Card Set Information
The Nursing Process 5 Steps:
lanning 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.
What's in the data base?
Physical examination findings
Information from other members of the health care
Types of data:
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?
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......
(WHATS THE CAUSE)
3. evidence......pt rates his incisional pain as an
(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 "
" or "
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: