assessment, nursing diagnosis and planning chapter 5

  1. data
    pieces of information on a specific topic
  2. database
    all the info gathered about a person
  3. methods of data collecting
    • structured format to obtain a comprehensive database based on the 11 functional health patterns.
    • begin with areas in which problems are evident, such as pain.
    • maslows basic needs.
  4. focused assessment
    factors causing or effecting the pain are explored. specific problem.
  5. first step of nursing processing
    assessment. begins at admission with the admission interview,history and physical assessment.
  6. subjective data
    info that the patient verbally describes.
  7. objective data
    facts that obtained through senses and hands on physical assessment.
  8. chart review
    useful for gathering info fro the nursing database and for obtaining info the student assignment.
  9. analysing
    analysis is used to sort and group assessment data so that nursing diagnosis can be chosen and priorities can be set.
  10. nursing diagnoses
    statement indicates the patients actual health status or a potential problem, the causative  or related factors and specific defining characteristics (signs & symptoms.)
  11. expected outcome
    realistic, obtainable, and measurable. have a defined time line and easily evaluated.
  12. nursing process
    • 1:assessment
    • 2:diagnosis
    • 3:planning
  13. intervention nursing orders
    • independent: can do w/o order form
    • dependent: need dr order.
    • interdependent: both between departments.
  14. goals
    • a broad idea thru nursing intervention.
    • short term. 7-10 days. before discharge.
    • long term weeks/months.
  15. symptoms
    • data the patient has said that is occuring that cant be verified by examination.
    • subjective
    • headache
  16. sign
    • abnormalities that can be verified by repeat examination.
    • objective
    • bruises
  17. nursing diagnosis NANDA
    • imparied
    • altered
    • risk for
    • decreased
    • ineffective
  18. etiologic factor
    cause of
  19. intervention
    nursing orders
  20. maslows
    • oxygenation
    • nutrition
    • elimination
    • safety
    • rest & comfort
    • hygeine
    • activity
    • sexual precreation
  21. construction of a nursing diagnosis
    • ND=
    • problem +etiology (cause)+ sign & symptoms.
    • problem: ND label(stem)
    • etiology:causative factors
    • S&S: evidence by(defining characteristics).
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assessment, nursing diagnosis and planning chapter 5
assessment, nursing diagnsis and planning