Review Material
Assessment - ANS✔✔ data collected to determine: abnormalities or anything problematic
-subjective, objective, primary (collected from pt), secondary (from. medical record or another
caregiver)
-use this information to cluster and reach a conclusion of problem
Diagnosis (analysis) - ANS✔✔ -Nanda-I because in 2002 no longer north American
-PES
*problem
*etiology-caused of problem
*symptom (not included in risk for), as evidenced by
Planning-outcome - ANS✔✔ patient goal- related directly to the nursing diagnosis
-patient focused, specific (measurable), time limited
-short term: end of shift
-long term: measured in days, weeks, months
Planning- intervention - ANS✔✔ -things we do to fix the problem
-independent- nurse initiated, no provider order needed
-dependent (collaborative): provider order needed
Implementation - ANS✔✔ just change intervention verb from will to to done
action phase of NP- but so is assessment and evaluation
, Evaluation - ANS✔✔ constantly checking to see if the plan in working
-if not, reconsider and make needed changes
-always back to holistic, PCC
choices, decisions, actions
How should you assess for NP - ANS✔✔ I-nfo you collect about your patient
-The systematic gathering of information related to the physiological, psychological,
sociocultural, developmental, and spiritual status of an individual group, or community
*Comprehensive
*Focused
*Emergency
Types of data collection - ANS✔✔ -Subjective: what the patient says/tells
-Objective: behaviors, activites, what we see, feel, hear, semll
-Factual data; vital signs, lab values
Sources of data - ANS✔✔ -Family or significant others
-Patient record
-Other healthcare professionals
-nursing/healthcare literature
Data interpretation and analysis - ANS✔✔ -Recognize significant data
-Compare data to standards
-Recognize patterns or clusters
-Identify strengths and problems