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The Nursing Process 5 Steps:
- Planning and goal setting
Is a professional nurses approach to identifying, diagnosis, and treating human responses to health and illness.
Its an ongoing process- you're never done!
The focus of assessment to establish a data base of information about the patients response to his health conditions to enable the nurse to determine care needs.
Nursing Assessment- What's in the data base?
- Health history
- Physical examination findings
- Lab results
- Information from other members of the health care
Types of data:
- 1.) Objective
- 2.) Subjective
Where does the data come from?
The patient, family, other members of the health care team, the medical record, and literature.
How do we get the data?
- 1. Observation
- 2. Interviewing
- 3. Examining
Diagnosis: (after you have all the data and put it together)
The statement of an actual or potential alteration in health status of a patient.
- 1. describes an indiviual response
- 2. oriented to the patient
- 3. changes as the pt response changes
- 4. Guides nursing activities
- 5. Compliementary to the medical diagnosis
- 2-3 part statement
Nursing Diagnosis contains:
- 1. statement of the problem......"PAIN" (NAME)
- 2. etiology.......surgical incision (WHATS THE CAUSE)
- 3. evidence......pt rates his incisional pain as an "8" (WHATS THE PROBLEM)
- Alteration in skin integrity
- R/T surgical inervention
- AEB 7cm abdominal incision
- 1. Set priorities (what deserves atention 1st)
- 2. Establish patient goals (a desired outcomeor chg in behavior the goal should reflect"resoultion" of the problem goals must be measureable)
- 3. Plan the nursing strategies ( what might work?)
- 4. Communicate the plan
- (put the plan in action)
Collect the data R/T the goal
Opened ended questions:
Prompts patients to describe a situation in more than one or two words.
Closed ended questions:
Limit the patients answers to one or two words such as "yes" or "no".
Is the identification f a disease condition bease on an evaluation of physical signs, symptoms, history, and diagnostic tests and procedures made by physicians.
NANDA Iternational defines nursing diagnosis into 5 steps:
- Health promotion