FUNDA SEMI

• Nursing process


  1. Assessing

  2. Nursing Diagnosis

  3. Planning

  4. Implementing

  5. Evaluating
• Validating Data


  • Cues - The subjective or objective data that can be directly observed by the nurse
  • Inferences - The nurse's interpretation or conclusions made based on the cues
• Documenting Data


  To complete the assessment phase, the nurse records client data. Accurate documentation is essential and should include all data collected about the client's health status. Data are recorded in a factual manner and not interpreted by a nurse.

  
• Nursing Diagnosis


  1. Analyze data

  2. Identify health, problems, risk, and strength

  3. Formulate diagnostic statements
• Diagnosing


  Refers to the reasoning process
• Diagnosis


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


  The standardized NANDA (North American Nursing Diagnosis Association) name for diagnosis. The client's problem statement consists of the diagnostic label plus etiology.
• Types of Nursing Diagnosis

  • Actual Diagnosis
  • Risk Nursing Diagnosis
  • Wellness Diagnosis
  • Possible Nursing Diagnosis
  • Syndrome Diagnosis
• Actual Diagnosis


  A client problem that is present at the time of the nursing assessment
• Risk Nursing Diagnosis


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


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


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


  A diagnosis that is associated with a cluster of other diagnosis
• Components of a NANDA Nursing Diagnosis

  • Problem (Diagnostic Label) and Definition
  • Etiology
  • Defining characteristics
• Qualifiers


  Words that have been added to some NANDA label to give additional meaning to the diagnostic statement
• Qualifiers


  • Deficient
  • Impaired
  • Decreased
  • Ineffective
  • Compromise
• Differences between Nursing Diagnosis and Medical Diagnosis

  • Formulating Diagnostic Statement
  • Classification of Nursing Diagnosis
• Formulating Diagnostic Statement


  1. Basic two-part Statements

  2. Basic three-part Statement

  3. One-part Statement
• Classification of Nursing Diagnosis

  • High-priority-life threatening and requires immediate attention
  • Medium-priority-resulting to unhealthy consequences
  • Low-priority-can be resolve with minimal interventions
• Guidelines for Writing a Nursing Diagnostic Statement

  • State in terms of problem, not need
  • Word the statement so that it's equally advisable
  • Use nonjudgmental statements
  • Make sure that both elements of the statement does not say the same thing
  • Be sure that cause and effect are correctly stated
  • Word the diagnosis specifically and precisely to provide direction for planning nursing interventions
  • Using nursing terminology rather than medical terminology to describe the client's response
  • Use nursing terminology rather than medical terminology to describe the probable cause of the client's response
• Planning


  1. Prioritize problem/diagnosis

  2. Formulate goals/desired outcomes

  3. Select nursing interventions

  4. Write nursing orders
• Nursing Interventions


  Any treatment, based upon clinical judgement and knowledge, that a nurse performs to enhance patient/client outcomes
• Types of Planning


  • Initial Planning
  • Ongoing Planning
  • Discharge Planning
• Initial Planning


  The nurse who performs the admission assessment usually develops the initial comprehensive plan of care
• Ongoing Planning


  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.
• Discharge Planning


  The process of anticipating and planning for needs after discharge
• Developing Discharge Plan


  • Informal Nursing Care Plan
  • Formal Nursing Care Plan
  • Standardize Care Plan
  • Individualized Care Plan
• Informal Nursing Care Plan


  A strategy for action that exists in the nurse's mind
• Formal Nursing Care Plan


  A written or computerized guide that organizes information about the client's care and provides continuity of care
• Standardize Care Plan


  A formal plan that specifies the nursing care for groups of clients with common needs
• Individualized Care Plan


  Tailored to meet the unique needs of the specific client
• Guidelines for Writing Nursing Care Plan

  • Date and sign the plan
  • Use category headings
  • Use standardized or approved medical or English symbols and keywords rather than complete sentences or communicate your ideas
  • Be specific
  • Refer to procedure books or other sources of information rather than including all the steps on a written plan
  • Tailor the plan to the unique characteristics of the client by ensuring that the client's choices are included
  • Ensure that the nursing plan incorporates preventive and health maintenance aspects as well as restorative ones
  • Ensure that the plan contains interventions for ongoing assessment
• Guidelines for Writing Nursing Care Plan

  • Date and sign the plan
  • Use category headings
  • Use standardized or approved medical or English symbols and keywords rather than complete sentences or communicate your ideas
  • Be specific
  • Refer to procedure books or other sources of information rather than including all the steps on a written plan
  • Tailor the plan to the unique characteristics of the client by ensuring that the client's choices are included
  • Ensure that the nursing plan incorporates preventive and health maintenance aspects as well as restorative ones
  • Ensure that the plan contains interventions for ongoing assessment of the client
  • Include collaborative and coordination activities in the plan
  • Include plans for the client's discharge and home care needs
• The Planning Process


  1. Setting Priorities

  2. Establishing client goals/desired outcomes

  3. Selecting nursing interventions and activities

  4. Writing nursing orders
• Setting Priorities


  The process of establishing a preferential sequence for addressing nursing diagnoses and interventions
• Grouping of nursing diagnoses

  • Life-threatening problems (loss of respiratory and cardiac functions)
  • Health-threatening problems (acute illness and decreased coping ability)
  • Low-priority problems (arise from normal developmental needs)
• 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

  • Specific
  • Measurable
  • Attainable
  • Realistic
  • Time-framed
• Short-term goal


  Useful for clients who require health care for a short period
• Long-term goal


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