized by the NANDA
-nursing dx= problem statement with NANDA
label + etiology
Actual Dx
-Problem presents at the time of the assessment
-Presence of signs and symptoms
Example: anxiety, ineffective breathing pattern
Risk Dx
-Problem does NOT exist
-Presence of risk factors are present and patient is more likely than other patients to develop problem
Example: someone is dizzy is at risk for falls
Health Promotion Dx
-Preparedness to implement behaviors to improve their health condition
-Begin statement with “readiness for enhanced…nutrition”
Example: overweight patient with coronary disease ready to lose weight
Wellness Dx
-Describes human responses to levels of wellness in an individual, family, or community.
Example: Readiness for enhance family coping
Syndrome Dx
-Used when diagnosis is associated with a cluster of diagnoses
Example: Disuse Syndrome, rape-trauma syndrome
Components of nursing Dx: problem statement (diagnostic label)
- Describes the client’s response to the health problem
- Qualifiers: deficient, impaired, decreased, ineffective
- Leads to outcome
Components to nursing Dx: etiology (related factors and risk factors)
- Identifies one or more probable causes of the health problem
- Related to factors and risk factors
- Including all related to factors
Components of a nursing Dx: defining characteristics
- Cluster of all signs and symptoms indicate the presence of a particular diagnostic label
- actual nursing diagnoses client’s have signs and symptoms
Tips for writing good nursing Dx
- write it in respect to patient’s response
- use r/t NOT due to
- write Dx in legally advisable terms
- write without judgment
- avoid reversing parts
- avoid redundancy
- be clear and concise
- don’t use medical Dx
- don’t rename a medical condition to fit nursing Dx
- don’t state 2 problems at the same time
Tips for writing outcomes and goals
- should be related to human response
- should be client centered begin with “the client will”
- should be clear and concise
- should be observable and measurable
- should be time limited
- should be realistic
- should be set together (nurse and patient)
- outcomes provide blueprint for evaluation
Terms that are measurable vs nonmeasurable
- Measurable: identify, describe, state, demonstrate, verbalize, discuss
- Nonmeasurable: know, understand, appreciate, feel, think, accept
Nursing intervention components
- focus on activities to promote, maintain, or restore health
- two types: independent and dependent
- assessment to determine health status
- diagnosis of responses requiring nursing interventions
- identification of nursing interventions to maintain or restore health
- implementation of measures to motivate, guide, support or teach family/client
- referrals as allowed by the Nurse Practice Act (social services, pastoral care)
- evaluation of client responses
- participation with consumers or other health care providers in improvement of health care system
Tips for writing interventions
- must be dated and signed in the clinical area
- use precise action verbs (want something to be done)
- define who, what, where, when and how often
- must be consistent with plan of care–every intervention must meet the outcome that has been set
- only one assessment order allowed
- based on scientific principles
Implantation: five activities
- Reassessing the client
- Determining the nurse’s need for assistance
- Implementing nursing interventions
- Supervising delegated care
- Documenting nursing activities
Evaluation
Look in book
Steps in formulation a nursing diagnosis
Analyze the data
Identify health problems, risks, strengths
Formulation diagnostic statements
Scientific rationale for nursing diagnosis
Based on scientific principles
Steps for planning
Prioritize problems and diagnoses
Formulate goals and desired outcomes
Select nursing interventions
Write nursing intervention
Process of implementing
Reassessing the client Determine the nurses need for assistance Implementing the nursing interventions Supervising delegated care Documenting the nurses activities
Process of evaluating
Collecting and comparing data related to desired outcomes
Relating nursing activities to outcomes
Drawing conclusions about problem status
Continuing, modifying or terminating the nursing care plan
