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14 Cards in this Set

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  • Back
Nursing Process - Planning
First step in developing a nursing diagnosis
Purpose
To develop a holistic individualized plan of care that is acceptable to the client and nurse and which results in the prevention, resolution, or reduction of the problem
Benefits
Individualizes client care
identifies priorities
promotes continuity of care
improves communication among health team members
facilitates evaluation of client's response to care
promotes professional development of staff
Characteristics
Prioritizing Nursing Diagnosis
rank in order of importance
gives direction to planning and implementation - tells the nurse what to do first
Nursing Dx. Which endanger the client's life, safety, or comfort are ranked as top priorities
order must also consider the client's perception of the problem
Method
Use Maslow's hierarchy of needs
Prioritize the following Nsg. Dx.
High risk for ineffective individual coping r/t unknown medical dx. (#3)
Diarrhea r/t unknown cause a.e.b. greater than 3 loose stools per day for 3 weeks. (#1)
High risk for altered nutrition: less than body requirements r/t chronic diarrhea for 3 weeks (#2)
Selection of Data
Examine the area on the assessment tool that is directly related to the problem.
Examine other related areas - this may include reviewing the entire assessment tool
ex: Self care deficit - data will be found under hygiene/skin integrity, but it also may be found under safety and mobility
Client Outcomes
A statement describing a specific behavior or response which the nurse expects the client to demonstrate as a result of the nursing interventions
Contains 3 components
-subject
-behavior (has to be measurable)
-criterion
Subject
Noun in the statement
Can be the
-client
-client's significant other
-physiological function of the client or anatomical part of the client's body
Behavior
Cognitive Objective or Outcome
-specifies the subject's understanding/knowledge of the health problem
ex: The client will list the signs and symptoms of hypoglycemia (add time frame)
ex: The client will explain the relationship between activity and breathlessness (add time frame)
Affective Objective or Outcome
-specifies the subject's acceptance of his health problem by incorporating health promotion practices into his lifestyle
ex: The client will adhere to a 1800 calorie ADA diet every day for the rest of his life
Physiological Objective or Outcome
-specifies the status of the subject's physiological function or a condition of a part of the client's body.
ex: Client's lung fields will remain clear during hospitalization
Psychomotor Objective or Outcome
-specifies the skill or task the subject is to perform
ex: Client will administer her insulin injection using sterile technique by (date)
Criterion
The condition under which acceptable behavior is to be performed.
-What must be done to achieve the outcome.
Answers the questions:
-how much?
-How often?
-With what assistance?
-When?
-Under what condition?
ex: The client will walk 10 feet, 4x/day.