Nursing Process: Assessment, Diagnosis, and Planning Outcomes Flashcards
Assessment
Collect, validate, organize and record data
Types and Sources of Data
Subjective Data
Objective Data
Primary Data
Secondary Data
?
What the patient says
Information communicated to the nurse by the client, family, or community
Subjective data
?
What professionals observe
- Gathered by physical assessment and from laboratory/diagnostic tests
- Can be measured or observed by the nurse or other healthcare providers
Objective data
?
Are obtained “secondhand”, for example, from the medical record or from another caregiver
Secondary data
?
Are the subjective and objective information obtained directly from the client in what the client says or what you observe
Primary data
Nursing Assessment Skills
- Observation
- Physical Assessment
- The Nursing Interview
?
Is purposeful, structured communication in which you question the patient to gather subjective data for the nursing database
The Nursing Interview
?
Refers to the deliberate use of all of your senses to gather and interpret patient and environmental data
* “HELP”
H - Help
E - Environment/equipment
L - Look
P - People
Observation
Types of Assessment
Initial and Ongoing
Comprehensive
Focused
Special Needs
?
Is very detailed, builds your patient database
Comprehensive
?
Is very detailed, builds your patient database
aka global assessment, patient database, nursing database
- Holistic information about client’s overall health status
- Enables you to identify problems and strengths
- Enhances your sensitivity to a patient’s culture, values, beliefs, and economic situation
- Uses skills of observation, physical assessment, and interviewing
Comprehensive
A ___ assessment is performed to obtain data about an actual, potential, or possible problem that has been identified, or is suspected
focused
An ___ focused assessment is used to evaluate the status of existing problems and goals
ongoing
An ___ focused assessment is used to follow up on client-reported symptoms or unusual findings during the first exam
initial
A ___ assessment is a type of focused assessment; provides in-depth information about a particular area of client functioning and often involves using a specially designed form
* Types include nutritional, pain, cultural, spiritual health, psychosocial, wellness, family, community, and functional ability
special needs
Nursing Interview: Obtaining a Client’s Health History
- Biographical data
- Chief complaint (CC)
- History of presenting illness (HPI)
- Client perception of health
- Client expectations of care
- Past health history (PMH)
Nursing Interview: Obtaining a Client’s Health History cont’d
- Family health history
- Social history
- Medication history and device use
- Complimentary and alternative modalities (CAM)
- Review of body systems
- Functional abilities
Organize Your Data
- NANDA-International Nursing Diagnosis Taxonomy II
- Maslow’s Hierarchy of Needs
Documenting Your Assessment
- Document as soon as possible after performing the assessment
- Only use agency-approved abbreviations
- Record the patients’ own words when possible - but only the most important ones
- Use concrete, specific information
- Record cues, not inferences
Diagnosis
- Analyze and interpret data
- Draw conclusions
- Verify conclusions
- Write the diagnostic statement
- Prioritize the problems
A ___ is any condition that requires intervention to promote wellness or to prevent or treat disease or illness
health problem
Understanding Health Problems
- Nursing
- Medical
- Collaborative
?
Describes a disease, illness, or injury, with a purpose of identifying pathology
Medical
?
Is a statement of client health status that nurses can identify, prevent, or treat independently
Nursing
?
Physiologic complications of disease, medical treatments, or diagnostic studies that nurses monitor to detect onset or change in status
Collaborative
?
Is the thinking process that enables you to make sense of data gathered during a comprehensive patient assessment; aka analysis or ___ process
Diagnostic reasoning
Types of Nursing Diagnoses
Actual
Risk/Potential
Possible
Wellness
?
Problem is present
A problem response that exists at the time of the assessment
Signs and symptoms (cues) that are present
Actual
?
Problem may occur
A problem response that is likely to develop in a vulnerable patient if the nurse and patient do not intervene to prevent it
No signs/symptoms of the problem, but the ___ factors are present that increase the patient’s vulnerability
Risk/Potential
?
Problem may be present
Use when your intuition and experience direct you to suspect that a diagnosis is present, but you do not have enough data to support the diagnosis
Main reason for including this type on a care plan is to alert other nurses to continue to collect data to confirm or rule out the problems
Possible
?
Describes health status but does not describe a problem; can apply to an individual, family, group, or community
2 conditions must be present:
- Client’s present level of ___ is effective
- Client wants to move to a higher level of ___
Wellness
Writing Diagnostic Statements
One-Part Statement
Two-Part Statement
Three-Part Statement
One-Part Statement
Used with ___ diagnoses, as it is not describing a problem, so there is no cause
Example: Readiness for Enhanced Nutrition
wellness
Two-Part Statement
Use for ___ and ___ diagnoses, as there may not be associated symptoms
Example: Risk for Deficient Fluid Volume related to excessive vomiting
risk, possible
Three-Part Statements
___ Format: ___, ___, ___
Example: Constipation related to low fiber intake as evidenced by difficulty defecating, hard stools, and bowel movements every 3 to 4 days
PES
Problem, Etiology, Symptoms
Planning Outcomes
Select standardized care plans
Create individualized care plans
Identify outcomes and goals
Types of Planning
Initial Planning
Ongoing Planning
Discharge Planning
? Planning
Begins with the first patient contact
Initial
? Planning
Refers to changes made in the plan as you:
- Evaluate the patient’s responses to care
- Obtain new data and make new nursing diagnoses
Ongoing
? Planning
Is the process of planning for self-care and continuity of care after the patient leaves a healthcare settting. Purpose is to:
- Promote the patient’s progress toward health or disease management outside of the facility
- Reduce early readmissions to hospital care
Discharge
Nursing Care Plans
The ___ (a type of patient care plan) is the central source of information needed to guide holistic, goal-oriented care to address each patient’s unique needs
comprehensive patient care plan
Why Is a Written Patient Care Plan Important?
- Ensures that care is complete
- Provides continuity of care
- Promotes efficient use of nursing efforts
- Provides a guide for assessments and charting
- Meets requirements of accrediting agencies
Standardized (model) nursing care plans detail the nursing care that’s usually needed for a particular nursing diagnosis or for all nursing diagnoses that commonly occur with a medical condition
?
Are a form of a standardized plan that’s created to produce specific patient outcomes in a specific situation
For instance, a facility may adopt this for a post-op patient; on post-op day 0, do these things, on post-op day 1, do these things, all leading to outcome of having a successful postop recovery
Critical pathways
?
Are NOT a care plan
Are in place to describe the minimum level of care that should be received and guide when things must be provided by; i.e. a facility states you need to conduct a comprehensive assessment on client once per shift, should be documented within 2 hours of the start of your shift
More of a checklist than care plan
Unit standards of care
How Do I Write an Outcome Statement?
Subject (i.e. the patient)
Action Verb (i.e. apply, explain, choose, demonstrate, eat)
Performance Criteria (i.e. how, what, when, where, amount, quality, distance, speed)
Target Time (i.e. realistic date by which performance or behavior should be achieved)
Special Conditions (i.e. additional assistance or resources needed)
SMART Goals
S - Specific
M - Measurable
A - Achievable
R - Realistic
T - Timely
- What do you want to do?
- How will you know when you’ve reached it?
- Is it in your power to accomplish it?
- Can you realistically achieve it?
- When exactly do you want to accomplish it?
Delegation
Nurses Cannot Delegate What They E.A.T.
E - Evaluation
A - Assessment
T - Teaching
Nurses also cannot delegate nursing diagnoses, clinical judgment, the formulation of patient care plans, as well as any interventions that would require professional nursing knowledge or skills
Only 1 phase of the nursing process can be delegated, which is?
Implementation
Only carrying out interventions that fall within that person’s scope of practice
