Assessment phase of the nursing process in which data are gathered to identify actual or potential health problems Subjective Data data of s/s that include the client’s feelings and statements about his or her health problems Objective Data observable, measurable information that can be validated or verified Primary Source the client Secondary Source family, significant others, other healthcare professionals, health records, and literature review Intial Assessment assessment performed when the patient enteres a healthcare facility, receives care from a home health agency, or is seen for the first time in an outpatient clinic Problem-Focused/Focused Assessment assessment performed with the goal of obtaining data about a problem that has already been identified and consists of a more narrow scope and shorter time frame than initial assessment Emergency Assessment assessment performed that takes place in life-threatening situations in which the preservation of life is the top priority; time sensitive for rapid identification of and intervention for health problem Time-lapsed Assessment assessment performed after the initial assessment to evaluate any changes in the patient’s health; (weeks, months, years) Validation reexamining information to check its accuracy; ensuring subjective and objective data agree; used to ensure data consists of cues not inferences Nursing Diagnosis actual, potential, or possible health problem identified by the nurse that is amenable to nursing intervention; a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Basic Two-Part: Problem and Etiology (TCC’s requirement)
Basic Three-Part: Problem, Etiology, and Signs/Symptoms (NANDA’s requirement)
The components of a basic two-part nursing diagnoses statement and the components of a basic three-part nursing diagnosis statement. Actual Nursing Diagnosis nursing diagnosis made when problem is present at time of assessment with associated s/s; three part statement including diagnostic label, related factors, and defining characteristics Risk Diagnosis nursing diagnosis made when the problem does not exist but the patient is at increased chances of developing a problem; two part statement including diagnostic label and related factors Wellness Diagnosis nursing diagnosis made when a patient has readiness for enhancement; one part statement Possible Diagnosis nursing diagnosis made when not enough evidence supports the problem but the nurse thinks that it is highly probable and wants to collect more information; two part statement stating potential problem followed by “unknown cause” NANDA-International currently accepted taxonomy of nursing diagnoses Prioritization decision-making process in which the nurse decides the order of the nursing diagnoses in terms of importance to the patient; to achieve this process follow the ABC’s then Maslows Hierarchy of Needs protocol Outcome Identification the formulation of goals and measureable outcomes that provide the basis for evaluating nursing diagnoses for the purpose of providing individualized care, promoting patient participation, planning realistic and measurable nursing care, defining collaborative care, establishing priorities, and establishing client goals and outcome criteria Specific, Measurable, Attainable, Realistic, and carried out in a specific Time frame, SMART
1. Subject (The patient will….)
2. Verb (verbalize, demonstrate)
3. Condition of modifier (pain relief)
4. Criterion of desired (AEB)
the requirement for outcome criteria/goal statements Planning the development of nursing strategies designed to ameliorate patient problems; multidisciplinary; Implementation/Intervention refers to the action phase of the nursing process in which nursing care is provided; can be independent, dependent, or collaborative; must be safe and appropriate for patient; must be achieveable; in a care plan, this action must have one directive verb and be measurable. Evaluation the judgment of the effectiveness of nursing care to meet patient goals based on the patient’s behavioral responses; requires reassessment, effectiveness of nursing interventions, and patient goal achievement The goal was met, the goal was partially met, the goal was not met at all the three factors to determine the effectiveness of the plan of care Continue the plan of care, modify the plan of care, or discharge the plan of care the decision made by the nurse after the effectiveness of the plan of care is determined Maslow’s Hierarchy of Human Needs theory that states that all humans are born with instinctive needs, grouped into five categories, and arranged in order of importence from those essential to physical survival to those necessary to develop a person’s fullest potential; second tool used to prioritize patient needs Airway, Breathing, Circulation the first tool used to prioritize patient needs.