NU205 Exam Two

Identify response to actual or potential health process
Factors that contribute to or cause health problems
Resources and strengths
Describe problems nurses can treat independently

1973 ANA Standards of Practice included diagnosing as a function of nursing

Approved a definition of nursing diagnosis - clinical judgement about responses to actual or potential health problems. Provide the basis for selection of nursing interventions to achieve outcomes for which the nurse accountable.

Identify problem
Identify risk factors/related factors
Predicting problems
Identifying resources & strengths

Give a clear identification of nursing process
Greater accountability
Establishes nursing as a profession and discipline

Currently 206
47 classes
13 domains

A potential diagnosis is submitted to Diagnosis Review Committee (DRC) of NANDA

Recognize Significant Data
Clustering Data/Tentative Diagnosis
Identify Strengths and Problems
Reaching Conclusions

compare patient assessment data to standards or generally accepted rules, models, patterns or measures

i.e. lab values, normal patterns, vital signs, growth & development

Points to a change in health status
Varies from standards of patient pop
Indication of a developmental delay

Determine relatedness of assessment data and find patterns

Cluster the data

Looking at the pieces of a jigsaw puzzle and attempt to describe the whole

Look at the whole puzzle from the cover and putt the pieces together

Make inferences about patient assessment data
Interpret meaning of cues
Tentative nursing diagnosis

Ability to cope
patient agreement with identification of strengths and problems
patients motivation

No problem
possible health problem
potential health problem
actual health problem

no nursing response indicated
reinforce healthy habits
initiate health promotion
Wellness diagnosis

suspected problem and additional data is needed to confirm/rule out

clarify gaps and inconsistencies

Missing info needed to determine data pattern

Data indicates conflicting info - patient says one thing, you see another

Risk diagnosis indicated
Something may lead to a problem - patient is AT RISK

Determine type of health problem:
nursing diagnosis
medical diagnosis
collaborative problem

begin planning, implementing and evaluating care

Consult with appropriate healthcare professionals

Several problems present

Group of nursing diagnoses usually seen together

Wellness
Possible
High Risk/Potential
Actual

Diagnostic Label

Describes patients health problem or response for which therapy is given

Suggests outcomes for resolution or prevention of a problem

Altered, impaired, decreased, ineffective, acute, chronic

Related factors or risk factors

Factors causing or contributing to an actual health problem

for actual health problems and actual nursing diagnoses

i.e. generalized weakness, sedentary lifestyle

For potential health problems and risk/potential nursing diagnoses

i.e. altered circulation, physical immobility

Defining Characteristics

Cluster of S&S that indicate the presence of a problem statement

For ACTUAL nursing diagnoses statements

Signs & symptoms are actually present

NOT present in high risk ND

Suggest evaluative criteria to determine: if actual health problem is resolving

Problem Statement
Etiology
Signs and Symptoms

Used in ALL types of ND

Combined with E and S

Just problem statement b/c the statement is refined to a very specific point

Nursing interventions can be derived from the problems statement

i.e. knowledge deficit (medications)

used for actual, high risk or possible ND

Joined by r/t

Used for ACTUAL ND as patient exhibits S&S

NOT used in high risk/potential ND

Use r/t and AMB or AEB

Promote accountability & autonomy

Effective communication tool

Facilitate individualized care

Premature diagnoses from incomplete data

Erroneous diagnoses from inaccurate data

Routine diagnoses from failure to tailor

Errors of omission

Systematic and continuous collection, validation and communication of patient data

Nursing Assistive Personnel (NAP)

i.e. vital signs, height and weight

Assign tasks
Validate data collected
Conduct interval
Physical assessment

State nurse practice act

RN's do comprehensive assessment
LPN/LVN can do focused assessments

Comprehensive (initial, admission)
Ongoing (focused, emergency, time-lapsed)
Special needs (nutritional, pain, cultural)

First assessment

not everyone admitted to hospital

when admitting to hospital

Shortly after admittance
Establishes a complete database
Data from all aspects
Establishes priorities
Creates references for comparison

During initial assessment or as routine data collection
Data about a specific problem already identified or to identify new

When a physiologic or psychological crisis presents

Identify life threatening problems

Compare current status to baseline data

(i.e. in home health, long term care)

To make necessary revisions in plan of care

Observation
Physical Assessment
The Nursing Interview

Health orientation
Developmental stage
Need for nursing
Practical consideratiosn

Complete
Factual and Accurate
Relevant
No using perceptions

Prep phase
Introduction phase
Working phase
Termination phase

Focus on identification of pathology and cause in the patient

Concerned with type of damage and cause

Focus on functional abilities of the patient

how does it affect the patients activities of daily living

Appraisal of health status

Identification of health problems

Establishment of database of interventions

inappropriate organization of data
omission of pertinent data
irrelevant or duplicate data
erroneous or misinterpreted data
failure to update db

Differentiate between cues and inferences

Data that is identified by the nurse

What you observe and see
What the client says

Skin has a bluish hue

Judgments or interpretations of cues

patient might be hypoxic

perform physical examination

clarifying statements

sharing inferences with other team members

whenever assessment findings reveal a critical change in patients health status

use ink, record timely, use good grammar and use standard medical abbreviations

Use patients own words

Put in quotes

Use specific, measurable terms

1973 ANA developed standard of practice for nursing process (6 steps)

Joint Commission on Accreditation of Healthcare Organizations requires documentation of care according to nursing process

Authoritative Statement

Make us accountable

Competent level of care

Promote health (education)
Prevent disease/illness
Restore health (rehab)
Facilitate coping with altered functioning (rehab)

Assessing
Diagnosing
Planning Outcomes
Implementing
Evaluating

Systematic
Dynamic
Interpersonal
Outcome Oriented
Universally applicable

Combo of:
Reasoned thinking
openness to alternatives
ability to reflect

Nurses apply knowledge to provide holistic care
Nursing is an applied discipline
Uses knowledge from other fields
Fast paced

Theoretical
Practical
Self
Ethical

Thinking (Theoretical knowledge)
Doing (Critical thinking)
Caring (self knowledge)
Patient situation (patient data)

Individualize care to max outcome ach
facilitate communication
evaluate patient response
create a record for evaluate, research
set priorities

Initial
Ongoing
Discharge

First person in contact with patient
addresses each problem identified in ND
Identifies patient goals, outcomes and nursing care

Carried out by any nurse who interacts with patient
Keeps plan up to date
Develop new diagnoses
Makes outcomes more realistic
Develops new outcomes
Identify interventions

Nurse who worked most with patient
Begins at admission
Plans for needs after discharge

establish patient outcomes
determine nursing interventions

Potential problems that nurses manage using both independent and physician-prescribed interventions

Greatest threat to patient well-being

i.e. ineffective airway clearance
ineffective breathing pattern, decreased cardiac output

Less threatening diagnoses

i.e. impaired skin integrity
Diarrhea
Constipation

Not life threatening or not specifically related to CHP

i.e. self care deficit: dressing/grooming

For every nursing diagnosis the nurse must write ONE expected outcome (a goal) that DIRECTLY demonstrates resolution of the problem statement

The opposite, healthy response of the problem statement (diagnostic label) of the ND

Patients may require HC for a short time
Patients may be frustrated by long term goals
Patients need the satisfaction of achieving goals

Specific, measurable statements about the desired outcome or change in a patients behavior

Evaluate whether a goal has been met

In terms of PATIENT behavior, not in terms of NURSING interventions

Expressing as nursing intervention
Using verbs not observable or measurable
Including more than one behavior in ST goals

Subject (patient or part of patient)
Verb (action words)
Conditions (circumstances such as WITH WALKER)
Perf Criteria (expected patient behavior)
Target time

Any treatment based on CJ that a nurse performs to enhance patient outcomes
Establishes the nursing activities
Carried out to achieve patient goals/EOutcomes

NI focus on reducing or eliminating the etiology of the problem statement

Nurse initiated
Physician initiated
Collaborative

Actions performed independently w/o a physicians order

Actions initiated by a physician in response to a med diagnosis, but carried out by a nurse

Monitor health status
Reduce risks
Resolve, prevent or manage problems
Facilitate independence
Assist with ADLs
Promote well-being

Date
Action Verb
Subject (who or what)
Descriptive Phrase (how, when, where, how often, how long, how much)
Signature

Care plan written by a RN that delineates necessary nursing care for an individual patient

Known and researched

Certain things you need to do for every similar patient

Cardboard sheet of paper
Snapshot of patient

Mind mapping technique to show interrelationships

Date and sign the NCP
Use key words
No complete sentences

Failure to involve patient
Developed from inaccurate or insufficient data
Outcomes too broad
Outcomes from poor ND
Failure to update NCP

Prioritize ND
Develop goal statements/expected outcomes
Select nursing interventions
Communicate plan of care