Assessment types of data collection
- Focused: done if pt complains of new of change in symptoms, you see a change in symptoms, a xray or test indicates change, new nursing diagnosis being considered, or diagnosis required frequent repeating measures.
Parts of assesment
- Nursing History
- Review of systems past visits surgeries etc
- physical health exam head to toe
types of data collection during an assessment
- Primary: pt derived subjective objective
- secondary: derived fro tests family other perfessionals etc
- baseline starting data
types of assessment data methods
- observation interview and examination
- gordons data sheet
- everything must be factual, accurate, and complete never use small medium or large unless no better method available.
definition of diagnosis
Diagnoses ﬂ ow from (are derived from) assessment. Diagnoses are also called conclusions drawn from an analysis of the assessment data, clinical inferences made on the basis of assessment, or clinical judgments that the nurse makes a er assessing the patient. e subject of the nursing diagnosis may be a patient, family, or community. An example of a patient-focused nursing diagnosis is body image disturbance. An example of a family- focused nursing diagnosis is ineﬀ ective family coping. An example of a community- focused nursing diagnosis is ineﬀ ective community management of a therapeutic regimen. e latter might occur when a community does not have the resources it needs to manage a public health problem, such as tuberculosis. e subject matter of the diagnosis may be a health problem or a life process. Examples of diagnoses that represent health problems are constipation, risk for ﬂ uid volume deﬁ cit, impaired bed mobility, and impaired social interaction. Examples of diagnoses that focus on life processes are impaired home maintenance management, altered family processes (alcoholism), and anticipatory grieving. It is the nursing diagnosis that directs the planning of patient goals and the selection of appropriate nursing interventions designed to achieve outcomes for which the nurse is accountable. Diagnoses require validation. O en, it is the patient who validates the diagnosis. For example, before making a diagnosis that the patient is grieving, the registered nurse validates this diagnosis with the patient. Sometimes, it is the family that validates the diagnosis. For example, the nurse may be thinking that a family with three children in high school is ready for developing enhanced parenting skills. Before inviting a parent to attend a series of classes on the modern teenagers and parenting strategies, the nurse validates the readiness diagnosis ﬁ rst. e nurse may say, “In my interactions with you, I get the impression that you are interested in learning new parenting strategies. Is that so?” Diagnoses may also be validated with colleagues. For example, a nurse indicates during the report, “I think the patient may be experiencing some decisional conﬂ ict about being discharged home. Would you assess the patient and see if you agree?” The subject of the nursing diagnosis may be a patient, family, or community. Chapter 1: The Nursing Process as a Clinical Framework Validation of diagnoses with patients, families, and even colleagues does not mean that the registered nurse suspends clinical judgment. A patient taking a drug that is hepatotoxic may attribute the experience of fatigue to stress, while the nurse suspects that the fatigue is related to drug therapy. Acquiescing to the patient’s hunch is not validating the diagnosis. e diagnosis that is of a higher priority is a drug-related fatigue, and steps need to be taken to ensure that liver function tests are obtained as soon as possible. is case requires laboratory validation and collaboration with the physician. If the liver function tests are negative, then the nurse may proceed with a diagnosis of fatigue related to sleep deprivation. is does not mean that the nurse avoids the complaint of stress. is complaint may be addressed even as the laboratory tests are being obtained. It is possible for patients to have two diagnoses—stress as well as fatigue related to hepatoxic eﬀ ects of drug therapy.is example points out the necessity for validating nursing diagnoses
components of a diagnosis
- a nursing diagnosis consists of a diagnostic label, the definition of the diagnosis, and its defining characteristics, related factors, and risk factors.
- defining characteristics:are like manifestations of the diagnosis, or signs or symptoms.
- related factors: causative in nature, associated with diagnosis.
- risk factors: reder to those variables that increase a ots vulnerability to developing an actual nursing diagnosis.
types of nursing diagnoses
- actual - refers to a huan response to a health condition of life process that is happening at the present time.
- risk- refers toa diagnosis that is likely to occur in a vulnerable person.
- wellness- refer to hman respinses to achieve even greater levels of wellness
- possible- diagnoess that are being investigated and not yet confirmed.
- syndrome- consists of a cluster of dignoses that are linked to the pts condition.
how to state nursing diagnosis 3 ways
the diagnoses can be written ineffective infant feeding pattern related to prematurity(manifested by an impaired ability to suck). but may also be documented using the name, related factor, and defining charateristics
how to priorice nrsing diagnoses
- maslows hiecharchy needs.
- self actualization needs
- esteem needs
- social needs
- safety needs
- physiological needs
outcome identification to see if diagnosis will work
- did the diagnoses i made flow from my assessment?
- did i validate the diagnoses woth thept, family, and colleagues?
- did i document the diagnoses in a manner that faciitates outcomes identification and planning?
criteria for formulating outcomes
- talk with peer in meeting
- culturally appropriate
- consider risks, benefits, costs, evidence, and clinical expertise.
- consistent with pts beliefs and environment
- time plan expected to occur
- modify on the basis oof changes in the pts condition or situation
- measurable goals
- ( note that these goals are pt-centered, future-oriented, and action/direction-oriented. because goals are always expressed in terms of pt goals to be achieved and not in terms of the nurse's work goals.
discharge Planning is used why?
- to accomplish the teaching requirements, the nurse has as an objective that the pt or caregiver at the time of discharge will know how to do the following
- accomplish adls
- meds safetly
- prcedures safetly
- signs of progress
- follow up care
- detect complications
types of plans
- handwritten care plans - pt background info,
- listing of pt probelm, and interventions.
- standardized care plans- preprinted plans
- electronic care plans allow plans to be shard across departments or units within hospitals when pts are transferred.
policies, procotcols, procedures, and standing orders
- policies are written instructions to address a commonly occurring problem in an instituionally approved manner.
- protocols preptinted instructions how to care for a group of pts with same problem.
- proceduresclinical tasks
- standing orders authority for the nurse to act in the absence of a dr.
steps in implementing interventions
- 1. make rounds to reassess the pts need for an intervention.
- 2. determine the amount of assistance needed to implement the interventin ina wat that minimizes pt discomfort, and maximzes pt safety
- 3. gather things before explain etc.
- 4. document the intervention adn the pt's response during and after implementation.
- 5.consult as needed with the other health professionals.
issues when supervising assisstive personnel
you are always responsibel for their work and performance with patients
what are the three different interventions
- independent intervention- turning client in bed
- dependent- dr order for drug drip
- collaborative- other professionals help