2nd Week

• 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