Professional Documents
Culture Documents
NURSING PROCESS =
SCIENTIFIC METHOD + CRITICAL THINKING
ASSESSMENT
NURSING DIAGNOSIS
PLANNING
The development of goals for care and possible activities to meet them
INTERVENTION
EVALUATION
Activity 1
Identify what step in the nursing process are the following? Pain related to myocardial ischemia as manifested by guarding left chest, grimacing, moaning pain score of 10/10, Bp 170/80 HR 123 -nursing diagnosis
At the end of the shift the patient will be able to ambulate at the end of the hallway. planning/expected outcome
Decreased use of accessory muscles; client reporting a decreased in shortness of breath and decrease in difficulty breathing? Goal met evaluation
Formal guideline for directing nursing staff to provide client care purpose of a nursing care plan is to identify problems of a patient and find solutions to the problems
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Problem list
Nursing Diagnosis
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Problem list Assessment Subjective=based on what the patient says Objective= based on your observation, laboratory data, and vitals signs
Nursing Diagnosis
5 kinds of nursing diagnosis Actual Risk Potential nursing diagnoses Possible nursing diagnoses Wellness diagnoses Syndrome diagnoses
Actual Diagnoses the persons data base contains evidence of signs and symptoms or defining characteristics of the diagnoses 3 part statement PES (Problem + etiology + signs and symptoms)
Nursing Diagnosis
Problem:
diagnosis
Signs
and Symptoms written as:as evidenced by" (AEB) = should include your assessment data of how you decided on that particular diagnosis
Ineffective airway clearance/ related to physiologic effects of pneumonia/ as evidenced by increased sputum, coughing, abnormal breath sounds, tachypnea, and dyspnea
Risk diagnosis
The persons data base contains evidence of related (risk factors of the diagnosis, but no evidence of the defining characteristics Problem + etiology Risk for impaired skin integrity/ related to obesity, excessive diaphoresis and confinement to bed No signs and symptoms
Possible diagnosis
The persons data base doesnt demonstrate the defining characteristics or related factors of the diagnosis, but your intuition tells you the diagnosis may be present One part statement and simply name the possible problem Ex. Possible ineffective individual coping
Wellness diagnoses
Being able to diagnose wellness diagnoses is based on recognizing when healthy clients indicate a desire to achieve a higher level of functioning in a specific area One part statement use the word potential for enhanced Pt says I wish I were a better parent Nursing diagnosis: Potential for enhanced parenting
Syndrome diagnosis
There are only two syndrome diagnosis on the NANDA list Disuse syndrome Rape and trauma syndrome You use a syndrome diagnosis when the diagnosis is associated with a cluster of other diagnosis (often seen in bedridden nursing home care residents) It is a one part statement. Simply name the syndrome
Impaired physical mobility Risk for constipation Risk for altered respiratory function risk for infection Risk for activity intolerance Risk for injury Risk for altered thought process Risk for body image disturbance Risk for powerlessness Risk for impaired tissue integrity
Activity 2
Identify what kind of nursing diagnosis
Impaired communication/ related to language barrier/ as evidenced by inability to speak or understand English and use of Spanish
actual nursing diagnosis
Activity #3
Identify if the statement is correct. If not correct the statement risk for injury related to lack of the side rails on bed
X
do not write statement in such a way that it may be legally incriminating : risk for injury related to disorientation
X
do not state the nursing diagnosis using medical terminology. Focus on the persons response to medical problems :Risk for self concept disturbance related to effects of the mastectomy
X
do not state two problem at the same time :fear related unfamiliarity with diagnostic procedures pain related to diagnostic procedure
Spiritual distress related to atheism as evidenced by statements that she has never believe in GOD
X
dont write a nursing diagnosis based on value judgment :there may be no diagnosis in this situation. The person may be at peace with her beliefs not with yours
Components of expected Outcome Subject: Who is the person expected to achieve the outcome? Verb: What actions must the person take to achieve the outcome? Condition; Under what circumstances is the person to perform the actions? Performance criteria: How well is the person to perform the actions: Target time: By when is the person expected to be able to perform the actions?
Subject: Mr. Smith Verb: will walk Condition; with a cane Performance criteria at least to the end of the hall and back Target time: by Friday
Measurable verbs
Share
Express Will loose Will gain Has an absence of Exercise Communicate Cough Walk Stand sit
Subject: Mrs. S Verb: will demonstrate Condition; will use her walker Performance criteria unassisted Target time: by Saturday
After 1 hour Mrs. G will verbalize decrease level of pain from 10/10 to 3/10.
Subject: Mrs G Verb: will verbalize Condition; decrease level of pain Performance criteria from 10/10 to 3/10 Target time: after 1 hour
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Intervention/ rationale
Should
be based on your scope of practice Make sure you know the rationale of your intervention Include health teaching
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Problem list
Nursing Diagnosis
Activty # 4 write a care plan for the following problem. 1. Pt who has diarrhea 2. Pt who is constipated 3. Pt who has a fever
Any condition in which gastrointestinal motility is slowed or esophageal reflux is possible places a client at risk for aspiration. Options 1 and 4 maybe appropriate nursing diagnoses but are not of highest priority. Option 3 is not likely to occur
The nurse is teaching a client with diabetes mellitus about dietary measures to follow. The client express frustration in learning the dietary regimen. The nurse would initially 1. Identify the cause of the frustration 2. Continue with the dietary teaching 3. Notify the physician 4. Tell the client that the diet needs to be followed
Use the steps of the nursing process. Assessment is the first step. Of the four options presented, the only assessment is option option1. option 2,3 and 4 are implentation. The initial action is to identify the cause of the frustration
Pain related to surgical incision as manifested by moaning, guarding incision site, pain 10/10 which part is etiology? which part is the problem? which part is the signs and symptoms?
Activity#6
What are the possible nursing diagnoses for someone who has the following condition? Pt who has a trache? Pt who has a stroke Post op patient