Funda

• Cues 


  are subjective or objective data that can be directly observed by the nurse
• Inferences 


  are the nurse's interpretation or conclusions made based on the cues.
• Accurate Documentation


  is essential and should include all data collected about the client's health status.
• Critical-Thinking 


  skill used by the nurse to interpret assessment data and identify client strengths and problems.
• Diagnosing


  refers to the reasoning process.
• Diagnosis


  is a statement or conclusion regarding the nature of a phenomenon.
• Diagnostic labels 


  the standardized NANDA names for diagnoses
• NANDA

  North American Nursing Diagnosis
• Actual Diagnosis

  • is a client problem that is present at the time of the nursing assessment
  • It is based on the presence of associated signs and symptoms
• Risk Nursing Diagnosis

  • is a clinical judgment that the problem does not  exist, but the presence of risk   factors indicate that the problem is  likely to develop unless nurses  intervene.
• Wellness Diagnosis

  • describe human responses to levels of wellness in an individual, family or community that have a readiness for enhancement.
• Possible Nursing Diagnosis

  • is one in which evidence about a health problem is incomplete or unclear.
• Syndrome Diagnosis

  • is a diagnosis that is associated with cluster of other diagnoses.
• Problem (Diagnostic Label) and Definition

  • describe the client’s health problem or response for which nursing therapy is given.
  • it describes the client’s health status clearly and concisely in a few words.
• Qualifiers 


  Are words that have been added to some NANDA label to give additional meaning to the diagnostic statement
• Etiology (Related Factors and Risk Factors)

  • identifies one or more probable causes of the health problem, gives direction to acquire nursing therapy, and enables the nurse to individualized clients card.
• Defining Characteristics

  • are cluster of signs and symptoms that indicates the presence of a particular diagnostic label.
• High- priority

  • life-threatening and requires immediate attention.

  Medium- priority

  • resulting in unhealthy consequences.

  Low- priority

  • can be resolved with minimal interventions.
• Nursing Interventions


  Is any treatment, based upon clinical judgement and knowledge, that a nurse performs to enhance patient/client outcomes
• Client Care plan


  The product of the planning phase -
• Initial Planning

  • The nurse who performs the admission assessment usually develops the initial comprehensive plan of care.
  • Should be initiated as soon as possible after the initial assessment, especially because of the trend toward shorter hospital days
• Ongoing planning

  • Is done by all nurses who work with the client.
  • Occurs at the beginning of the shift as the nurse plans the care to be given that day.
  • The nurse carries out the daily planning
• Discharge Planning

  • the process of anticipating and planning for needs after discharge
  • Is a crucial part of comprehensive health care and should be addressed in each client’s care plan.
• Informal Nursing Care plan 


  is a strategy for action that exist in the nurse’s mind.
• Formal Nursing Care plan

  • is a written or computerized  guide that organizes information about the client’s care.
• Standardized Care plan 


  is a formal plan that specifies the nursing care for groups of clients with common needs.(e.g. All clients with myocardial infarction)
• Individual Care plan


  is tailored to meet the unique needs of the specific client
• Setting Priorities 


  Is the process of establishing a preferential sequence for addressing nursing diagnoses and interventions.
• Establishing Client goals/ Desired Outcomes

  • The nurse and client set goals for each nursing diagnosis.
  • What the nurse hopes to achieve by implementing the nursing interventions.
• Characteristics of Outcome Criteria:

  1. S- SPECIFIC
  2. M- MEASURABLE
  3. A- ATTAINABLE
  4. R- REALISTIC
  5. T- TIME- FRAMED
• Short-Term Goal


  are useful for clients who require health care for a short period of  time.
• Long-Term Goal 


  Often used for clients who lived at home and have chronic health problems and in nursing homes.
• Independent Interventions

  • are those activities that nurses are licensed to initiate on the basis on their knowledge and skills.
• Dependent Interventions


  are those activities carried out under the physician’s orders or supervision, according to specified routines.
• Collaborative Interventions 


  are those actions the nurse carries out in collaboration with other health team members, such as physical therapist, social workers, dietitians, and physicians.
• Nursing Orders 


  re instruction for specific individualized activities the nurse performs to help the client meet established health care goals.
• Implementing

  • Is the phase in which the nurse implements the nursing interventions.
  • It consists of doing and documenting  activities that are specific nursing actions needed to carry out the interventions
  • The nurse performs or delegates the nursing activities for the interventions that were developed in the planning step.
• Cognitive Skills

  • Includes problem solving, decision making, critical thinking and creativity
  • They are crucial to safe, intelligent care
• Intrapersonal Skills

  • are all activities, verbal and non-verbal, people use when interacting directly with one another. 
  • The effectiveness of the nursing actions often depends on the nurse’s ability to communicate with others. 
  • The nurse uses therapeutic communication to understand the client and in turn be understood.
• Technical Skills

  • are “hands-on” skill such as manipulating equipment, giving injections and bandaging, moving, lifting, and repositioning clients
  • Also called tasks, procedures, or psychomotor skills.
  • Required knowledge and frequently manual dexterity.