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Difference between nursing process ad Medical Process
- nursingholistic focus
- teach for independecnce
- consult w/ medicine for treatment of disease
- involved w/individuals, families, and groups
- MEDICALdisease focus
- teach tx of disease
- consults with nursing for planning ADLS
- mostly involved with individuals
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diagnosing refers to
the reasoning process
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nursing diagnosis is
the problem statement consisting of the diagnostic label plus etiology
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actual diagnosis is
- problem presents at the time of assessment
- pesence of associated signs and symptoms
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risk diagnosis is
problem doesnt actually exist but has risk factors
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Health promotion Diagnosis is
- Preparedness to implement behaviors to improve their health condition
- Example: Readiness for enhanced Nutrition
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Wellness diagnosis is
- Describes human responses to levels of wellness in an individual, family, or community
- Example: Readiness for Enhanced Family Coping
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Syndrome Diagnosis is
- Used when diagnosis is associated with a cluster of diagnoses
- Examples: Disuse Syndrome, Rape-Trauma Syndrome
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Components of A nursing diagnosis are
- problem statement (clients response to the health problem)
- etiology - CAUSE OF THE PROBLEM OR RISK FACTORS
- as evidenced by statement
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defining characteristics are
cluster of signs and symptoms THAT indicate the presence of a particular dagnostic label
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as evidenced by statement is
- signs and symptoms
- evidence that supprts that a diagnosis is present
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nursing diagnosis examples and all of the components
- PAIN, ACUTE R/T EFFECTS OF SURGERY AS EVIDENCED BY PAIN RATED AS AN “8”, GUARDING OF INCISIONAL AREA, GRIMACING WHEN MOVING
- CONSTIPATION R/T PROLONGED IMMOBILITY AS EVIDENCED BY NO BM FOR 5 DAYS, FEELINGS OF FULLNESS
- NUTRITION,IMBALANCED:LESS THAN BODY REQUIREMENTS R/T DIFFICULTY SWALLOWING AS EVIDENCED
- BY CHOKING ON FOOD, DECREASED INTAKE
- NUTRITION, IMBALANCED:LESS THAN BODY REQUIREMENTS R/T ß APPETITE AS EVIDENCED BY EATING 10% OF EACH TRAY, STATEMENTS OF NO APPETITE
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tips for writing a good nursing diagnosis
- Write it in respect to the patients response
- Use R/t not Due To or any other wording
- Write diagnosis in legally advisable terms
- Write the diagnosis without a
- value judgement
- Avoid reversing parts
- Be certain to avoid redundancy
- Be clear and concise
- Don’t put medical diagnosis in nursing diagnosis
- Don’t rename a medical condition to fit nursing diagnosis
- Don’t state 2 problems at the same time
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how to know which nursing diagnosis is correct
- tells you problem
- how do you treat that problem
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nursing diagnosis has to be something a nurse can ....
- treat
- ie NOT AIRWAY CLEARANCE, INEFFECTIVE R/T CHRONIC PULMONARY DISEASE
- BUT CORRECT = AIRWAY CLEARANCE, INEFFECTIVE R/T COPIOUS, VISCOUS SECRETIONS
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TIPS for writing outcomes/goals
- Should be related to human response
- Should be client centered- begin with “The client will…”
- Should be clear and concise
- Should be observable and measurable
- Should be time limited
- Should be realistic
- Should be set together (nurse and patient)
- OUTCOMES PROVIDE A BLUEPRINT FOR EVALUATION
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most importnat thing about outcomes is that
it has a timeline and is measurable
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two types or nursing interventions =
- dependent - need an order
- independent - nursing function
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perfect time for ROM
bed bath
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TIPS FOR WRITING INTERVENTIONS
- Must be dated and signed in the clinical area
- Use precise action verbs
- Define who, what, where, when, and how often
- Must be consistent with plan of care – every intervention must meet the outcome that has been set
- Only one assessment order allowed
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most important about nursing order
does it meet the outcome you set
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Items under the Diagnosing heading = AIF
- analyze data
- identify health problems, risks, and strengths
- formulate diagnostic statements
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PES =
- three part nursing diagnosis
- Problem
- Etiology (what is causing the problem)
- Signs and Symptoms
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items under planning = PFSW
- prioritize problems/diagnosis
- formulate goals/desired outcomes
- select nursing interventions
- write nursing interventions
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what is important to remeber out pt with the same diagnosis
even though they have same diagnosis they need a individualized care plan
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Five activities of the Implementing Phase
RDISD
- Reasses the client
- determine the nurses need for assistance
- implement the nursing interventions
- supervise delegated care
- document nursing activities
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Five activities of Evaluation
CCRDM
- collect data related to desired outcomes
- compare data with desired outcome
- relate nursing activities to outcome
- draw conclusions about problem status
- modify or terminate nursing care plan
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Nursing steps
- Assessment
- Diagnosis
- Planning
- Implementation
- evaluation
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