assessment, nursing diagnosis and planning chapter 5
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pieces of information on a specific topic
all the info gathered about a person
methods of data collecting
- structured format to obtain a comprehensive database based on the 11 functional health patterns.
- begin with areas in which problems are evident, such as pain.
- maslows basic needs.
factors causing or effecting the pain are explored. specific problem.
first step of nursing processing
assessment. begins at admission with the admission interview,history and physical assessment.
info that the patient verbally describes.
facts that obtained through senses and hands on physical assessment.
useful for gathering info fro the nursing database and for obtaining info the student assignment.
analysis is used to sort and group assessment data so that nursing diagnosis can be chosen and priorities can be set.
statement indicates the patients actual health status or a potential problem, the causative or related factors and specific defining characteristics (signs & symptoms.)
realistic, obtainable, and measurable. have a defined time line and easily evaluated.
intervention nursing orders
- independent: can do w/o order form
- dependent: need dr order.
- interdependent: both between departments.
- a broad idea thru nursing intervention.
- short term. 7-10 days. before discharge.
- long term weeks/months.
- data the patient has said that is occuring that cant be verified by examination.
- abnormalities that can be verified by repeat examination.
nursing diagnosis NANDA
- risk for
- rest & comfort
- sexual precreation
construction of a nursing diagnosis
- problem +etiology (cause)+ sign & symptoms.
- problem: ND label(stem)
- etiology:causative factors
- S&S: evidence by(defining characteristics).
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