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Published byAllison Franklin Modified over 9 years ago
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Validation is the act of “ double checking “ or verifying data to confirm that it is accurate and factual.
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It helps differentiate “cues” from “ inferences”. Cues : are subjective and objective data Inferences : are conclusions that nurses withdraw upon cues E.g; red, swollen lesion (cues) leads to an inference ( infection)
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Data should be verified when there are inconsistencies between assessment data. Not all data should be verified Be careful from making wrong assumptions based on asssessments
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Documentation : is recording client data. E.g. Intake and output E.g. Quotes from patient own words
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Reflects what the clients needs and problems are.
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NANDA : is an international North America Nursing Diagnosis Association
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Is to : define, refine, and promote taxonomy of nursing diagnostic terminology of general use to professional nurses. No Arabic version, yet.
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Nursing diagnosis is : a clinical judgement about individual, family, and community responses to actual and potential health problems and life processes.
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Nursing diagnoses are not medical diagnoses
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Medicine deals with disease processes while nursing manages patients responses to illness and health related issues
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1- Actual 2- Potential ( risk for) 3- wellness 4- possible 5- syndrome Only first two types are used in Jordan.
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1- problem statement 2- Aetiology ( causal relationship between a problem and its related risk factors) 3- Defining characteristics ( subjective and objective findings)
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1- Anxiety related to surgical management as evidenced by patient own words “ I am anxious about this operation..”
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2- Pain related to surgical incision as manifested by pain score 7/10 and slightly elevated BP and heart rate.
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They are potential complications of disease that nurses and other health team members should be aware of and cooperate to manage in a multidisciplinary approach
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Potential complication of head injury: increased intracranial pressure
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