Exam 3 - NURS 208
what are the components of nursing assess, diagnose, plan, implement, eval-
process uate
nursing care plan, medical plan of care,
what are the five types of plans of care rehabilitation plan of care, palliative plan
of care, and psychiatric plan of care
based on physiological symptoms and
medical plan of care
disease processes
is a clients response to a real or potential
nursing plan of care
illness (the patient's response)
identification of a disease condition
based on specific evaluation of physical
medical diagnosis
signs, symptoms, history tests, and pro-
cedures
is a statement of a patient's response to
nursing diagnosis an actual or potential health problem that
the nurse is licensed and competent
it includes collecting, organizing, validat-
what is the assessment process
ing, and documenting data
- establish a baseline
- establish a database about a client's
response to health
what is the purpose of assessment - establish a database about a client's
response to illness
- establish a database about the ability to
manage health care needs
- initial: it is performed to establish impor-
tant data when first come in (all aspects
of health)
- problem-focused: routine, ongoing data
based on something from initial assess-
what are the 4 types of assessment
ment
- emergency: physiologic or psychologi-
cal crisis
- time-lapsed: compares certain status to
previous status
, Exam 3 - NURS 208
who is the best source for data about a
the client
client
- obtaining reliable data observations
- determining relevant from irrelevant
data
- determining unimportant from impor-
what are assessment priorities tant data
- validating data
- organizing data
- categorizing data
- identifying gaps in data
subjective (what the patient says) and
what are the different types of data
objective (what is observed)
advantages:
- fast answers
- less complicated
advantages and disadvantages to close - easy to find using internet
ended questions disadvantages:
- doesn't tell you a lot
- you don't have to think which means
your not stretching your brain
advantages:
- learn more by answering these ques-
tions
advantages and disadvantages of open
- get more detailed information
ended questions
- more specific answers
disadvantages:
- can take a long time to answer properly
database inappropriately organize, perti-
nent data omitted, irrelevant or duplicate
data collected erroneous or misinterpret-
what are common problems with data
ed data collection, failure to establish
collection
rapport, interpretation of data is recorded
rather than the observed behavior, failure
to update the database
what is important when planning an in- time, place, seating arrangement, dis-
terview tance from patient, and language
, Exam 3 - NURS 208
- preparatory stage
- introduction: explaining
what are the stages of an interview - working: subjective and objective data
- termination: summarizing health issues
that may have been identified
it is important to keep data as free from
error, bias, and misinterpretation as pos-
why is it important to validate data sible. it is important in determining invalid
information which can lead to inappropri-
ate nursing care
from the assessment phase you can an-
how do phases of the assessment set alyze, synthesize, reflect, make judge-
the stage for diagnosis ments, and draw conclusions which can
lead you to the diagnosis
what is the purpose of the diagnosis
- analyzing and synthesizing data
stage
- creating a list of suspected problems/di-
agnosis
- ruling out similar problems/diagnosis
- naming actual and potential prob-
lems/diagnoses and clarifying what's
what is included in the diagnosis stage
causing or contributing to them
- determining risk factors that must be
managed
- identifying resources, strengths, and ar-
eas for health promotion
- find patterns and relationships
- make inferences
- suspend judgment without data
- state the problem
what do you do in the diagnosis stage
- examine assumptions
- compare patterns with norms
- identify factors contributing to the prob-
lem
what are the three types of diagnostic
statements
, Exam 3 - NURS 208
problem-focused: is a clinical judgment
concerning an undesirable human re-
sponse to a health condition/life process
that exists in an individual, family, group,
or community
risk: s a clinical judgment concerning
the vulnerability of an individual, family,
group, or community for developing an
undesirable human response to health
conditions/life processes
health promotion: is a clinical judgment
concerning motivation and desire to in-
crease well-being and to actualize hu-
man health potential.
1. recognizing significant data and com-
paring to standards
2. recognizing patterns or clusters
what are the four steps of data interpre-
3. identifying strengths, problems, and
tation and analysis
complications
4. reaching conclusions about care need-
ed
- P: problem (diagnostic label)
- E: etiology (cause, known or unknown)
what are the four components of a diag-
- S: signs and symptoms (defining char-
nostic statement
acteristics)
- Actual diagnosis or risk diagnosis
-Individualizing patient care
-Defining domain of nursing to health
what are the benefits of a nursing diag- care administrators, legislators, and
nosis providers
-Seeking funding for nursing and reim-
bursement for nursing services
- If used incorrectly, patient might be mis-
what are limitations of a nursing diagno-
diagnosed.
sis
- Nursing practice might be restricted.
what is included in an actual problem
what are the components of nursing assess, diagnose, plan, implement, eval-
process uate
nursing care plan, medical plan of care,
what are the five types of plans of care rehabilitation plan of care, palliative plan
of care, and psychiatric plan of care
based on physiological symptoms and
medical plan of care
disease processes
is a clients response to a real or potential
nursing plan of care
illness (the patient's response)
identification of a disease condition
based on specific evaluation of physical
medical diagnosis
signs, symptoms, history tests, and pro-
cedures
is a statement of a patient's response to
nursing diagnosis an actual or potential health problem that
the nurse is licensed and competent
it includes collecting, organizing, validat-
what is the assessment process
ing, and documenting data
- establish a baseline
- establish a database about a client's
response to health
what is the purpose of assessment - establish a database about a client's
response to illness
- establish a database about the ability to
manage health care needs
- initial: it is performed to establish impor-
tant data when first come in (all aspects
of health)
- problem-focused: routine, ongoing data
based on something from initial assess-
what are the 4 types of assessment
ment
- emergency: physiologic or psychologi-
cal crisis
- time-lapsed: compares certain status to
previous status
, Exam 3 - NURS 208
who is the best source for data about a
the client
client
- obtaining reliable data observations
- determining relevant from irrelevant
data
- determining unimportant from impor-
what are assessment priorities tant data
- validating data
- organizing data
- categorizing data
- identifying gaps in data
subjective (what the patient says) and
what are the different types of data
objective (what is observed)
advantages:
- fast answers
- less complicated
advantages and disadvantages to close - easy to find using internet
ended questions disadvantages:
- doesn't tell you a lot
- you don't have to think which means
your not stretching your brain
advantages:
- learn more by answering these ques-
tions
advantages and disadvantages of open
- get more detailed information
ended questions
- more specific answers
disadvantages:
- can take a long time to answer properly
database inappropriately organize, perti-
nent data omitted, irrelevant or duplicate
data collected erroneous or misinterpret-
what are common problems with data
ed data collection, failure to establish
collection
rapport, interpretation of data is recorded
rather than the observed behavior, failure
to update the database
what is important when planning an in- time, place, seating arrangement, dis-
terview tance from patient, and language
, Exam 3 - NURS 208
- preparatory stage
- introduction: explaining
what are the stages of an interview - working: subjective and objective data
- termination: summarizing health issues
that may have been identified
it is important to keep data as free from
error, bias, and misinterpretation as pos-
why is it important to validate data sible. it is important in determining invalid
information which can lead to inappropri-
ate nursing care
from the assessment phase you can an-
how do phases of the assessment set alyze, synthesize, reflect, make judge-
the stage for diagnosis ments, and draw conclusions which can
lead you to the diagnosis
what is the purpose of the diagnosis
- analyzing and synthesizing data
stage
- creating a list of suspected problems/di-
agnosis
- ruling out similar problems/diagnosis
- naming actual and potential prob-
lems/diagnoses and clarifying what's
what is included in the diagnosis stage
causing or contributing to them
- determining risk factors that must be
managed
- identifying resources, strengths, and ar-
eas for health promotion
- find patterns and relationships
- make inferences
- suspend judgment without data
- state the problem
what do you do in the diagnosis stage
- examine assumptions
- compare patterns with norms
- identify factors contributing to the prob-
lem
what are the three types of diagnostic
statements
, Exam 3 - NURS 208
problem-focused: is a clinical judgment
concerning an undesirable human re-
sponse to a health condition/life process
that exists in an individual, family, group,
or community
risk: s a clinical judgment concerning
the vulnerability of an individual, family,
group, or community for developing an
undesirable human response to health
conditions/life processes
health promotion: is a clinical judgment
concerning motivation and desire to in-
crease well-being and to actualize hu-
man health potential.
1. recognizing significant data and com-
paring to standards
2. recognizing patterns or clusters
what are the four steps of data interpre-
3. identifying strengths, problems, and
tation and analysis
complications
4. reaching conclusions about care need-
ed
- P: problem (diagnostic label)
- E: etiology (cause, known or unknown)
what are the four components of a diag-
- S: signs and symptoms (defining char-
nostic statement
acteristics)
- Actual diagnosis or risk diagnosis
-Individualizing patient care
-Defining domain of nursing to health
what are the benefits of a nursing diag- care administrators, legislators, and
nosis providers
-Seeking funding for nursing and reim-
bursement for nursing services
- If used incorrectly, patient might be mis-
what are limitations of a nursing diagno-
diagnosed.
sis
- Nursing practice might be restricted.
what is included in an actual problem
