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Related Flashcards
Related Topics
Cards In This Set
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Assessment
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Gathering data
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Diagnosis
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Identify problems
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Plan
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Set goals with plan of care and desired outcomes, nursing interventions.
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Implementation
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Perform nursing inerventions
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Evaluation
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Look at goals to see if they have been met.
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Cue
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Information that we gain through the use of our senses.
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Inference
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Nurses interpretation of the cue.
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Role of nurse in assessment process
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Conducts and documents nursing assessments of pt's.
Gathers Sub and Obj data, Adjust assessments as pt status changes, Relays assessment findings to other members of the health care team. |
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Medical Diagnosis
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The identification of a disease condition based on an evaluation of symptoms, pt complaints, and diagnostic testing.
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Nursing Diagnosis
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A clinical judgment about an individual, family or community response to an actual or potential health problem.
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Actual
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Problem exist, supported by data we have collected, defining characteristics.
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Potential or Risk
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We have data that supports the possibility that a problem could develop. Risk factors present.
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Wellness
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Pt. Wishes to receive optimal level of health care enhancing their wellness.
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Health Promotion
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Enhance our health behaviors to increase our own well-being.
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Planning phase
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Pt goals and outcomes
Nursing Interventions. Communication of the plan of care |
