Concepts Chapter 17 Nursing Diagnosis & 18 Planning Nursing Care – Flashcards

High- emergent Intermediate- non life threatening low- affects patients future well being

patients condition patients preferences holistic view ethical care

a goal is a broad statement that describes desired change in a patients condition, perceptions, or behavior. its and aim, intent, or end. An expected outcome is measurable change that must be achieved to reach a goal. many times several must be met to meet a single goal.

knowledge, standards, experience, and attitude

always partner with patients when setting their individualized goals. mutual goal setting includes the patient and family, when appropriate, in prioritizing the goals of care and developing a plan of action.

a patients highest possible level of wellness and independence in function, based on patient needs, abilities, and resources.

a measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing interventions

links outcomes to NANDA-I nursing diagnoses.

SMART. S- specific M- measurable A- attainable R- realistic T- timed

treatments or actions based on clinical judgment and knowledge that nurses perform to enhance patient outcomes.

the scientific rationale for it possess the necessary psychomotor and interpersonal skills be able to function within a setting to use health care resources effectively

1. nurse initiated- independent- actions that a nurse initiates 2. health care provider initiated- dependednt- require an order from a physician or other health care professional 3. collaborative- interdependent- require combined knowledge, skill, and expertise of multiple health care professionals

determine wheather it is appropriate for the patient the ability to recognize incorrect therapy is important when administering medications or implementing procedures

1. desired patient outcomes 2. characteristics or the nursing diagnois 3. research based knoweldge for the intervention 4. feasibility of the interventions 5.acceptability to the patient 6. nurse's competency

1. Domains 2. Classes 3. Interventions interventions are linked with NANDA international nursis diagnosis

the nursing diagnoses, goals and expected outcomes, and interventions. and a section for evaluation of findings so any nurse is able to quickly identify a patients clinical needs and situation. reduces the risk for incomplete, incorrect, or inaccurate care. and changes as the patients problems and status change

contributions from all disciplines involved in patient care.

critical time when nurses collaborate and share important info that ensures the continuity of care for apr and prevents errors or delays in providng nursing interventions it's transferring essential information from one nurse to the next during transitions of care ask question, clarify, and confirm important details about a patient's progress and continuing care needs.

helps apply knowledge gained from the nursing and medical literature and the classroom to a practice situation is more elaborate that a care plan used in a hospital or care community agency because its purpose is to teach the process of planning care

patient care plans that provide the multidisciplinary healthcare team with activities and tasks to be put into practice sequentially. the main purpose is to deliver timely care at each phase of the care process for a specific type of patient.

visual representation of a patients nursing diagnoses that allows you to diagram interventions for each. group and categorie nursing concepts to give you a holistic view of your patients health care needs and help you make better clinical decisions in planning care. help you learn the interrelationships among nursing diagnoses to create a unique meaning and organization of information

planning incolves consulation with other members of the health care teamconsultation is a process whre you seek the expertise of a specialist, such as your nursing instructor, a physician, or a clinical nurse educator to identify whays to handel problems in patient management or in planning and implementation of therapies consultation occurs at any step in the nursing process, most often during planning and implementation

when: the exact problem remains unclear how: begin with your understanding of the patients clinical problem direct the consultation to the right proffessional provide the consultant with relecant info abut the problem, summary, methods used to date, and outcomes. do not influence consultants be available to discuss the consultants finding incorporate the suggestions!

introduced in 1950 Fry proposed formulation of diagnosis 1953 first national conference held 1973 ANA included diagnosis as a seperate activity in its publication of nursing: a social policy statement 1980, and 1995 NANDA founded 1982

problem focused risk and health promotion

it helps yo to be thourough, comprehensice, and accurate when identifying nursing diagnoses that apply to your patients. the diagnostic reasoning process involves using the assesssment data gathered about a patient to logically explain a clinical judgement or a nursing diagnosis

a set of cues, signs or symptoms gathered during assessment, compared with standards to reach a conclusion about a patients response to a health problem

an objective or subjective sign, symptom, or risk factor that when analyzed with other criteria, leads to a diagnostic conclusion.

when comparing patterns, judge wheather the grouped signs and symptoms are expected for a patient {if its considered a current condition, history, and whether they are withing the range of healthy responses} by isolating any defining characteristics not withing healthy norms, you can identify a specific problem.

identify the correct diagnostic label with associated diefining characteristics or risk facrs and a related factor.

allows you to individualize a nursisng diagnosis for a specific patient

labeling health promotion problem focused nursing diagnosis

1. problem 2. etiology 3. symptoms

1. actual 2. potential/ risk 3. wellness 4. disease prevention

actual = pain potential = fall wellness = readiness for enhanced relationship prevention= infection, kind of overlaps with risk

how has this health problem affected you and your family? what do you believe will help or fix the problem? what wories you the most about the problem? which cultural practices are important to you?

it helps you critically think about a patients diagnoses and how they relate to one another helps organize and link data about a patients multiple diagnoses in a logical way graphically represents the connections among concepts that relate to a central subject

data collection interpretation and analysis of data clustering diagnostic statement

identify pt response, not the medical diagnosis identify a NANDA diagnostic statement rather than a symptom identify a treatable cause or risk factor rather that a clinical sign or chronic problem that is not treatable through nursing intervention id problem caused by the treatment or diagnostic study itself id the patent response to the equiptment rather that the equiptment itself id parients problems rather that your problems with nursing care identify the patient problem rather thatn the nursing intervention id the patient problem rather than the goal of care id the problem and its cause to avoid a circular statement make professional rather that prejudicial judgements avoid legally inadvisable statements idnetif on ly one patient problem in the diagnostic statement

enter them on the written plan of care or on the electronic health information record. this helps organize the data in to clusters, and enhances the ability to select accurate diagnoses when initiating an original care plan,, place the highest priority nursing diagnosis first.