4 types of nursing diagnoses
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Actual-problem based diagnosis
health promotion- relates to clients preparedness
risk- clinical judgement that a problem does not exist but the presence of
risk factors indicates problem is likely to develop
syndrome- clinical nursing judgement when client has several nursing
diagnosis
Narrative charting
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, written notes that include routine care, normal findings, and client
problems
Types of Statements
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- facts
- inferences ( conclusions drawn from facts)
- judgments
- opinions
documentation formats
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a) Flow Charts - record and show trends in vital signs, blood glucose levels,
pain level and other frequently performed assessments
b) Narrative Documentation - records information as a sequence of events
c) Charting by exception (CBE) - standardized forms that identify normal
findings/values and allows selective documentation of abnormal findings.
d) Problem oriented medical records (POMR) - consists of database,
problem list, care plan, and progress notes.( ex. SOAP, PIE, DAR)
Nursing Process phases (5)
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, A - Assessment/Data Collection
Initial phase where data is gathered, the client interview takes place,
confidentiality of the client is maintained, and data is organized.
D - Diagnosis/ problem
Client problems identified and prioritized as a result of the disease process,
which can be addressed with nursing practice.
P - Planning/outcomes
Identifying client long and short-term goals, goal agreement between
client and nurse, and formulating goals using three domains.
I - Implementation
Nursing mediation is carried out, including activities such as managing pain,
educating, and monitoring.
E - Evaluation
Final phase of the process where progress to goals and outcomes is
examined, and any need for a change in the plan is indicated.
deductive reasoning
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reasoning in which a conclusion is reached by stating a general principle
and then applying that principle to a specific case (The sun rises every
morning; therefore, the sun will rise on Tuesday morning.)
SMART goals
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Specific, Measurable, Attainable, Realistic, Timely
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Actual-problem based diagnosis
health promotion- relates to clients preparedness
risk- clinical judgement that a problem does not exist but the presence of
risk factors indicates problem is likely to develop
syndrome- clinical nursing judgement when client has several nursing
diagnosis
Narrative charting
Give this one a try later!
, written notes that include routine care, normal findings, and client
problems
Types of Statements
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- facts
- inferences ( conclusions drawn from facts)
- judgments
- opinions
documentation formats
Give this one a try later!
a) Flow Charts - record and show trends in vital signs, blood glucose levels,
pain level and other frequently performed assessments
b) Narrative Documentation - records information as a sequence of events
c) Charting by exception (CBE) - standardized forms that identify normal
findings/values and allows selective documentation of abnormal findings.
d) Problem oriented medical records (POMR) - consists of database,
problem list, care plan, and progress notes.( ex. SOAP, PIE, DAR)
Nursing Process phases (5)
Give this one a try later!
, A - Assessment/Data Collection
Initial phase where data is gathered, the client interview takes place,
confidentiality of the client is maintained, and data is organized.
D - Diagnosis/ problem
Client problems identified and prioritized as a result of the disease process,
which can be addressed with nursing practice.
P - Planning/outcomes
Identifying client long and short-term goals, goal agreement between
client and nurse, and formulating goals using three domains.
I - Implementation
Nursing mediation is carried out, including activities such as managing pain,
educating, and monitoring.
E - Evaluation
Final phase of the process where progress to goals and outcomes is
examined, and any need for a change in the plan is indicated.
deductive reasoning
Give this one a try later!
reasoning in which a conclusion is reached by stating a general principle
and then applying that principle to a specific case (The sun rises every
morning; therefore, the sun will rise on Tuesday morning.)
SMART goals
Give this one a try later!
Specific, Measurable, Attainable, Realistic, Timely
