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Pertinent Assessment Data & Nursing Diagnoses Cheat Sheet (DRAFT) by

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Nursing Process

1. Assessment (Objective & Subjec­tive)
2. Diagnoses
3. Planning
4. Implem­ent­ation
5. Evaluation

Assess­ment: Objective Data

Data which is verbally spoken and expressed by the patient and other reliable sources, such as parents, spouses, careta­kers, etc. These can be problems, concerns, and stated needs.

Assess­ment: Subjective Data

Data which can be felt, such as through seeing, touch, smell, heard, etc. A physical examin­ation could lead to objective data, and compiled older inform­ation such as charts, medical history, lab results, and diagnosis.

Nursing Diagnoses vs Medical Diagnoses

Deals with the human response to bio-ph­ysi­o-socio stressors
Focuses on treating and curing (patho­logy)
And/Or health problems the nurse is licensed and competent to treat
Deals with the disease process and/or medical condit­ion/s.

Nursing Diagnoses Format

Step 1
Step Two
Step Three
Patient's needs or problem determined from the assessment
The cause (etiology) of the problem
The signs/­sym­ptoms (evidence of the problem)
NANDA approved statement found in the book
r/t = related to
Aeb or mb = as evidenced by or manifested by.
Example: #1 Sleepl­essness r/t pain from surgical incision aeb bags under eyes, inability to comfor­tably sleep in her usual position due to surgical scar location, and patient rating her pain 8/10.

Priori­tizing: How to prioritize

Existing problem
Actual. A firm diagnosis supported by validated data and statem­ents.
High Risk
Has risk factors, but no signs of symptoms. More vulnerable to develop problems
Tentative. Requires additional data to confirm or rule out a problem

Nursing Diagnoses: Part One

Must be NANDA approved format modifiers
Risk For..
♦ Risk For: These statements do not contain a symptoms and signs (evidence) portion, as they aren't happening yet.

Nursing Diagnoses: Part Two & Three

Indicates a relati­onship between the problem and its etiology
Cannot be a medical diagnosis
Must be modifiable by nursing interv­entions
The nurse must hold a license and be able to do something about it
It will fall into one of the five catego­ries...
Pathop­hys­ical, Enviro­nme­ntal, Situat­ional, Psycho­log­ical, Matura­tional
♦ Part 3: What are the important points of step 3 in the nursing diagnosis?
-Aeb and m/b must be based on your verified assessment data.
There is no aeb or m/b for "Risk for…"