A nursing diagnosis consists of 3 parts or what is referred to PES format:P= ProblemE =EtiologyS =Signs and Symptoms
  • how do you formulate a risk dx? what does a risk dx consist of?
  • what is the implementation phase of the nursing process
  • how do you formulate an actual nursing dx; what does it consist of
  • what are the 3 types of nursing interventions - provide examples
Are actions or treatments based on knowledge or judgment that the nurse performs to meet the patient outcomes.
  • what are nursing interventions
  • what is the evaluation phase of the nursing process
  • What are the steps of the nursing process?
  • what is the purpose of the problem
1-Failure to be precise or fully indicate the nursing action. 2-Failure to indicate frequency 3-Failure to indicate quantity 4-Failure to indicate method
  • what are frequent errors when writing nursing interventions
  • what is the difference between a medical and nursing dx
  • what is the evaluation phase of the nursing process
  • what is the implementation phase of the nursing process
‐ Observable and measurable information.‐ Remember to include your senses: smell, hearing, touch and sight.
  • objective data
  • focused assessment
  • sign
  • observation
an objective behavior or responseyou expect the client to achieve in a short period of time usually less than one week.
  • subjective data
  • short term goal
  • sign
  • long term goal
‐ Family members‐ Significant others‐ Past & current health records, laboratory tests,diagnostic procedures, consultations from other healthcare professionals.
  • health promotion dx
  • primary source of data
  • secondary sources of data
  • define the nursing process
A medical diagnosis describes a disease process. A nursing diagnosis describes an individual, family orgroup response to an actual or potential problem.
  • how do you formulate an actual nursing dx; what does it consist of
  • what is the purpose of scientific rationale for student nurses
  • what is the difference between a medical and nursing dx
  • what are the 3 types of nursing interventions - provide examples
include expected outcomes ormeasurable criteria to evaluate the achievement of the goal.
  • components of a correctly written goal
  • guidelines to remember when writing goals
  • what are the 3 types of nursing interventions - provide examples
  • Implementing Interventions: personal skills
VALIDATE‐Confirm and verify the information.‐ Keep it free from errors, bias, or misinterpretation.
  • clustering of data often contains
  • what is the purpose of the problem
  • what are the 4 types of NANDA-I dx
  • collect the data then BLANK the data
a systematic problem solving approach toward providing individualized nursing care.
  • What is an expected outcome
  • Define a goal
  • What are nursing interventions
  • Define the nursing process
1-framework for care to indiv, families, & communities 2-orderly & systematic 3-interdependent 4-provides specific care for the indiv, fam, & comm 5- client centered 6-appropriate for use throughout lifespan 7-used in ALL settings
  • what are the 3 types of nursing interventions - provide examples
  • what is the evaluation phase of the nursing process
  • What are the characteristics of the nursing process?
  • what is the implementation phase of the nursing process
Is defined by NANDA‐I , "describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community. It is supported by risk factors that contribute to increasedvulnerability" (NANDA, 2007). Ex. infection after surgery
  • actual dx
  • risk dx
  • nursing dx
  • wellness dx
ADPIE A=assessment D=diagnosis P=planning I=implementation E=evaluation
  • what are nursing interventions
  • What are the steps of the nursing process?
  • what are the 3 types of nursing interventions - provide examples
  • what is the implementation phase of the nursing process
As you cluster data, you begin to consider various diagnoses that may relate to the client. You must remember that if certain defining characteristics do not exist for a specific diagnosis, then you must not use the diagnosis.
  • What are the characteristics of the nursing process?
  • identify how you develop a nursing diagnosis
  • what is the purpose of scientific rationale for student nurses
  • identify how you develop a nursing diagnosis (what is first / next etc)
‐Information obtained from the patient (only)
  • subjective data
  • data
  • primary source of data
  • prioritizing nursing dx ex 2
Clinical judgment of a person, family, or community desire to enhance their well being and readiness to implement health behaviors of a higher level. Ex. nutrition
  • nursing dx
  • focused assessment
  • health promotion dx
  • secondary sources of data
This step begins after the care plan has been developed by the nurse. This is the step of the nursing process where the nurse performs the interventions as a meansof achieving the goals.
  • the implementation process takes into account 5 activities
  • what is the implementation phase of the nursing process
  • what is the difference between a medical and nursing dx
  • how do you formulate an actual nursing dx; what does it consist of
‐ What are your symptoms?‐ When did they start?‐ What activity were you doing ?‐ What makes it better or worse?‐ What are you doing to relieve the symptom?
  • prioritizing nursing dx ex 1
  • interventions can be BLANK or BLANK
  • what are frequent errors when writing nursing interventions
  • focused assessment questions
Identified as subjective and/or objective data that supports the problem.‐ Identified by the nurse from the clustering ofsignificant data including assessment findings.
  • symptom
  • focused assessment
  • signs & symptoms
  • medical dx
1-reassessing 2-review/revise existing nursing dx & care plan 3-organizing resources & delivery of care 4-Anticipating/preventing any complications 5-Implementing interventions
  • what is the purpose of scientific rationale for student nurses
  • what are frequent errors when writing nursing interventions
  • the evaluation phase has 5 components
  • the implementation process takes into account 5 activities
develop a plan of care.This is accomplished by developing client centered goalsand expected outcomes. - use critical thinking to develop nursing interventions to resolve the client's problem and achieve the goals.
  • How does the nurse obtain assessment info?
  • what is the difference between a medical and nursing dx
  • what does the planning phase of the nursing process consist of
  • health promotion dx
consist of a problem and the etiology only - there are NO signs & sypmtoms because it hasn't happened yet
  • identify sources of data for obtaining information from the client
  • how do you formulate a risk dx? what does a risk dx consist of?
  • how do you formulate an actual nursing dx; what does it consist of
  • what is the purpose of the problem
is the reason for choosing the particular intervention based on supportive evidencefrom textbooks, journals, and/or online nursingreferences (so we know why we are doing the task we are doing)
  • what is the implementation phase of the nursing process
  • what is the difference between a medical and nursing dx
  • what is the evaluation phase of the nursing process
  • what is the purpose of scientific rationale for student nurses
Subjective findings verbalized or stated by the client ex. ("I have a headache" " I feel sick in my stomach.")
  • syndrome
  • symptom
  • subjective data
  • sign
subjective
  • signs are
  • symptoms are
  • Data is 1,2,3
  • subjective data
North American NursingDiagnosis Association International
  • What is NANDA-I
  • short term goal
  • Data is 1,2,3
  • objective data
Information verbalized or stated by the client.
  • primary source of data
  • sign
  • subjective data
  • symptom
objective
  • signs are
  • sign
  • symptom
  • long term goal
1-Maslow 2- Pt preference what does the pt think is important 3-Anticipation or future problems
  • the etiology is linked to the problem with the phrase
  • interventions can be BLANK or BLANK
  • 3 helpful guides in prioritizing needs
  • the evaluation phase has 5 components
subjective & objective, primary & secondary, people, healthcare professionals, medical chart, test & lab results etc
  • how do you formulate a risk dx? what does a risk dx consist of?
  • identify sources of data for obtaining information from the client
  • identify how you develop a nursing diagnosis (what is first / next etc)
  • what are the 3 types of nursing interventions - provide examples
" a broad statement that describes the desired change in a client's condition or behavior."
  • define a goal
  • objective data
  • long term goal
  • wellness dx
‐Identification of a disease condition based on specificfindings such as diagnostic tests and procedures.‐ Remains the same as long as the disease is present.
  • actual dx
  • medical dx
  • nursing dx
  • risk dx
Collects data about a problem that has already been identified. This type of assessment determines whetherthe problem still exists, or any changes.
  • emergency assessment
  • focused assessment
  • subjective data
  • primary assessment
An objective finding perceived by the examiner ex. (fever, rash, etc.)
  • sign
  • subjective data
  • symptom
  • normal
past medical hx - family hx - reason for admission - current meds - previous hospitalizations & surgeries - psychosocial assessment - nutrition - complete physical assessment
  • What are the steps of the nursing process?
  • what is the purpose of the problem
  • what is the evaluation phase of the nursing process
  • How does the nurse obtain assessment info?
Evaluation is the final stage of the nursing process. You as the nurse determine if the patient has achieved the expected outcomes not if the nursing interventions were completed.
  • what is the purpose of the problem
  • what are the 4 types of NANDA-I dx
  • what is the etiology
  • what is the evaluation phase of the nursing process
1-client centered 2-singular 3-observable 4-measurable 5-time limited 6-mutual 7-realistic
  • guidelines to remember when writing goals
  • what are the 3 types of nursing interventions - provide examples
  • what is the purpose of the problem
  • components of a correctly written goal
defining characteristics which are specific assessment findings that support anursing diagnosis.
  • prioritizing nursing dx ex 2
  • clustering of data often contains
  • guidelines to remember when writing goals
  • what is the purpose of the problem
"related to" ; The etiology cannot be related to a medical diagnosis.
  • the etiology is linked to the problem with the phrase
  • Implementing Interventions: personal skills
  • the implementation process takes into account 5 activities
  • Implementing Interventions :cognitive skills
collected, validated, then clustered
  • Data is 1,2,6
  • Data is 1,2,2
  • Data is 1,2,3
  • Data is -88,3
1-independent ex. positioning 2-dependent ex. med admin 3-collaborative or interdependent ex. OT
  • what are the 3 types of nursing interventions - provide examples
  • what are frequent errors when writing nursing interventions
  • What are the steps of the nursing process?
  • what are the 4 types of NANDA-I dx
An outcome is a measurable change in the client's status that you expect to occur related to the implemented care.
  • what is an expected outcome
  • what are the 4 types of NANDA-I dx
  • focused assessment questions
  • what is the etiology
critical thinking ; good decisions
  • Guidelines to remember when writing goals
  • Implementing Interventions :cognitive skills
  • Prioritizing nursing dx ex 1
  • During the clustering of data what is used
to identify the health status orproblem of the individual using the approved NANDA - I list. Ex.Pain, acute
  • what is the purpose of the problem
  • what are the 3 types of nursing interventions - provide examples
  • what is the evaluation phase of the nursing process
  • what is an expected outcome
1-cognitive 2-personal 3-psychomotor
  • Implementing Interventions: requires 0 skills
  • Implementing Interventions: requires 2 skills
  • Implementing Interventions: requires 3 skills
  • Implementing Interventions: requires 103 skills
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