assessment, nursing diagnosis and planning chapter 5

pieces of information on a specific topic

all the info gathered about a person

• 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.

factors causing or effecting the pain are explored. specific problem.

assessment. begins at admission with the admission interview,history and physical assessment.

info that the patient verbally describes.

facts that obtained through senses and hands on physical assessment.

useful for gathering info fro the nursing database and for obtaining info the student assignment.

analysis is used to sort and group assessment data so that nursing diagnosis can be chosen and priorities can be set.

statement indicates the patients actual health status or a potential problem, the causative  or related factors and specific defining characteristics (signs & symptoms.)

realistic, obtainable, and measurable. have a defined time line and easily evaluated.

• 1:assessment
• 2:diagnosis
• 3:planning

• independent: can do w/o order form
• dependent: need dr order.
• interdependent: both between departments.

• a broad idea thru nursing intervention.
• short term. 7-10 days. before discharge.
• long term weeks/months.

• data the patient has said that is occuring that cant be verified by examination.
• subjective
• headache

• abnormalities that can be verified by repeat examination.
• objective
• bruises

• imparied
• altered
• risk for
• decreased
• ineffective

cause of

nursing orders

• oxygenation
• nutrition
• elimination
• safety
• rest & comfort
• hygeine
• activity
• sexual precreation

• ND=
• problem +etiology (cause)+ sign & symptoms.
• problem: ND label(stem)
• etiology:causative factors
• S&S: evidence by(defining characteristics).