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True or False: medical diagnoses represent situations that are the primary responsibility of nurses? False; role of doctors Assessment process health history and physical assessment NANDA North American Nursing Diagnosis Association nursing diagnosis definition a clinical judgement about individual, family, or community responses to actual or potential health problems/life processes that provides that basis for definitive therapy toward achievement of outcomes for which a nurse is accountable what is different between nursing diagnoses and medical diagnoses more holistic view components of a nursing diagnosis a label; definition; defining characteristics a label may include a qualifier (impaired, altered, decreased, ineffective, acute, or chronic) definition a precise description (not documented on chart) defining characteristics descriptors of a client's behavior that determine whether a nursing diagnosis is present related factors states what is causing or contributing to the nursing diagnosis (what the nurse can treat) actual nursing diagnoses describes human responses to health conditions/life processes that exist in an individual, family or community risk for nursing diagnoses describes human responses that may develop in a vulnerable person, family or community. The plan is aimed at preventing the problem wellness nursing diagnoses describes human responses to wellness in an individual, family, or community that have the potential for growth and/or the potential for enhancement to a higher state of well-being writing a nursing diagnosis or an actual label problem, r/t etiology, AEB writing a nursing diagnosis for a risk label problem, r/t etiology AEB data supporting Dx True or False; nursing diagnoses should be derived from a single cue? false True or False; the etiology of nursing diagnoses directs nursing interventions true whats wrong with this diagnosis, "Alterations in bowel elimination: constipation related to cancer of the colon" -related to cannot be a medical diagnosis -missing AEB where did the Nursing Outcomes Classification System (NOC) come from the University of Iowa initial planning starts right away while doing assessment ongoing planning client's health condition may change rapidly discharge planning they go hope and it starts right away what is establishing priorities what needs to be done immediately and what can safely be postponed expected outcome the desirable end result of nursing care what does an expected outcome include a subject, verb, performance criteria, target time what should an expected outcome be measurable, timed, and can be directly observed short term time frame of expected outcome 1 hour - 1 week long term time frame of expected outcome weeks - months the most important part of an expected outcome it should be agreed upon by the patient types of outcomes -cognitive -psychomotor -affective -physiological cognitive outcome increases patient knowledge psychomotor outcome patient is able to demonstrate new skills affective outcome patient changes beliefs/attitudes physiological outcome physical change in the patient patient outcome variables developmental stage, psychosocial background nursing variables resources, current standard of care, research findings, ethical and legal guides to practice list a few problems related to outcome identification and planning failure to involve the patient, insufficient data, outcomes stated are too broad, inaccurate nursing orders nurse-initiated interventions independent of the physician (assist with activities, reduce risk of injury or infection, reposition client) physician-initiated interventions within the scope of nursing practice but requires a physician's order for the nurse to implement collaborative interventions treatments initiated by other providers (PT, OT, pharmacist) and carried out by a nurse elements of an intervention who, what, where, when, why, how who person providing care - nurse, RT, PT what care that will most effectively meet the client's needs where home, clinic, hospital when the time that care if delivered or the sequence of events required why provides the rationale for care and includes evidence that the care will meet the client's needs how defines the methods of interventions NIC nursing intervention classification nursing intervention classification a system that is a standardized method of identifying nursing interventions where was NIC developed University of Iowa what is different about NIC much more specific what type of goal? "by 03/30/16 the patient will walk the length of the hallway" psychomotor what type of goal? "patient will list 5-low fat snacks to replace high-fat foods" cognitive what type of goal? "patient will value her health sufficiently to stop smoking" affective how to evaluate cognitive goal have patient repeat or apply information how to evaluate psychomotor goal have patient demonstrate skills how to evaluate affective goal observe patient behaviors and conversation how to evaluate physiological goal assessment skills to collect and compare data


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