N137Nursing_Diagnosis_Omaha_Revision_

N137Nursing_Diagnosis_Omaha_Revision_ - Nursing Diagnosis...

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    Nursing Diagnosis Nursing Diagnosis And the Omaha System And the Omaha System
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    What is a nursing diagnosis? The second step of the nursing process. The human response to actual or potential health problems as assessed by the nurse. A clinical judgment about an individual, family, or community response to actual and potential health problems/ life processes (Kozier, et al., 1998).
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    Essential components- PES format Problem statement : Health problem (actual or potential) Etiology (cause) : past experiences, genetic influence, environmental factors, pathophysiological changes Signs & symptoms (defining characteristics): subjective (the client says) & objective (what has been observed)
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    Data collection Review background data pertinent to the diagnosis Complete a biopsychological history and assessment Prioritize nursing diagnoses
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    Care plan Nursing diagnosis is the foundation of nursing care plan Nursing care plan has to be prioritized
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    Goals Use behavioral objective terminology; be measurable Short-term – stepping stone to long-term goals Long-term – at the end of discharge
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    Eight Taxonomy Exchanging – nutrition, body temperature, elimination/excretion, oxygen Communicating – verbal, nonverbal Relating – interpersonal relationship Valuing – coping, health belief
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    Eight Taxonomy (Cont’d) Moving – activity vs. rest, self-care Perceiving – about self Knowing – external knowledge, memory Feeling – pain, grieving, anxiety, suicidal idea, violence
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    Conclusion Clients with certain diseases might have similar nursing diagnoses Standard nursing language Has room to extend
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    Omaha System Omaha System
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    Omaha System
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This note was uploaded on 09/08/2010 for the course HS 104 at San Jose State University .

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N137Nursing_Diagnosis_Omaha_Revision_ - Nursing Diagnosis...

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