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a statement about the actual or potential problem that can be managed thru INDEPENDENT nursing action

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nursing diagnosis

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describe what a Nursing Diagnosis is using the 4 "C"

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Concise Clear Client-specific Client-oriented (indivualized)

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nursing diagnosis is the ________ for planning

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foundation

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nursing diagnosis reflects the client's current

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condition

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nursing diagnosis draws conclusions from

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data

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since 1973 nurse researchers & educators formulated plans to standardize communication & categories of

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nursing care

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in 1982 the group that standardize nursing care became know as the

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NANDA (North American Nursing Diagnosis Association)

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what year was the NANDA revised to NANDA-I (international)

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2002

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standardization of nursing terminology (nursing diagnoses) became a effective nursing tool for ________

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communication

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medical diagnosis is concerned with & identifies

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disease

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a medical diagnosis is based off of _______ & establishing it's _______

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physical signs, cause

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provides basis for prognosis (projected outcome) & medical treatment decisions

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medical diagnosis

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what is the difference b/t medical diagnosis & nursing diagnosis?

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medical is concerned with the disease process while nursing is concerned with the person & how the disease effects their functioning

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pneumonia, hypertension, ect are examples of

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medical diagnosis

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assesses function and how a client's needs can be met

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nurse

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you assess abnormal breathe sounds, ineffective cough, & no sputum, so your nursing diagnosis would be

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"Ineffective Airway Clearence"

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"Hyperthermia" and "Pain" are examples of a

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nursing diagnosis

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purpose of nursing diagnosis is to identify nursing

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priorities

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directs nursing interventions to meet client's needs

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nursing diagnosis

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nursing diagnosis guides in formulate expected

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outcomes

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nursing diagnosis provides a basis of ________ to determine if nursing care was beneficial

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evaluation

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nuring diagnosis is of help when making staff

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assignments

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gives exactly where the pt is with health and steps to make the problem better

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nursing diagnosis

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diagnostic statement consist 2 or 3 parts...whats the 3 parts? *PES*

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Problem Etiology Signs & symptoms

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you have to use ________ approved labeling to state the client's problem

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NANDA-1

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"Ineffective Airway Clearance" is an example of the first part (problem) of the

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diagnostic statement

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part of the diagnosis statement that is the cause of the problem

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etiology

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Ineffective Airway Clearance R/T increased secretions AEB unproductive cough. What part is the etiology?

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increased secretions

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summary of the data, for ex. abnormal breathing sounds & ineffective cough without sputum

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signs and symptoms

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when writing a diagnostic statment the first two parts (problem & cause) are linked by

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"related to" or R/T

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the last part (symptoms) of a diagnostic statement is linked by

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"as evidence by" or AEB

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Ineffective Airway Clearance R/T increase secretions AEB unproductive cough or abnormal breath sounds.-example of

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diagnostic statement

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when formulating a nursing diagnosis make sure it's something that can be treated without

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physician's order

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treating without the physicians order is called

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independent nursing action

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a problem that you & the physician work together on, for example he prescribes meds, you decide when to give them

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collaborative problem

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nursing diagnosis contains the following steps

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establishing significant data & writing a diagnostic statement

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after nursing diagnosis you begin

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planning care

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the development of goals to reduce or eliminate problems & to identify interventions to meet goals

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planning

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list the 4 steps in planning care:

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Setting priorities Establishing expected outcomes Selecting nursing interventions Writing a nursing care plan

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survival needs or life-threatening problems would be considered

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highest priority

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problems like social, psychological, need for love, companionship & fulfillment are of

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lower priority

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reason for the client's admission and the nursing diagnosis may be ________-ex. dehydration vs the pressure ulcers that client admitted for

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unrelated

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materials, human resources, time & equipment can affect the order of

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priority

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the ______ can determine the priority of their health concerns; for ex. s/o with the need for oxygen still smoking

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client

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learning objective and behavioral objective is similar to

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expected outcomes

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measurable client behavior that indicates whether they achieved expected benefit from nursing care

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expected outcomes

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client's expected outcome may also be called

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goal or objective

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an expected outcome has 4 characteristics, list them:

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client-oriented specific reasonable measurable

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the client will walk aroumd the room once q shift is an example of

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client oriented

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walk around the room once q shift is an example of being

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specific

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the outcome should be within the cient's capabilities; this is characterize as being

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reasonable

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b/c you can observe a client walking that would make the behavoir

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measurable

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who determines outcome, when working together?

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nurse and client

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List some verbs used in expected outcomes statements

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identify list has an increase/dncrease in sit-stand-walk relate perform

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outcome a client can reach within hours or a few days; client will walk 20 min longer each day for 3 days

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short term objective

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outcome that is longer to reach that some clients will not achieve in the hospital; for ex. "return to college" after self-care is achieved

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long term objective

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produces short OR long term desired outcome

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nursing interventions

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nursing interventions may include setting a specific ______ to achieve goals & checking them off per completion

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date

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"Ineffective Airway Clearance related to pysiologic effects of pneumonia as evidence by increased sputum, cough, and abnormal lung sounds" what would be an expected outcome?

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"Within 24 hours, the client will state that breathing is easier"

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positioning a client for breathing is an example of a nursing intervention that is

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independent

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teaching client deep breathing is an example of a nursing intervention that is

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collaboratve

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encourage use of an incentive spirometer, administering O2 that was ordered, ensure that respiratory therapy Tx is administered as ordered is all nursing interventions that are

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dependent

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the nursing intervention, offering fluids frequently, has to be

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physician ordered

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WRITTEN formal guideline for directing staff to provide care

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nursing care plan

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a nurse or nursing team formulates care plans in

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nursing care or team conference

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nursing care plans include

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nursing diagnosis expected outcomes nursing orders

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care plans are wriiten shortly after ________ and is ______ as condition changes

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admit, updated

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care plans are written on

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Kardex or computer generated file

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becomes part of a client's permanent health record

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care plan

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documentation of the nursing care plan is required by

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Joint Commission Nursing homes Medicare

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the joint commission (TJC) was formely know as the JCAHO which stands for

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Joint Commision on Accreditation of Healthcare Organization

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the nursing care plan evaluates

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outcomes

CH 35 Nursing Diagnosis & Planning – Flashcards

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