Professional Documents
Culture Documents
/etho& of pro"!em+so!ving
(mp!ement care
Eva!uate care
6
Nee& for Nursing *rocess
Assessment
Nursing Diagnosis
*!anning
(mp!ementation
Eva!uation
10
Assessment
Data co!!ection
0erification of &ata
!ustering of &ata
Documentation of &ata
11
Assessment + Data o!!ection
1ea!th assessment
Data"ase formation2hea!th histor$
*h$sio!ogic assessment2ph$sica! e3am
12
Assessment 4 Data o!!ection
Sources
Ac5uisition
13
Assessment
7sua!!$ measura"!e
15
Ac5uisition
Sources of Data
*h$sica! assessment
/e&ica! recor&s
0A+"ack
27
Surgica! 1istor$
Socia! 1istor$
Occupation
29
*ast 1istor$
Surgica! 1istor$
Socia! 1istor$
Occupation
30
0a!i&ation of Data
Denies fevers
32
0a!i&ation of Data
No me&s
No hemorrhoi&s
33
0a!i&ation of Data
!uster &ata
Diagnostic reasoning 4
recognition of significance of fin&ings
36
!ustering of Data
&ea*y s(o$er
1eav$ &rinker
Documentation of fin&ings
7se of too!
No interpretive statements
40
Nursing Diagnosis
Nursing Diagnosis
/e&ica! Diagnosis
43
Nursing Diagnosis
*athoph$sio!og$
Treatment+re!ate&
*ersona!
Environmenta!
/aturationa!
45
Nursing Diagnosis21ow to
-ormu!ate
H*ESE metho&
Syndrome
49
Actua!
= *arts
= *arts
? *art
? *art
Iisk 4 = part
*ossi"!e 4 = part
Fe!!ness 4 ? part
S$n&rome 4 ? part
55
Nursing Diagnosis
Reco!ni"e pattern
Smoking
A!coho! consumption
A"&omina! pain2constipation
57
Nursing DiagnosisK
(ncorrect -ormat
A"&omina! painLonstipation
67
Nursing Diagnosis Tips
E3amp!esK
* Sepsis
* Asthma
* D$srh$thmia
71
o!!a"orative *ro"!ems
A>6s
Know!e&ge &eficit
1$pothermia
*ain) acute
Socia! iso!ation
80
1ow wou!& $ou prioriti.e /r, 9!enn6s
present pro"!em !istG
Smoking
*oor &iet
A!coho! consumption
onstipation
81
*!anning++Outcomes
=, Esta"!ishment of goa!s ++ Deve!op
outcome criteria,
Affective (fee!ing% H
*s$chomotor (&oing% H
82
*!anning++Outcomes
/easura"!e) o"serva"!e
-avora"!e status
Attaina"!e) realistic
Specific
/easurea"!e
Action / Attaina"!e
Iea!istic
Target
84
*!anning++Outcomes
Se!ect) hoose
Ongoing assessment
!ient teaching
A&ministration of me&s
*erformance of treatments
(n&ivi&ua!i.e& to c!ient
*h$sician6s or&ers
*rotoco!s
Stan&ing or&ers
SourcesK
/et
*artia!!$ met
Not met
Ongoing eva!uation
98
ritica! Thinking &
the Nursing *rocess