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NURSING DIAGNOSIS Is a client that is present of the nursing assessment. Refers to reasoning process, whereas the term a diagnosis is a statement or conclusion regarding the nature of phenomenon. Nursing diagnosis is a judgment made only after thorough, systematic data collection. Nursing diagnosis describe a continuum of health states: deviations from health, presence of risk factors, and areas of enhanced personal growth.
Is the systematic and continuous collection, organization, validation, and documentation of data (information) A nursing assessment should include the client s perceived needs; health problems related experience, health practices, values lifestyles.
FOUR TYPES OF ASSESSMENT: 1. 2. 3. 4. Initial assessment Problem-focused assessment Emergency assessment Time-lapsed reassessment
FOUR CLOSELY RELATED ACTIVITIES 1. Collective Data - Is the process of gathering information about the client s health - Must be both systematic and continuous. *Database all the information about the client - includes the nursing health history, physical assessment, primary care provider s history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personal. 2. Organizing Data - This is often referred to as a nursing health history; nursing assessment, or nursing database form. 3. Validating Data - Complete, factual, and accurate because the nursing diagnoses and interventions are based on this information - Validation is the act of double-checking or verifying data to confirm that it is accurate and factual
or personnel are needed by both the nurse and the client. FACTORS: 1. then a problem may be given a lower priority than usual. .- The nurse validates data when there are discrepancies between data obtained in the nursing interview (subjective data) and the physical examination (objective data). and establishing a written plan for nursing interventions. *Cues are subjective or objective data that can be directly observed by the nurse. the client s perception of what is important.Sometimes. Medical treatment plan . 3. Resources available to the nurse and the client . values. PLANNING Involves setting priorities. They are recorded in a factual manner and not interpreted by the nurse.Availability of resources like money.Involving the client in prioritizing and care planning enhances cooperation. and beliefs and to separate fact from influences. interpretation and assumption. *Priority Setting is the process of establishing a preferential sequence for addressing nursing diagnoses and interventions. nurses need to be aware of their own biases. SHORT-TERM GOALS are useful: . Urgency of the health-problem . To collect data accurately. writing goals/desired outcomes.The priorities for treating health problems must be congruent with treatment by other health professionals. conflicts with the nurse s knowledge of potential problems or complications.Values concerning health may be more important to the nurse than to the client.Life-threatening situations require that the nurse assign them in high priority.If resources are scarce in health care agency. (Sense of touch. sense of sight) *Inferences are the nurse s interpretation on conclusions made based on the cues Documenting Data Accurate documentation is essential and should include all data collected about the client s health status. equipment. 2. 4. Client s health values and beliefs . 5. Client s priorities . .
such as physical therapists. Dependent Interventions Are activities carried out under the physician s orders or supervision. they are actually performed during the implementing step Include both direct and indirect care. environmental management. emotional support and comfort. nurse-initiated. physician-initiated. making referrals to other health care professionals. ongoing. INTERVENTIONS Are identified and written during the planning step of the nursing process.y y For clients who require health care for a short time For those who are frustrated by long-term goals that seem difficult to attain and who need the satisfaction of achieving a short-term goal LONG-TERM GOAL y Clients in acute care settings also need long-term goals to guide planning for their discharge to long-term agencies or home care. dieticians. ongoing assessment. and collegial relationships between. However. Collaborative Interventions Are actions the nurse carries out in collaboration with other health team members. and otherprovider-initiated treatments. especially in a manage care environment. teaching counseling. Independent Interventions Are those activities that nurses are to initiate on the basis of their knowledge and skills Includes physical care. and physicians. social workers. purposeful activity in which clients and healthcare professionals determine: . Physician s orders completed to nurse o Medication o Intravenous therapy o Diagnostic tests o Treatments o Diet o Activity EVALUATION Is a planned. health personnel. or according to specified routines. Its nursing activities reflect the overlapping responsibilities of.
Answers the question what effect does the setting have on the quality of care? 2. 3. the nurse can draw one of three possible conclusions 1. partially met. Outcome evaluation .Answers the question is the care relevant to the client s needs? 3. . process designate to evaluate and promote excellence in the health care provided to clients.o o Client s progress toward achievement of goals/outcomes Effectiveness of the nursing plan *During the evaluation step the nurse collects data for the purpose of comparing it to preselected goals and judging the effectiveness of the nursing care. The goal was partially met. that s.Are written in terms of client within the nursing process. Evaluation Statement Parts: 1. When determining whether the goal has been achieved. it is relatively simple to determine whether a desired outcome has been met. Conclusion . Quality Assurance (QA) Program is an ongoing.Focuses on how the care was given. or not met. the client response is the same as the desired outcome 2. the differences lie in: y y When the data are collected How the data are used Comparing data with outcomes If the first two parts of the evaluation process have been carried out effectively. .Standards focus on the manner in which the nurse uses the nursing process. 2. The goal was met. . Supporting data are the list of client responses that support the conclusion. systematic. Requires evaluation of Three Components: 1. that is.is a statement that the goal/desired outcome was met. either a short-term goal was achieved but the long-term was not. *The act of assessing (data collection) is the same. . Structure evaluation focuses on the setting in which care is given .Focuses on demonstrable changes in the client s health status as a result of nursing care. The goal was not met. Process evaluation .
4. Nursing Audit focuses on evaluating nursing care through the review of records. written. Individual peer review focuses on the performance of an individual nurse. DOCUMENTING AND REPORTING OF CARE OF PLAN Discussion is an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem. and uses a systematic approach with the intention of improving the quality of care rather than ensuring the wualty of care. Types: 1. 3. Clinical record (Chart or client record) care Purposes of Client Records 1. Report is oral. Nursing Audit Audit means the examination or review of records Retrospective audit is the evaluation of a client s record after discharge from and agency. focuses on process rather than individuals. Communication Planning client care Auditing care health agencies Research Education Reimbursement is a formal legal document that provides evidence of a client s .- Follows client care rather than organizational structure. *The process of making an entry on a client record is called recording. charting. 2. or documenting. direct observation of nursing care. 5. 2. Record is written or computer-based. Peer Review another type of evaluation of care. Concurrent audit is the evaluation of a client s health care is still recieving care from the agency. or computer-based communication intended to convey information to others. Retrospective means relating to the past events. 6. and review if clinical records to determine whether the specific evaluative criteria have been met. *These evaluations use interviewing.
established by Lawrence Weed. Legal Documentation 8. and client problems. Components: 1.7.Assessment is the interpretation or conclusions drawn about the subjective and objective data. a behavior.reflects planning and implementation and includes immediate and future nursing action. a nursing diagnosis. S Subjective data consists of information from what the client says. Problem List derived from the database. Focus Charting is intended to make the client concerns and strengths the focus of care. P Plan is a plan of care designed to resolve the stated problem. Progress notes is a chart made by all health professionals. Problem-oriented medical record (POMR) or Problem-oriented record (POR) . the data are arranged according to the problems the client has rather than the source of the information. or client strength. . a sign or symptom. Plan of care initial list of orders or plan of care with reference to the active problems 4. 2. Source-orientated record traditional client record. 3. O Objective data consists of information that is measured or observed by the senses A . Focus may be a condition. Action . 3. Health care analysis Documentation Systems 1. information on about a particular problem is distributed throughout the record. but chronological order is frequently used. including data from flow sheets. Database consist of information 2. 2. There is no right or wrong order of information. SOAP format is used to correspond the problems. normal findings. It consists of written notes that include routine care. Data reflects the assessment phase of the nursing process and consists of observations of the client status and behaviors. *Response category reflects the evaluation phase of the nursing process and describes the nursing client s response to any nursing and medical care. and acute change in the client s condition. Narrative charting traditional part of the source-oriented record. In this type of record. Three columns for recording: 1. Serves as an index to the numbered entries in the progress notes.