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
Nursing |
Medical |
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
#_______ |
______________________ |
r/t__________ |
aeb__________ |
Priority |
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 |
Potential |
Tentative. Requires additional data to confirm or rule out a problem |
Nursing Diagnoses: Part One
Must be NANDA approved format modifiers |
Impaired.. |
Ineffective.. |
Altered.. |
Risk For.. |
Decreased.. |
♦ 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…"
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