Week 9: Nursing assessment, diagnosis and planning Flashcards
5 steps in nursing process
Assessment, Diagnosis, Planning, Implementation and Evaluation
which step involves critical thing and data collection?
assessment
Types of data in assessment
Subjective (e.g. I have pain in my chest) and Objective (e.g BP 162/90)
Sources of data in assessment
Client (primary), Secondary sources: family and significant other, health care team, medical records
Ways to collect data in assessment
interview, physical examination, form completion, nursing health history, family history
what is a diagnosis?
- Nursing diagnosis: a clinical judgement about client responses to an actual or potential health problem
- Medical diagnosis: the identification of a disease condition on the basis of specific evaluation of signs and symptoms
- Collaborative Problem: an actual or potential complication that nurses monitor to detect a change in client status
which step involves analyzing data, identifying health problems and forming diagnostic statements?
Nursing diagnosis
what is diagnostic reasoning?
a process of using assessment data to create a nursing diagnosis.
what are defining characteristics?
clinical criteria or assessment findings that help confirm an actual nursing diagnosis
what is clinical criteria?
Objective or subjective signs and symptoms that lead to a diagnostic conclusion
What are the types of nursing diagnosis?
Actual/problem-focused nursing diagnosis, Risk nursing diagnosis, Syndrome nursing diagnosis, Health promotion/wellness nursing diagnosis and Possible nursing diagnosis
A nursing diagnosis comprises of?
- The problem or diagnostic label (has two components: qualifier and focus of the diagnosis)
- The related factor (written as “related to”)
- The defining characteristics (written as “as evidenced by”)
which step has to do with formulating goals and expected outcomes?
Planning
Classification of priorities
high-priority nursing diagnoses, intermediate-priority nursing diagnoses and low-priority nursing diagnoses
3 phases in setting priorities
initial, ongoing and discharge
what is client goal?
A specific, measurable outcome/behaviour or response reflecting client’s highest
possible wellness level and independence
what is short-term goal?
An objective outcome/behaviour or response expected within hours to a week
what is long-term goal?
An objective outcome/behaviour or response expected within days, weeks, or months
what are expected outcomes?
Specific, measurable (objective) change in a client’s status that is expected in response to nursing care
Care plans may be referred to as?
o Nursing care plan
o Institutional care plans
o Computerized care plans
o Care plans for community-based settings
o Critical/clinical pathways
