| A | B |
|---|
| ANA | AMERICAN NURSES ASSOCIATION |
| ANA STANDARD 1: | ASSESSMENT |
| ASSESSMENT INCLUDES | DATA, DATABASE, INTERVIEW |
| DATA | PIECES OF INFORMATION ON A SPECIFIC TOPIC |
| DATABASE | ALL THE INFORMATION GATHERED ABOUT A PATIENT |
| ASSESSMENT (THE INTERVIEW) | CONVERSATION WHERE FACTS ARE OBTAINED |
| DATA OBTAINED FROM THE PATIENT VERBALLY | ARE CALLED SUBJECTIVE DATA |
| INFORMATION OBTAINED THROUGH THE SENSES AND HAND'S ON PHYSICAL EXAMINATION | OBJECTIVE DATA |
| VITAL SIGNS AND RESULTS OF DIAGNOSTIC TESTS | OBJECTIVE DATA |
| THE INTERVIEW HAS 3 STEPS: | (1), THE OPENING WHEN RAPPORT IS ESTABLISHED WITH THE PATIENT, (2) THE BODY OF THE INTERVIEW WHEN THE NECESSARY QUESTIONS ARE PRESENTED (3) THE CLOSING SEGMENT OF THE INTERVIEW |
| THE COURSE OF THE INTERACTION IS | DIRECTED TO ELICIT SPECIFIC INFORMATION CONCERNING THE PATIENTS HEALTH STATUS OR FEELINGS ABOUT THEIR HEALTH (INTERVIEW) |
| BODY OF THE INTERVIEW | ASKING THE NECESSARY QUESTIONS, EXAMINE THE PATIENT |
| CLOSING | ANY QUESTIONS, ALL FOR NOW, THANK THEM |
| ASSESSMENT (CHART REVIEW) | IS AN ASSESSMENT TOOL THAT ASSISTS IN OBTAINING THE INFORMATION NEEDED TO INTERVIEW THE PATIENT OR TO PREPARE FOR THE DAYS PATIENT ASSIGNMENT |
| TO PERFORM CHART REVIEW | (1)METHODICALLY LOOK THRU THEIR CHART, IF THE PATIENT HAS JUST BEEN ADMITTED YOU CAN SEEK INFO ONLY FROM THE FACE SHEET AND DOCTORS ORDERS |
| FACE SHEET (CHART REVIEW) | INCLUDES, AGE, SEX, MARITAL STATUS/SIGNIFICANT OTHER, RELIGION, OCCUPATION, RESIDENCE, NEXT OF KIN & ADDRESS, ALLERGIES, INSURANCE STATUS |
| DOCTORS ORDERS (CHART REVIEW) | ADMITTING DIAGNOSIS, DATE OF ADMISSION, CURRENT ORDERS REGARDING, DIET, ACTIVITY, FREQUENCY OF VITAL SIGNS MEASUREMENT, DAILY WEIGHT, TREATMENTS, MEDS, DIAGNOSTIC TESTS ORDERED, IV FLUIDS, THERAPIES ORDERED |
| TO DO A REVIEW IN PREP FOR YOUR CLINICAL ASSESSMENT | (1)LOOK AT THE FACE SHEET (2)MOST CURRENT DRS ORDERS, AS WELL AS THOSE FOR THE PREVIOUS 2 DAYS, THE MAR (MEDICATION ADMINISTRATION RECORD, DRS ADMITTING HISTORY, PHYSICAL ASSESSMENT, SCAN ANY SURGICAL PROCEDURES, PATHOLOGY REPORTS, AND CONCLUSIONS |
| NURSES NOTES (CHART REVIEW) | STATUS DURING THE LAST 24 HOURS |
| DOCTORS PROGRESS NOTES (CHART REVIEW) | FINDINGS FROM THE LAST 2 DAYS, STATUS OF PROBLEMS |
| (MAR) MEDICATION ADMINISTRATION RECORD (CHART REVIEW) | MEDICATIONS RECEIVED, FREQUENCY OF PRN MEDICATIONS, ALLERGIES |
| DOCTORS PATIENT HISTORY & PHYSICAL (CHART REVIEW) | CURRENT COMPLAINT, CHRONIC PROBLEMS, PHYSICAL FINDING ABNORMALITIES, ALLERGIES, IMPRESSIONS |
| SURGERY OPERATIVE REPORT (CHART REVIEW) | PROCEDURE DONE, ORGANS REMOVED, TYPE OF INCISION, DRAINS OR EQUIPMENT IN PLACE, BLOOD LOSS, PROBLEMS DURING SURGERY |
| PATHOLOGY REPORT (CHART REVIEW) | PRESENCE OF MALIGNANCY OR INFECTION |
| CURRENT DIAGNOSTIC TESTS (CHART REVIEW) | CHECK FOR ANY ABNORMAL FINDINGS, CBC, UA, BLOOD CHEMISTRIES, XRAY FILMS, CULTURE AND SENSITIVITY, OTHER TESTS |
| NURSING ADMISSION HISTORY AND ASSESSMENT (CHART REVIEW) | REASON FOR HOSPITAL STAY,CIGS SMOKED, ALCOHOL, LAST BOWEL MOVEMENT, SPECIAL DIETS, USE OF AIDS OR PROTHESIS, IDENTITY OF SIGNIFICANT OTHER, PREV HOSPITAL STAYS OR SURGERIES, BASELINE VITALS, PHYSICAL ABNORMALITIES |
| NURSING CARE PLAN OR PROBLEM LIST | FOUND ON CHART ALSO |
| ASSESSMENT (THE PHYSICAL EXAMINATION) | IS CONDUCTED BY THE RN, PARTS MAY BE DELEGATED TO THE LPN |
| TO CONDUCT THE EXAMINATION, USE TECHNIQUES OF INPSPECTION | (1)INSPECTION--LOOKING (2)AUSCULTATION--LISTENING, (3) PALPATION--TOUCHING (4)PERCUSSION--THUMPING |
| ASSESSMENT (PHYSICAL EXAM) | HEIGHT, WEIGHT, VITAL SIGNS, HISTORY OF DRUGS, ALLERGIES, MEDS, BRIEF MEDICAL HISTORY, ETC |
| AFTER THE ADMISSION ASSESSMENT | EACH PATIENT SHOULD BE VISITED AND ASSESSED DURING THE FIRST HOUR OF EACH SHIFT, PERFORM HEAD TO TOE, SHOULD TAKE 10 MIN |
| QUICK HEAD TO TOE ASSESSMENT (STEP ONE INITIAL OBSERVATION) | INTIAL OBSERVATION (BREATHING, HOW PATIENT IS FEELING, APPEARANCE, AFFECT, SKIN COLOR |
| QUICK HEAD TO TOE (STEP 2 HEAD) | HEAD ( LEVEL OF CONSCIOUSNESS, ABILITY TO COMMUNICATE, MENTATION STATUS, APPEARANCE OF EYES |
| QUICK HEAD TO TOE (STEP 3 VITAL SIGNS) | VITAL SIGNS ( TEMPERATURE, PULSE, RATE, RHYTHM, RESPIRATIONS, RATE, PATTERN AND DEPTH, BLOOD PRESSURE, COMPARE WITH PREV READINGS) |
| QUICK HEAD TO TOE (STEP 4 HEART AND LUNG ASSESSMENT, NEUROLOGIC CHECK) | HEART AND LUNG ASSESSMENT, NEUROLOGIC CHECK (AUSCULTATION OF HEART AND LUNGS, WILL BE DONE TO DETERMINE A BASELINE, NEUROLOGIC CHECK IS DONE NOW IF ORDERED OR INDICATED) |
| QUICK HEAD TO TOE (STEP 5 ABDOMEN) | STEP 5 ABDOMEN) SHAPE, SOFT OR HARD, BOWEL SOUNDS, APPETITE, LAST BOWEL MOVEMENT, VOIDING STATUS |
| QUICK HEAD TO TOE (STEP 6 EXTREMITIES | EXTREMITIES) NORMAL MOVEMENT, SKIN TURGOR AND TEMP, PERIPHERAL PULSES, EDEMA |
| QUICK HEAD TO TOE, STEP 7 TUBES AND EQUIPMENT PRESENT | OXYGEN CANNULA, LITER FLOW RATE, CHEST TUBE, NG TUBE, SUCTION SETTING, URINARY CATH, DRAINAGE, IV CATH, SITES FLUIDS, PULSE OXIMETER, TRACTIONS |
| QUICK HEAD AND TOE, STEP 8 PAIN STATUS | WHAT IS YOUR PAIN LEVEL 1-10 |
| PEG | PERCUTANEOUS ENDOSCOPIC GASTROSTOMY |
| CUES | ARE PIECES OF DATA OR INFORMATION THAT INFLUENCE DECISIONS |
| ASSESSMENT (ANALYSIS) | ONCE THE INFO HAS BEEN GATHERED, THE DATABASE IS ANALYZED FOR CUES THAT INDICATE DEVIATIONS FROM THE NORM. |
| PROBLEMS ARE INDENTIFIED SO THAT NURSING DIAGNOSES CAN BE WRITTEN AS REQUIRED BY THE | ANA STANDARD II: DIAGNOSIS |
| THE DATABASE IS | ANALYZED, PIECES OF DATA ARE SORTED, RELATED DATA ARE GROUPED (CLUSTERED), AND MISSING DATA ARE IDENTIFIED |
| NURSING DIAGNOSIS STATEMENTS | ARE USED TO STATE THE SPECIFIC PROBLEMS |
| INFERENCES | CONCLUSIONS MADE BASED ON OBSERVED DATA |
| 2ND STEP: NURSING DIAGNOSIS | RESULTS IN THE DEVELOPMENT OF A DIAGNOSTIC STATEMENT |
| NURSING DIAGNOSIS STATEMENT | INDICATES THE PATIENTS ACTUAL HEALTH STATUS OR THE RISK OF A PROBLEM DEVELOPING, THE CAUSATIVE OR RELATED FACTORS, AND SPECIFIC DEFINING CHARACTERISTICS (SIGNS AND SYMPTOMS) |
| MEDICAL DIAGNOSIS (DRS VERSION) | IS NEVER INCLUDED IN THE NURSING DIAGNOSIS |
| DIAGNOSTIC LABELS | HAVE BEEN FORMULATED BY THE NORTH AMERICAN NURSING DIAGNOSIS ASSOCIATION (NANDA) AND ARE REVISED EVERY 2 YEARS |
| ONCE THE NURSING DIAGNOSES ARE IDENTIFIED | THE PLANNING PHASE OCCURS |
| THE NANDA LIST OF DIAGNOSTIC LABELS IS | USED TO FORM THE FIRST PART (STEM) OF THE NURSING DIAGNOSES USED IN NURSING CARE PLANS |
| THE NURSING DIAGNOSIS | DESCRIBES A HEALTH PROBLEM AMENABLE TO NURSING INTERVENTION |
| THE STEM LABEL (THE PROBLEM) | IS COMBINED WITH THE CAUSE OR CAUSATIVE FACTORS |
| POTENTIAL | RISK FOR INJURY |
| AEB | AS EVIDENCED BY |
| R/T | RELATED TO |
| STEPS IN WRITING A NURSING DIAGNOSIS | NURSING DIAGNOSIS (STEM), RELATED CAUSE (R/T), AS EVIDENCED BY (AEB), SIGNS AND SYMPTOMS (S/S) |
| RISK FOR INFECTION | HIGH POTENTIAL |
| NURSING DIAGNOSIS (ETIOLOGIC FACTORS) | ARE THE CAUSES OF THE PROBLEM |
| SIGNS | ARE ABNORMALITIES THAT CAN BE VERIFIED BY REPEAT EXAMINATION AND ARE OBJECTIVE DATA |
| SYMPTOMS | ARE DATA THE PATIENT HAS SAID ARE OCCURING THAT CANNOT BE VERIFIED BY EXAM, SYMPTOMS ARE SUBJECTIVE DATA |
| NURSING DIAGNOSIS (DEFINING CHARACTERISTICS) | ARE THOSE CHARACTERISTICS (SIGNS AND SYMPTOMS) THAT MUST BE PRESENT FOR A PARTICULAR NURSING DIAGNOSIS TO BE APPROPRIATE FOR THAT PATIENT |
| DEFINING CHARACTERISTICS | SUPPLY THE EVIDENCE THAT THE NURSING DIAGNOSIS IS VALID |
| NURSING DIAGNOSIS | DEFINES THE PATIENTS RESPONSE TO ILLNESS |
| MEDICAL DIAGNOSIS | LABELS THE ILLNESS |
| CONSTRUCTION OF A NURSING DIAGNOSIS= | (1) PROBLEM + (2) ETIOLOGY--CAUSE + (3) SIGNS & SYMPTOMS--AS EVIDENCED BY DEFINING CHARACTERISTICS |
| NURSING DIAGNOSIS (PRIORITIZATION OF PROBLEMS) | PRIORITIES OF CARE ARE SET SO THAT THE NURSE WILL FIRST ATTEND TO THE MOST IMPORTANT INTERVENTIONS FOR THE HIGH PRIORITY PROBLEMS FOR EACH PATIENT |
| PHYSIOLOGIC NEEDS | TAKE PRECEDENCE |
| PHYSIOLOGIC NEEDS | (1) AIR (2) CIRCULATION (3) PAIN OR FOOD? PAIN ON A SHORT TERM BASIS |
| AFTER PHYSIOLOGIC NEEDS ARE MET | SAFETY PROBLEMS TAKE PRIORITY |
| AFTER SAFETY | LOVE & BELONGING, SELF ESTEEM, SELF ACTUALIZATION |
| EVERY NURSE MUST ATTEMPT TO LOOK AT EACH PATIENT | HOLISTICALLY, KEEPING PSYCHOSOCIAL NEEDS IN MIND WHILE WORKING ON PHYSICAL PROBLEMS |
| PHYCHOSOCIAL NEEDS INCLUDE | CALLING PATIENTS BY THEIR CORRECT NAMES, GIVING THEM OPPORTUNITIES TO MAKE SOME DECISIONS ABOUT THEIR CARE, PROTECTING THEIR PRIVACY, AND SHOWING RESPECT HELP MEET THESE NEEDS |
| 3RD STEP PLANNING | IT CORRELATES WITH THE 4TH ANA STANDARD PLANNING |
| PLANNING (GOALS AND EXPECTED OUTCOMES) | WHAT DO YOU EXPECT TO ACHIEVE WHILE THE PATIENT IS IN YOUR CARE |
| GOAL | IS A BROAD IDEA OF WHAT IS TO BE ACHIEVED THROUGH NURSING INTERVENTION |
| SHORT TERM GOALS | ARE THOSE THAT ARE ACHIEVABLE WITHIN 7-10 DAYS OR BEFORE DISCHARGE, |
| LONG TERM GOALS | TAKE MANY WEEKS OR MONTHS TO ACHIEVE, RELATE TO REHAB |
| QUESTIONS THAT THE NURSE CONSIDERS IN THE PART OF THE PLANNING PROCESS | 1. WHAT ARE THE GOALS FOR THIS PATIENT?, 2. HOW CAN THEY BE EXPRESSED AS EXPECTED OUTCOMES SO THAT THE SUCCESS OF NURSING CAN BE EASILY EVALUATED?, 3. SHOULD THE GOALS FOR THIS PATIENT BE BOTH SHORT AND LONG TERM? 4. WHAT ARE THE PRIORITIES OF CARE? |
| ANA STANDARD III | OUTCOME IDENTIFICATION |
| OUTCOME IDENTIFICATION | REQUIRES INDIVIDUALIZED OUTCOMES |
| EXPECTED OUTCOMES | ARE DERIVED FROM THE GOALS, |
| EXPECTED OUTCOMES | IS A SPECIFIC STATEMENT OF THE GOAL THE PATIENT IS EXPECTED TO ACHIEVE AS A RESULT OF NURSING INTERVENTION |
| EXPECTED OUTCOMES | SHOULD BE REALISTIC, AND ATTAINABLE AND SHOULD HAVE A DEFINED TIME LINE |
| EXPECTED OUTCOMES | SHOULD ALSO CONTAIN MEASURABLE CRITERIA THAT CAN BE EVALUATED TO SEE WHETHER THE OUTCOME HAS BEEN ACHIEVED, COLLABORATION WITH THE PATIENT REGARDING THE EXPECTED OUTCOMES IS IMPORTANT |
| THERE MUST BE AN AGREEMENT ON THE IMPORTANCE OF THE EXPECTED OUTCOME | WITH THE PATIENT, AND OTHER HEALTH PROFESSIONALS INVOLVED IN THE PATIENTS CARE |
| DISCHARGE CRITERIA | SAME AS EXPECTED OUTCOME |
| PLANNING (INTERVENTIONS -NURSING ORDERS) | SELECT APPROPRIATE NURSING INTERVENTIONS TO ALLEVIATE THE PROBLEMS AND ASSIST THE PATIENT IN ACHIEVING THE EXPECTED OUTCOMES |
| CONSIDER ALL POSSIBLE INTERVENTIONS | FOR RELIEF OF THE PROBLEMS, THEN SELECT THOSE MOST LIKELY TO BE EFFECTIVE |
| WRITE THE INTERVENTIONS ON THE | NURSING CARE PLAN OR NURSING ORDERS |
| QUESTIONS TO CONSIDER CHOOSING NURSING INTERVENTIONS? | 1, WHAT NURSING ACTIONS ARE NECESSARY TO MONITOR THE STATUS OF A HIGH RISK PROBLEM? 2, WHICH NURSING INTERVENTIONS CAN BEST HELP THE PATIENT REACH THE EXPECTED OUTCOMES? 3, WHAT NURSING INTERVENTIONS COULD POSSIBLY PREVENT A POTENTIAL PROBLEM FORM BECOMING AN ACTUAL PROBLEM? |
| NURSING CARE PLAN (NURSING DIAGNOSIS) | NURSING DIAGNOSIS (IMPAIRED PHYSICAL MOBILITY R/T TO DECREASED MOTOR FUNCTION, AEB INABILITY TO BEAR WEIGHT ON LEFT LEG |
| NURSING CARE PLAN (EXPECTED OUTCOMES) | EXPECTED OUTCOMES, PATIENT WILL AMBULATE TO THE NURSES STATION USING WALKER, UNASSISTED BY 4/4/03 |
| NURSING CARE PLAN (NURSING INTERVENTION) | NURSING INTERVENTION (ENCOURAGE ACTIVE ROM TO RIGHT LEG AND ARM Q4H WHILE AWAKE, ASSIST PATIENT IN WALKING WITH WALKER IN ROOM TID |
| NURSING CARE PLAN (EVALUATION) | EVALUATION--EXPECTED OUTCOME MET, 3/3/03, PK, SPN |
| INTERVENTIONS COULD INCLUDE THE FOLLOWING | ASSIST PATIENT WITH EXERCISES, DAILY BATH, AM AND PM, INSTRUCT HER TO CALL FOR HELP BEFORE GETTING OUT OF BED, REINFORCE TEACHING OF EXERCISES THAT WILL STRENGTHEN MUSCLES |
| INTERVENTIONS | SHOULD INCLUDE GIVING MEDICATIONS AND PERFORMING ORDERED TREATMENTS |
| PLANNING (DOCUMENTATION OF THE PLAN) | THE PLANNING PROCESS IS NOT FINISHED UNTIL THE NURSING CARE PLAN IS IN THE PATIENTS CHART OF MEDICAL RECORD OR COMPUTER PROGRAM TO ASSIST IN CONSTRUCTING THE NURSING CARE PLAN |
| ONCE THE PLAN IS CONSTRUCTED | IT IS PRINTED OUT, REVIEWED, AND PLACED IN THE CHART |
| THE NURSING PLAN SHOULD BE CONSTRUCTED | RIGHT AFTER THE ADMISSION DATABASE IS COLLECTED, MUST BE READILY AVAILABLE TO EACH NURSE WHO IS ASSIGNED TO THE PATIENT, ONCE Q24H THE CARE PLAN IS REVIEWED AND UPDATED, UPDATES ANYTIME, NEW PLAN IS TO BE PRINTED AND PUT INTO PATIENTS RECORD |
| SUBJECTIVE DATA | ARE INFORMATION THAT THE PATIENT VERBALIZES THAT ARE APPARANT ONLY TO THE PATIENT |
| OBJECTIVE DATA | ARE FACTS THAT ARE OBTAINED THRU USING THE SENSES AND THE HANDS ON PHYSICAL ASSESSMENT |
| CHART REVIEW | IS USEFUL FOR GATHERING INFO FOR THE NUSING DATABASE AND FOR OBTAINING INFO FOR A STUDENT ASSIGNMENT |
| A NURSING HISTORY AND ASSESSMENT ARE PERFORMED | AT ADMISSION |
| THE NURSE SHOULD PERFORM | A QUICK HEAD TO TOE ASSESSMENT OF EACH ASSIGNED PATIENT AT THE BEGINNING OF EACH SHIFT |
| ANALYSIS | IS USED TO SORT AND GROUP ASSESSMENT DATA SO THAT NURSING DIAGNOSES CAN BE CHOSEN AND PRIORITIES CAN BE SET |
| THE NURSING DIAGNOSIS STATEMENT | INDICATES THE PATIENTS ACTUAL HEALTH STATUS, OR A POTENTIAL PROBLEM, CAUSE OR RELATED FACTORS, AND SPECIFIC DEFINING CHARACTERISTICS (SIGNS AND SYMPTOMS) |
| NURSING DIAGNOSES | SHOULD BE CHOSEN FROM THE NANDA LIST |
| EXPECTED OUTCOMES | ARE WRITTEN BASED ON THE NURSING DIAGNOSIS AND PROBLEMS |
| EXPECTED OUTCOMES | SHOULD BE REALISTIC,ATTAINABLE, MEASUREABLE, TIME LINE AND BE EASILY EVALUATED |
| PLANNING | 3RD STEP, INVOLVES CHOOSING APPROPRIATE NURSING INTERVENTIONS AND DOCUMENTING THE PLAN |
| NURSING ORDERS | ARE THE INTERVENTION CHOSEN THAT WILL BEST ASSIST THE PATIENT TO ACHIEVE THE EXPECTED OUTCOME |
| NURSING PLAN | REVIEWED AND UPDATED EVERY 24H |
| MAN HAS PNEUMONIA,WEAK, HEADACHE, HIGHEST PRIORITY? | THE NEED FOR OXYGEN (AIR) |
| REFLEX INCONTINENCE R/T NEUROLOGIC IMPAIRMENT AEB? | INABILITY TO RETAIN URINE |
| NANDA NURSING DIAGNOSIS STEM FOR EXCESSIVE VOMITING? | FLUID VOLUME DEFICIT |
| BP 146/92, DRAINAGE, PAIN IN LEFT HIP, DEPRESSED, HUNGARY, WHICH IS SUBJECTIVE? | PAIN IN LEFT HIP |
| OBJECTIVE | ELEVATED BP |
| THE ROLE OF THE LPN | ASSISTS WITH THE ADMISSION ASSESSMENT |
| PATIENTS RELIGION FOUND ON? | FACE SHEET |
| CORRECT WRITTEN DIAGNOSIS | IMPAIRED SKIN INTEGRITY R/T REMOVAL OF GALLBLADDER AEB RIGHT UPPER QUADRANT INCISIONAL WOUND |
| GOAL RATHER THAN EXPECTED OUTCOME | PATIENT WILL RETAIN USE OF LEFT ARM AND LEG (NO TIME LINE) |
| STATED AS A EXPECTED OUTCOME? | PATIENT WILL DEMONSTRATE CORRECT USE OF INCENTIVE SPIROMETER WITHIN 24H |
