-Focus on something that is positive, rather than illness
-Assessment of client’s strengths
-How their behavior correlates with their knowledge.
-improving physical functional status
-Acquiring new roles
-Achieving maturation/developmental tasks
-Developing new strengths.
2. Write a related to phrase
3. Write the defining characteristics
(signs & symptoms)
-related to the Goals & Expected Outcomes
-Acceptable to the client
2. Nursing health history- data about the client’s current level of wellness
3. Physical Exam
4. Review medical records and diagnostic tests
5. Collaborate with entire health care team and client’s significant other if appropriate
2. Working Phase
3. Termination Phase
1.Current Level of Wellness
2. Review of body systems
3. Family & Health History
4. Sociocultural History
5. Spiritual Health
6. Mental and Emotional reactions to illness
it is probable you will not cover all of the questions in each system every time you collect a history.
-WHAT is the problem: Pain, loss of fluid
-HOW did it happen: Accident, delivery, lifting an object, surgery
-WHERE is the problem: Chest, abdomen
-WHY is it a problem: Patient’s perspective, lab values
What does the patient’s health history tell you about the patient’s problem?
What does your physical assessment tell you about the patient’s problem?
What are the lab values/diagnostic data/vital signs/monitoring assessment that contribute to this problem or concern?
b.Elevated blood pressure
c.Fear of surgery
d.Discomfort on breathing
describes the essence of a client’s response to health conditions in as few words as possible.
a condition or etiology identified from the client’s assessment data.
3. Situational (Environmental or Personal)
“as evidenced by”
This is called..?
–Interpretation of data
–Clustering of Data: making the diagnosis fit the signs & symptoms
–The diagnostic statement: nursing diagnosis stated as a medical diagnosis or medical terminology is used to describe the cause
-An aim, intent, or end
In writing goals for your patient, make sure you can evaluate them.
-reflect a client’s highest possible level of wellness and independence in function.
A goal must be realistic and can be realistically achieved and based on the client’s needs and resources
Deficient Knowledge related to function of external fixation & performance of pin care manifested by temperature of 100.6 & erythema surrounding pin site
Patient will verbalize knowledge of rationale for the external fixator and indicators of pin site infection.
Patient demonstrates performance of pin care at least 24 hr before hospital discharge.
They may depend on an order from the physician
b. Maintain IV infusion at 100 mL/hr
c. Administer anti-emetic as ordered
d. Consult with dietitian on initial foods to offer client
e. Control aversive odors or unpleasant visual stimulation that trigger nausea
Specific nursing interventions so that any nurse is able to quickly identify a client’s clinical needs and situation.