NURS608 Exam 3 Blueprint
1.Assessment: collecting, validating, and communicating patient data
2.Diagnosis: analyzing patient data to identify patient strengths and problems
Steps of Nursing Process 3.Plan: specifying patient outcomes and related nursing interventions
4.Implement: carrying out the care plan
5.Evaluate: measuring extent to which patient achieved outcomes
Problem (Diagnostic Label) + Etiology (Cause or Related Factors) + Signs/Symptoms
Writing a Problem-Focused Nursing (Defining Characteristics)
Diagnosis [Diagnostic Label] + “related to” + [Etiology] + “as evidenced by” + [Defining
Characteristics]
Risk (Diagnostic Label) + Risk Factors
Writing a Risk-Focused Nursing Diagnosis
[Diagnostic Label] + "as evidenced by" + [Risk Factors]
Writing a Health Promotion-Based Nursing Health Promotion (Diagnostic Label) + Signs & Symptoms (Defining Characteristics)
Diagnosis [Diagnostic Label] + "as evidenced by" + [Defining Characteristics]
Syndrome (Diagnostic Label) + 2 or more supporting Nursing Diagnoses
Writing a Syndrome Nursing Diagnosis
[Diagnostic Label] + "as evidenced by" + [Nursing Diagnosis] + [Nursing Diagnosis]
Diagnosis
Related Factors
Defining Characteristics
Components of a Nursing Diagnosis
Risk Factors
At-Risk Populations
Associated Conditions
• Systematic: part of an ordered sequence of activities
• Dynamic: great interaction and overlapping among the five steps
Characteristics of the Nursing Process • Interpersonal: human being is always at the heart of nursing
• Outcome oriented: nurses and patients work together to identify outcomes
• Universally applicable: a framework for all nursing activities
, An RN uses a systematic, dynamic way to collect and analyze data about a client,
the first step in delivering nursing care. Assessment includes not only physiological
data, but also psychological, sociocultural, spiritual, economic, and life-style
Nursing Process: Assessment factors as well. For example, a nurse's assessment of a hospitalized patient in pain
includes not only the physical causes and manifestations of pain, but the patient's
response—an inability to get out of bed, refusal to eat, withdrawal from family
members, anger directed at hospital staff, fear, or request for more pain
mediation.
The nursing diagnosis is the nurse's clinical judgment about the client's response to
actual or potential health conditions or needs. The diagnosis reflects not only that
the patient is in pain, but that the pain has caused other problems such as anxiety,
Nursing Process: Diagnosis
poor nutrition, and conflict within the family, or has the potential to cause
complications— for example, respiratory infection is a potential hazard to an
immobilized patient. The diagnosis is the basis for the nurse's care plan.
Based on the assessment and diagnosis, the nurse sets measurable and
achievable short- and long-range goals for this patient that might include moving
from bed to chair at least three times per day; maintaining adequate nutrition by
Nursing Process: Outcomes/Planning eating smaller, more frequent meals; resolving conflict through counseling, or
managing pain through adequate medication. Assessment data, diagnosis, and
goals are written in the patient's care plan so that nurses as well as other health
professionals caring for the patient have access to it.
Nursing care is implemented according to the care plan, so continuity of care for the
Nursing Process: Implementation patient during hospitalization and in preparation for discharge needs to be assured.
Care is documented in the patient's record.
Both the patient's status and the effectiveness of the nursing care must be
Nursing Process: Evaluation
continuously evaluated, and the care plan modified as needed.
• Medical assessments target data pointing to pathologic conditions
Medical vs. Nursing Assessments
• Nursing assessments focus on the patient’s response to health problems
Observable and measurable data that can be seen, heard, or felt by someone
other than the person experiencing them
Subjective Data
- Example: elevated temperature, skin moisture, vomiting, auscultating heart or lung
sounds
Information perceived only by the affected person
Objective Data
- Example: pain experience, feeling dizzy, feeling anxious
• Purposeful
• Prioritized
• Complete
Characteristics of Data
• Systematic
• Factual and accurate
• Relevant
• Bias
• Failure to consider the total situation
• Impatience
• Inappropriate organization of the database
Potential Errors in Decision Making and
• Omission of pertinent data
Data Collection
• Inclusion of irrelevant or duplicate data
• Failure to establish rapport and partnership
• Recording an interpretation of data rather than observed behavior
• Failure to update the database
• High priority: greatest threat to patient well-being
Priority Nursing Diagnosis • Medium priority: nonthreatening diagnoses
• Low priority: diagnoses not specifically related to current health problem
1.Assessment: collecting, validating, and communicating patient data
2.Diagnosis: analyzing patient data to identify patient strengths and problems
Steps of Nursing Process 3.Plan: specifying patient outcomes and related nursing interventions
4.Implement: carrying out the care plan
5.Evaluate: measuring extent to which patient achieved outcomes
Problem (Diagnostic Label) + Etiology (Cause or Related Factors) + Signs/Symptoms
Writing a Problem-Focused Nursing (Defining Characteristics)
Diagnosis [Diagnostic Label] + “related to” + [Etiology] + “as evidenced by” + [Defining
Characteristics]
Risk (Diagnostic Label) + Risk Factors
Writing a Risk-Focused Nursing Diagnosis
[Diagnostic Label] + "as evidenced by" + [Risk Factors]
Writing a Health Promotion-Based Nursing Health Promotion (Diagnostic Label) + Signs & Symptoms (Defining Characteristics)
Diagnosis [Diagnostic Label] + "as evidenced by" + [Defining Characteristics]
Syndrome (Diagnostic Label) + 2 or more supporting Nursing Diagnoses
Writing a Syndrome Nursing Diagnosis
[Diagnostic Label] + "as evidenced by" + [Nursing Diagnosis] + [Nursing Diagnosis]
Diagnosis
Related Factors
Defining Characteristics
Components of a Nursing Diagnosis
Risk Factors
At-Risk Populations
Associated Conditions
• Systematic: part of an ordered sequence of activities
• Dynamic: great interaction and overlapping among the five steps
Characteristics of the Nursing Process • Interpersonal: human being is always at the heart of nursing
• Outcome oriented: nurses and patients work together to identify outcomes
• Universally applicable: a framework for all nursing activities
, An RN uses a systematic, dynamic way to collect and analyze data about a client,
the first step in delivering nursing care. Assessment includes not only physiological
data, but also psychological, sociocultural, spiritual, economic, and life-style
Nursing Process: Assessment factors as well. For example, a nurse's assessment of a hospitalized patient in pain
includes not only the physical causes and manifestations of pain, but the patient's
response—an inability to get out of bed, refusal to eat, withdrawal from family
members, anger directed at hospital staff, fear, or request for more pain
mediation.
The nursing diagnosis is the nurse's clinical judgment about the client's response to
actual or potential health conditions or needs. The diagnosis reflects not only that
the patient is in pain, but that the pain has caused other problems such as anxiety,
Nursing Process: Diagnosis
poor nutrition, and conflict within the family, or has the potential to cause
complications— for example, respiratory infection is a potential hazard to an
immobilized patient. The diagnosis is the basis for the nurse's care plan.
Based on the assessment and diagnosis, the nurse sets measurable and
achievable short- and long-range goals for this patient that might include moving
from bed to chair at least three times per day; maintaining adequate nutrition by
Nursing Process: Outcomes/Planning eating smaller, more frequent meals; resolving conflict through counseling, or
managing pain through adequate medication. Assessment data, diagnosis, and
goals are written in the patient's care plan so that nurses as well as other health
professionals caring for the patient have access to it.
Nursing care is implemented according to the care plan, so continuity of care for the
Nursing Process: Implementation patient during hospitalization and in preparation for discharge needs to be assured.
Care is documented in the patient's record.
Both the patient's status and the effectiveness of the nursing care must be
Nursing Process: Evaluation
continuously evaluated, and the care plan modified as needed.
• Medical assessments target data pointing to pathologic conditions
Medical vs. Nursing Assessments
• Nursing assessments focus on the patient’s response to health problems
Observable and measurable data that can be seen, heard, or felt by someone
other than the person experiencing them
Subjective Data
- Example: elevated temperature, skin moisture, vomiting, auscultating heart or lung
sounds
Information perceived only by the affected person
Objective Data
- Example: pain experience, feeling dizzy, feeling anxious
• Purposeful
• Prioritized
• Complete
Characteristics of Data
• Systematic
• Factual and accurate
• Relevant
• Bias
• Failure to consider the total situation
• Impatience
• Inappropriate organization of the database
Potential Errors in Decision Making and
• Omission of pertinent data
Data Collection
• Inclusion of irrelevant or duplicate data
• Failure to establish rapport and partnership
• Recording an interpretation of data rather than observed behavior
• Failure to update the database
• High priority: greatest threat to patient well-being
Priority Nursing Diagnosis • Medium priority: nonthreatening diagnoses
• Low priority: diagnoses not specifically related to current health problem
