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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.