Nursing Assessment
Assessment, Diagnosis, Plan, Implementation, Evaluation
What are the steps of the nursing process?
North American Nursing Diagnosis Association International.
What is NANDA?
Setting priorities, creating goals and expected outcomes that are patient-centered, and implementing nursing interventions that are patient specific.
What is planning in the nursing process?
Implementation.
What is the fourth step of the nursing process?
The final step of the nursing process, which determines if the application of the process has been effective and demonstrated improvement in the clients' condition.
What is evaluation?
Collect data from the client and interpret the data to ensure the client database is complete.
What is assessment?
"Actual" , "Risk For", and "Health Promotion"
What are three types of nursing diagnoses?
Are a measurable criteria created to evaluate whether goals are met.
What are expected outcomes?
Treatment that the nurse implements based on the assessment findings.
What is a nursing intervention?
Evaluation of the goals and outcomes to judge a clients' response to care.
What is criterion based evaluation?
The professional nurse offers care without incorporating their own values and beliefs and respects the values of the client. The nurse asks appropriate questions about the patient's culture
What is cultural considerations in assessment?
NANDA approved nursing diagnosis, etiology or related factors, symptoms or defining characteristics.
What are the components of a nursing diagnosis?
Measured over a period of several days weeks or months
What is a long term goal?
Created to assist health care professionals to make appropriate health care decisions regarding specific clinical situations
What are clinical practice guidelines?
Each time a client is assessed a determination must be made regarding the validity of the care plan.
What is care plan revision?
Physical and developmental; emotional; social; spiritual; and intellectual factors, as well as previous hospitalizations, immunizations, and previous surgery
What are elements that should be included in a health history?
Observable and measurable facts, referred to as a sign of disorder
What is a objective data?
1. Patient-centered 2. Singular goal or outcome. 3. Observable. 4. Measurable. 5. Time-limited. 6. Mutual factors. 7. Realistic.
What are the seven guidelines for writing goals and outcomes?
Holds nurses accountable for demonstrating all steps in the nursing process.
What is the purpose of the nurse practice act?
This is done after a determination that the goals and outcomes have been met.
When is a care plan discontinued?
A visual representation of a clients' health problems.
What is Concept mapping?
A tool that diagrams the critical thinking associated with making accurate nursing diagnoses.
What is a concept map?
Part of the planning process. Must be safe;within legal scope of nursing practice and compatible with medical orders
What are planned nursing interventions?
Activities performed throughout the course of patient care including ADLs, counseling, and teaching, life saving measures, preventative measures, physical care (medications, treatments, procedures).
What is direct care?
Reassessment, redefining diagnoses, goals and expected outcomes, and interventions.
What elements are included in modifying a care plan?