Nursing Diagnosis Flashcards
What describes a patient’s response to a medical illness or disease process?
Nursing diagnosis
What must be done each time an ECO is not met?
Revision
An example of this type of assessment is when a nurse looks at a surgical incision for redness and asks about any pain (but does not complete a head-to-toe assessment)
Focused assessment
List the components of a SMART expected client outcome
S-Specific M-Measurable A-Attainable R-Realistic T-Time oriented
The nurse should check with this person before activating a nursing diagnosis for a care plan
The patient
This describes how assessment and evaluation are different
Time (assessment is before)
What kind of data is when a patient says “there is a sharp pain radiating down my arm?”
Subjective data
Type & source of data: Temperature 103.1 (obtained with thermometer)
Secondary objective
An example of this type of ECO is: “Patient will walk 25 feet by the end of shift today.”
Short term goal
Identify the priority problem and explain how you decided the priority: impaired tissue perfusion vs risk for falls.
Impaired renal perfusion (actual problem) and by Maslow’s Hierarchy of Needs and ABCs.
An example of this type of knowledge is when a nurse uses a Kangaroo pump to administer enteral tube feeding.
Practical knowledge
Within the nursing diagnosis, this is where the student nurse will look when determining the most relevant interventions for a plan of care?
Etiology
Where the nurses should look to evaluate once it is determined the care plan needs a revision
The nursing process (Each step)
The nurse uses this information to select a nursing diagnosis (ex: fever, thick wound drainage, elevated WBC)
Clustered data cues
List the 5 right of delegation
- Right task
- Right person
- Right supervision
- Right circumstance
- Right communication
This type of nursing diagnosis only has a two-part statement, the problem and the etiology.
Potential nursing diagnosis “risk for”
An example of this is: the nurse administers medication ordered by a physician
Dependent intervention
This organization created a taxonomy of terms to describe a universal nursing language describing nursing terms
NANDA international
This term describes ischemia in the following statement: “impaired skin integrity related to ischemia as evidenced by redness and visible subcutaneous tissue.”
Etiology
An example of this is: the nurse coordinates a nutrition consult with a the dietician
Interdependent intervention (collaborative)
Which is the better ECO & explain why: Patient will eat 50% of lunch today vs nurse will answer call lights in a timely manner within 1 hour.
Patient will eat 50% of lunch today— patient centered
ECO: patient will perform incentive spirometry to 2500 ml
Action: Pt performed incentive spirometry to 2000 ml
How should the nurse document this outcome and what should be done about it?
Not met-Revise the care plan
This is where the nurse should refer to when planning the expected client outcome (ECO)
NANDA (patient problem)
Identify how assessment is related to implementation
The effectiveness of the intervention; assessing the impact of ECO
