Nursing Process/Plan of Care
3 part Nursing diagnostic statement (Actual)?
1. problem 2. etiology 3. S/Sx
Medical assessment
Focus is on disease and pathology.
How do you choose and NANDA?
1. Identify the broad topic that seems to fit the cue cluster. 2. Use nursing diagnostic handbook to narrow search.
What are the components of a goal statement?
1. Subject ex) Patient 2. Action ex) Walk 3. performance criteria ex) 300 ft. with a walker 4. target time ex) end of shift 5. special conditions ex) with a walker
What does every evaluation statement need?
1. date 2. was the outcome met? 3. evidence the outcome was met
Goals of planning phase:
1. establish priorities (Maslow) 2. identify and write expected patient outcomes (NIC/NOC/NANDA) 3. select evidence based nursing interventions 4. communicate the plan of care
Preparing for an interview:
1. know the purpose 2. read client's chart 3. form goals and opening statements 4. schedule uninterupted time 4. have forms and equipment ready 5. comepose yourself 6. provide privacy and remove distractions
2 part Nursing diagnostic statement (risk)?
1. problem r/t etiology 2. NANDA label r/t related factors
What are we doing during assessment phase?
Data collection.
Medical Diagnoses
Describes a disease, illness, or injury for which the physician directs the primary treatment.
Nursing diagnostic statement, problem?
Describes health state or health problem of patient. (NANDA)
Long term goals?
Describes the optimal level of functioning you expect the patient to achieve.
What are we doing during the evaluation phase?
Evaluating the client's progress towards their goals, the effectiveness of the nursing care plan, and the quality of the care that was provided.
What is implementation in the nursing process?
Putting you plan, nursing intervention, into action.
What are we doing during the documentation phase?
Recording patient's response and patient's pain to implementations of nursing interventions.
(Actual) Nursing Diagnoses
actual problem for the client, exhibits S/Sx.
What is the nursing process?
ADPIE
What is a cue, and what do we do with them?
A cue is a S/Sx, we determine the etiology and problem.
What are nursing interventions?
A strategy selected by the nurse in order to achieve the best outcomes for the clients. They must be safe, within the legal scope of nursing practice, and compatible with medical orders.
Nursing Diagnoses
Actual or potential health problems that can be prevented or resolved by independant nursing intervention. A statement of client health status that nurses can identify, prevent, or treat independantly.
How do we use critical thinking?
Analyse and interpret data, draw conclusions about client's health status, verify problems with client, prioritize the problems, record the diagnostic statements.
What are we doing during the diagnositc phase?
Analyzing data, and data review.
What can you do to facilitate subjective data collection?
Ask open ended questions.
What is ADPIE?
Assessment, Diagnosis, Planning Outcomes, Planning Interventions, Implementations, Evaluation
Initial planning:
Begins with first client contact, written as soon as possible after the initial assessment.
Ongoing planning:
Changes made inthe plan as you evaluate the patient's responses to care.
Nursing diagnostic statement, etiology?
Identifies factors believed to cause or contribute to the problem. (Cause)
Why is an acurate nursing diagnosis important?
If the nursing diagnosis in inacurate the careplan will be ineffective.
Subjective Data
Information perceived only by the affected person; what the person says.
What is the nusing process?
It is a problem solving method to guide nursing activities.
Objective Data
Observable and measurable data; can be seen, heard, of felt by someone other than the person experiencing the S/Sx.
What are the 3 parts of the nursing diagnostic statement?
Problem, Etiology, Defining Characteristics
Short term goals?
Provides positive reinforcement for those clients working towards a long-term goal.
Nursing diagnostic statement, defining characteristics?
The subjective and objective data that signal the existence of a problem. (S/Sx, observed during assessment)
Validating Data
Verification of data if client's statements differ at different time; if subjective/objective data do not match or make sense; data far outside the normal range; factors are present that interfere with accurate measurement.
Nursing assessment
focus is on the client's responses to illness; physical, emotional, social, etc.
(Risk) Nursing Diagnoses
potential problem if we don't keep issue from happening.