mod 1.1 1.2 1.3 2.1 6.1 Flashcards
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What are some activities done during assessment ?
Obtain a nursing health history Conduct a physical assessment Review client records Review nursing literature Consult supper persons Consult health care professionals
Purpose of assessment is
To establish a database about the clients response to health concerns or illness and the ability to manage health care needs.
Purpose of nursing diagnosis is
To identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions.
Activities of diagnosing
Interpret and analyze data
-compare data against standards
-cluster or group data
-identify gaps and inconsistencies
Determine strengths, rushed and problems
Formulate nursing diagnosis and collaborative problem statements
What’s an actual diagnosis
A client problem that is present at the time of the nursing assessment.
Ex) inefffective airway clearance and anxiety.
What’s a risk diagnosis ?
A clinical judgement that a problem does not exis, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.
Ex) risk for injection risk for falls.
What must a goal statement include?
A time frame, be realistic, mutually developed, observable or measurable.
Wholly compensatory
Nurse agency totally compensates for client self-care deficits.
Partially compensatory
Nurse agency supplements clients limited self-care ability.
Supportive educative
Nurse agency provides support counseling and teaching.
Cognitive domain of learning
Intellectual behavior understanding. Ex) alert and orientated and able to listen and interact
Affective domain of learning
Feelings related to values, attitudes, and opinions. Ex) asking them to change what they may value more.
Psychomotor domain of learning
Integration of mental and motors abilities. Ex) ability to use motor skills for activity, giving injection.
Teaching nandas
Deficient knowledge ex-(low-cal diet)
Readiness for enhanced knowledge ex-(exercise and activity)
Noncompliance ex-(with medication plan)
Teaching nanda with deficient knowledge as etiology
Risk for impaired parenting related to deficient knowledge(skills in infant care and feeding)
Risk for injection related to deficient knowledge (stds and their prevention)
Anxiety related to deficient knowledge (bone marrow aspiration)
Others that can be used: risk for injury, ineffective breast feeding, coping, or health maintenance