NURS 175- Midterm II Flashcards
What are the Six Phases of Assessment in the Nursing Process?
- Collect data
- Identify cues and make inferences about data
- Validate/verify data by checking with the patient
- Cluster data
- Identify patterns
- Report and record data
What are the four different ways you can cluster data?
- Categories based on body systems
- Health patterns (e.g. nutrition, elimination, activity etc.)
- Functional approach ( cues, inference, category)
- Human needs approach (Maslow’s)
What is a Nursing Diagnosis?
a clinical judgement that provides the basis for nursing interventions using common nomenclature
What is the difference between a nursing diagnosis and a medical diagnosis?
Nursing- focused on human response to health problems
Medical- focus is on disease
What is NANDA and in what stage of the Nursing Process is it used?
North American Nursing Diagnosis Association
- diagnosis
What are the four steps of forming a diagnosis?
- Consider assessment data, cues, clusters, analysis
- Choose NANDA label
- Determine etiology
- List the manifestations (sings/symptoms)
A “Risk For” diagnosing label indicates that…
there is no manifestation or evidence to identify the health problem
How should you prioritize nursing diagnoses?
- Maslow’s
- Actual before potential
What is a potential diagnosis?
problem/situation that could be prevented
What is an actual diagnosis?
actual problem has been identified and nursing process should include all three parts
What is a syndrome diagnosis?
a short cut to describe a pattern of signs and symptoms that form a distinct clinical disorder
-groups several other NANDA diagnoses together
What is a wellness diagnosis?
used for patients who are already healthy but want to maintain or improve their wellness level
When does the planning stage begin and end?
The planning stage begins upon introduction to your patient/family and ends upon discharge/transfer/death
What are the three types of planning?
- Initial- admission assessment; directs patient care
- Ongoing- continually changing plans based on patient response
- Discharge- anticipates and plans for when patient moves on
____ can be used to help make outcomes specific.
scales
What is NOC, and in what stage of the nursing process is it used?
- Nursing Outcomes Classification
- Canadian nurses mostly create their own outcome statements
- planning stage