Post on 06-Apr-2018
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Analyze Assessment Data
ANALYZE (including validation) &
CLUSTER data so pt prob can be ID
ByGordons, bybody system & by anythingelse that seems to go together
DIVIDE data -subjective & objective
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Nursing Diagnosis
Once pt prob ID, nursing dx needs be made.
Choose most approp nursing diagnosis(es)
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Form correctly worded
3 PART
NURSING DIAGNOSIS STATEMENT
3 Parts:
Problem/diagnostic label in NANDAterminology
Etiology/Related Factors
Support of the diagnostic statement/
defining characteristics
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Nursing Diagnosis
`Must be a NANDA diagnosis
`
Clustering assessment data correctlyreveals pt prob, which then translatedinto prob statement
`Compare w/ definition & definingcharacteristics listed in NANDA textto validate your choice.
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Etiology: Always Stated as R/T
Describes the process that is acontributing factor, but is NOT a cause &effect statement
MUST BE TREATABLE!
Cannot be the medical dx
Cannot be a cause & effect statement
Cannot be restatement of definingcharacteristics
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Etiology: Always Stated as R/T
`Comes from one of following 4 categories:
R/T pathophysiology of the disease: biological
or psychological
R/T tx related effect
R/T situational factor: environmental or pt
R/T maturational factor: A contributing factor
based on development of the pt
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Etiology: Always Stated as R/T
NANDA text for possibilities
MUST personalize to pt!
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Support of Diagnostic Statement
Always stated as AEB (as evidenced by)
Comes from defining characteristics(see NANDA book)
Must be personalized to pt!
These are clustering clues that got you
to NANDA Dx
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Putting It All TogetherExample
`Fatigue
`R/T Sleep deprivation from studying forexams in nursing school
`AEBfalling sleeping in class, loss of
interest in usual activities, & verbalstatements of student saying Imexhausted from school!
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Goals & Expected Outcomes
Goals - non-specific desired
outcomes
Expected Outcomes Must Have:
4 parts
Specific criteria which must be
met
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4 Parts of the Expected
Outcome A SUBJECT (the pt)
An action VERB (will .)
A PERFORMANCE CRITERION (what you
want to see)
A TARGET TIME (when you want to see it)
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Criteria for Expected Outcomes
Must meet4 part criteria
Must also be:
Client centered Singular in goal
Observable
Measurable
Time limited
Realistic
Mutually agreed upon
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Expected Outcome Statement
`The student(subject) will sleep (verb) atleast 6 hours per night(performancecriteria) during this semester (target time)
` Is it:x Client centered?
x Singular?
x Observable?
x Measurable?
x Time Limited?
x Realistic?
x Mutually agreed upon?
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Interventions
Example:
The instructor (person to perform)
Will schedule (action) each unit exammonthly (frequency)
so that it does not overlap w/
another instructors exam (method)
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Interventions in StudentCare Plans
Each intervention must be
accompanied by a SCIENTIFIC
RATIONALE
Look in NANDA book & textbooks
to find
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Evaluation
Met?
Partially met?
State how.
Unmet?
State why.