when does the assessment process begin?
what is the next step?
- initial meeting between nurse and client/ family
- obtain information about the client's current and past problems
in addition to your interview, assessment includes information you obtain from:
existing records, past diagn...
when does the assessment process begin?
what is the next step? - ANSWER- - initial meeting between nurse and client/
family
- obtain information about the client's current and past problems
in addition to your interview, assessment includes information you obtain from: -
ANSWER- existing records, past diagnostic testing, information from family, and
in some instances, contact with previous health care providers, schools, or other
referral sources
subjective data - ANSWER- (stated)
- client's perception of data and what client or family says about the data
objective data - ANSWER- (observed)
- data directly observed or verified through physical exams or tests
- document specific, measurable terms
nursing diagnosis - ANSWER- - a comprehensive biopsychosocial statement that
captures the essence of the client's health care needs/ problems
- describes the client's human responses to health issues and medical diagnoses
types of nursing diagnosis - ANSWER- problem- focused
risk and high- risk
possible
health promotion
syndrome
problem- focused nursing diagnosis (4 components) - ANSWER- - human
response to health conditions/ life processes that can exist in an individual,
family, or community
, - supported by defining characteristics that cluster in patterns of related cues or
inferences
components:
label, definition, defining characteristics, and related factors
label for problem- focused ND - ANSWER- the label should be clear, concise
terms that convey the meaning of the diagnosis
definition for problem- focused ND - ANSWER- - the definition should add clarity
to the diagnostic label
- it should also help to differentiate a particular diagnosis from similar diagnosis
defining characteristics of problem- focused ND - ANSWER- - signs and
symptoms that, when seen together, represent the nursing diagnosis (major and
minor)
related factors of problem- focused ND (4 categories) - ANSWER- - related factors
are contributing factors that have influenced the change in health status
4 categories:
- pathophysiologic, biologic, or psychological
- treatment- related
- situational
- maturational
Risk and High Risk Nursing Diagnosis - ANSWER- - human response to health
conditions/ life processes that may develop in a vulnerable individual, family, or
community
- supported by risk factors that contribute to increased vulnerability: risk and
high risk
risk - ANSWER- expected or predictive diagnoses for all individuals who are
undergoing some situation
high- risk - ANSWER- for people with additional risk factors that may be more
vulnerable for the problem to occur
Possible Nursing Diagnosis - ANSWER- - describe a suspected problem requiring
additional data to confirm or rule out
- nurse can confirm presence of major signs and symptoms and label as problem
focused ND or
- nurse can confirm presence of potential risk factors and label as Risk ND or
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