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45 Cards in this Set

  • Front
  • Back
Nursing Process
a systematic rational method of plannong and providing nursing care
collecting data, organizing data, validating data, documenting data. 1st step
analyze data, identify health problems risks and strengths, formulate diagnostic statements. step 2
prioritize problems and diagnosis, formulate goals/desired outcomes, select nursing interventions, write nursing orders, step 3
reassess the client, determine the nurses need for assistance, implement nsg interventions, supervise delegated care, document nsg activities. step 4
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
classification system or set of catagories arranged on the basis of a single principle or set of principles.
diagnostic labels
standardized nanda names for the Dx
nursing diagnosis
clients problem statement, consisting of diagnostic label plus etiology
actual diagnosis
client problem that is present at the time of the nursing assessment (ineffective breathing pattern or anxiety)
risk nursing diagnosis
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)
wellness diagnosis
describes human responses to levels of wellness in an indiviual, family or community that have a readiness for enhancement. (Readiness for enhanced family coping)
possible nursing diagnosis
one in which evidence about a health problem is incomplete or unclear. (Possible Social Isolation)
Syndrome diagnosis
a dianosis associated to a cluster of other diagnoses. (Risk for Constipation)
3 components of nursing diagnosis
problem and definition, etiology, defining characteristics.
words that have been added to some Nanda labels to give additional meaning to dianostic label(deficient, impaired, decreased, ineffective, compromised)
inadequate in amount quality or degree, not sufficient, incomplete
made worse, weakened, damaged, reduced, deteriorated
lesser in size, amount or degree
not prodicing the desired effect
to make vulnerable to threat
etiology component of nsg dx
identifies one or more probable causes of the health problem gives direction to required nsg therapy, and enables nse to individualize nsg care.
Defining chacteristics
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.
basic 2 part dx statements
PROBLEM (statement of clients response- Nanda label) and Etiology (factors contributing to or probable causes of the responses. parts are connected with related to
basic 3 part statements
PROBLEM r/t ETIOLOGY as manifested by S/S (defining characteristics manifested by the client
One part statements
wellness dx and syndrome dx. Rape-Trauma Syndrome
Subjective data
symptoms or covert data, apparentonly to the personand can be described or verified only by the person
Objective data
signs or overt data, detectable by an observeror can be measured or tested against an acceptible standard
primary source of data
secondary or indirect sources
family members other support persons, other health professionals, records and reports, labs and diagnostic testing, and relevant literature
gather data by using senses
planned communicationor a conversation with a purpose
cephalocaudal or head to toe
starts at head pregresses to neck, thorax, abd and extremities and ends at toes
screening exam or review of systems
brief review of essential functioning of various body parts or systems
double checking data or verifying that it is true and accurate
nursing intervention
any treatment based upon clinical judgementand knowledge that a nurse performs to enhance patient/client outcomes
informal nursing care plan
strategy of action that exists in the nurses mind
formal nursing care plan
written or computerized guide that organizes info about the clients care
standardized care plan
formal plan that specifies the nursing care for groups of clients with common needs
Individualized care plan
tailored to the individual needs of the client- when standarized does not meet the needs
standards of care
desribe nsg actions for clients with similar medical conditions rather than individuals and they describe achievable rather than ideal nursing care
preprinted to indicate actions commonly required for a particular group of clients
policis and procedures
developed to govern the handling of frequently occurring situations
standing order
written document about policies, rules, or orders regarding client care
multidisciplinary care plan, collaborative care plan or critical pathways
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