MTE Flashcards
Systematic, decision making method focusing on identifying and resolving actual and potential health problems
Nursing Process
Subjects of Nursing process
Indiv
Fam
Groups
Communities
Identifies existing needs
Nursing Care Plan
Form of communication between the nurse and patient, nurse to nurse, and nurse to other allied health care team
Nursing Care Plan
Types of NCP
Informal NCP, Formal NCP
Strategy of action that exists in mind
Informal NCP
Written or computerized, organized NCP
Formal NCP
Subdivisions of Formal NCP
Standardized CP, Individualized CP
Formal CP for group of clients
Standardized Cp
Formal CP that is unique, for each client
Individual CP
Team effort
Care pathway
Best practice
Care bundles
STEPS IN ASSESSMENT
Collecting, Validating, Organizing, Interpreting, Documenting
Source of data that comes from the patient/subject
Primary Source
Source of data that comes from significant others, medical records, health care members, medico-legal
Secondary source
Types of Data
Subj, Obj
Data validated by the patient
Subj
Data that are directly observable by the nurse
Obj
What type of data
Symptoms:
Signs:
Subjective
Objective
Analysis of subjective and objective data to make nursing judgement
Diagnosis
Components of Diagnosis
P
E
S
Defining characteristics
Signs and symptoms
Related factors and causes
Etiology
Diagnostic label
Problem statement
Defining, distribution, and integration of standardized nursing diagnosis
NANDA International (NANDA-I)
Meaning of NANDA - I
North American Nursing Diagnosis Association - International
Types of Nursing Diagnosis
Problem focused diagnosis (actual)
Risk Diagnosis (potential)
Health Promotion Diagnosis (wellness)
Syndrome diagnosis
Scientific explanation of the problem // root cause
Scientific BG
