2nd Week

Cards (29)

  • Diagnosis
    1. Formulate the Nursing Diagnosis
    2. Identify the problem
    3. Analyze
  • Time-lapsed Assessment - Several months
    after initial assessment
  • Evaluation - Determine if goals are met or not, assesses effectiveness of nursing intervention
  • Nursing Intervention - Action taken by the nurse to achieve desired outcome.
  • INITIAL ASSESSMENT - performed after admission
  • Problem-focused assessment - Ongoing process
    integrated with nursing care
  • EMERGENCY ASSESSMENT -During any physiological or psychological crisis of the client
  • Primary source - client or family
  • Secondary source - Physical exam, nursing history, team members, lab reports, diagnostic tests
  • HEALTH ASSESSMENT -Review of systems
  • Nursing diagnosiis - can change from day to day
  • Medical diagnosis - stays the same as long as the disease is present
  • Actual - the problem is already existing
  • Risk - The causes that can make the problem become
    present are already there
  • Wellness - The patient is not ill, the patient is well
  • Possible - The patient has the tendency to develop the
    problem
  • Syndrome - composed of 2 or more problem
  • Problem Statement -The client’s response to a
    problem
  • Etiology
    ▪ What’s causing/contributing to the
    client’s problem
  • Defining Characteristics or S/S
    ▪ what’s the evidence of the
    problem
  • Planning - expected outcomes are identified
  • Planning - priorities can change
  • SMART
    S - Specific
    M- Measurable
    A - Attainable
    R- Realistic
    T - Time-bounded
  • Intial planning - Admission; short and quick
  • Ongoing - Confinement; day to day planning depending to the type of the problem the patient is presenting
  • Dischage Planning - before discharge
  • Short-term goals - if the patients problem wil last no longer than 6 months
  • Long-term goals - if the patient's problem will last for more than 6 months
  • Evaluation - examines if nursing interventions are working