Topics For Nc1 Excelsior Final

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Nursing Process

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a systematic rational method of plannong and providing nursing care

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assessing

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collecting data, organizing data, validating data, documenting data. 1st step

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diagnosing

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analyze data, identify health problems risks and strengths, formulate diagnostic statements. step 2

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planning

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prioritize problems and diagnosis, formulate goals/desired outcomes, select nursing interventions, write nursing orders, step 3

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implementing

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reassess the client, determine the nurses need for assistance, implement nsg interventions, supervise delegated care, document nsg activities. step 4

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evaluating

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collect data related to outcomes, compare data with outcomes, relate nsg actions to client goals/outcomes, draw conclusions about problem status, continue modify or terminate the client's care plan

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taxonomy

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classification system or set of catagories arranged on the basis of a single principle or set of principles.

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diagnostic labels

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standardized nanda names for the Dx

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nursing diagnosis

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clients problem statement, consisting of diagnostic label plus etiology

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actual diagnosis

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client problem that is present at the time of the nursing assessment (ineffective breathing pattern or anxiety)

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risk nursing diagnosis

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clinical judgement that a problem does not exist but the presence of risk factors indicates that a problem is likely to develope unless nurses intervene. (risk for infection)

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wellness diagnosis

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describes human responses to levels of wellness in an indiviual, family or community that have a readiness for enhancement. (Readiness for enhanced family coping)

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possible nursing diagnosis

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one in which evidence about a health problem is incomplete or unclear. (Possible Social Isolation)

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Syndrome diagnosis

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a dianosis associated to a cluster of other diagnoses. (Risk for Constipation)

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3 components of nursing diagnosis

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problem and definition, etiology, defining characteristics.

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Qualifiers

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words that have been added to some Nanda labels to give additional meaning to dianostic label(deficient, impaired, decreased, ineffective, compromised)

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Deficient

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inadequate in amount quality or degree, not sufficient, incomplete

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impaired

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made worse, weakened, damaged, reduced, deteriorated

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decreased

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lesser in size, amount or degree

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ineffective

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not prodicing the desired effect

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compromised

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to make vulnerable to threat

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etiology component of nsg dx

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identifies one or more probable causes of the health problem gives direction to required nsg therapy, and enables nse to individualize nsg care.

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Defining chacteristics

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cluster of s/s that indicate the presence of a particular diagnostic label. for actual nsg dx, is the clients s/s. for risk dx, no sub or obj data is present.

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basic 2 part dx statements

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PROBLEM (statement of clients response- Nanda label) and Etiology (factors contributing to or probable causes of the responses. parts are connected with related to

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basic 3 part statements

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PROBLEM r/t ETIOLOGY as manifested by S/S (defining characteristics manifested by the client

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One part statements

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wellness dx and syndrome dx. Rape-Trauma Syndrome

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Subjective data

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symptoms or covert data, apparentonly to the personand can be described or verified only by the person

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Objective data

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signs or overt data, detectable by an observeror can be measured or tested against an acceptible standard

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client

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primary source of data

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secondary or indirect sources

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family members other support persons, other health professionals, records and reports, labs and diagnostic testing, and relevant literature

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observing

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gather data by using senses

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interviewing

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planned communicationor a conversation with a purpose

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cephalocaudal or head to toe

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starts at head pregresses to neck, thorax, abd and extremities and ends at toes

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screening exam or review of systems

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brief review of essential functioning of various body parts or systems

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validation

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double checking data or verifying that it is true and accurate

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nursing intervention

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any treatment based upon clinical judgementand knowledge that a nurse performs to enhance patient/client outcomes

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informal nursing care plan

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strategy of action that exists in the nurses mind

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formal nursing care plan

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written or computerized guide that organizes info about the clients care

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standardized care plan

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formal plan that specifies the nursing care for groups of clients with common needs

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Individualized care plan

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tailored to the individual needs of the client- when standarized does not meet the needs

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standards of care

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desribe nsg actions for clients with similar medical conditions rather than individuals and they describe achievable rather than ideal nursing care

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protocols

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preprinted to indicate actions commonly required for a particular group of clients

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policis and procedures

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developed to govern the handling of frequently occurring situations

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standing order

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written document about policies, rules, or orders regarding client care

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multidisciplinary care plan, collaborative care plan or critical pathways

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standardized plan that outlines the care required for clients with common, predictable usually medical conditions. sequence the care that must be given on each day during the projected length of stay for the specific type of condition