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I Sntans creening

D Aiagnoses ssesmentEnglish Version

Inattention to one side andover attention to the oppositeside of the body which isexperiences impairmentin sensory and motor response

Any limitation in independent,purposeful physical movementof the body or of one ormore extremities

Unilateralneglect

Any limitation of independent

Continuous/frequent aimlessmovement from place to placethat expose individual to harm

Problem in

Decreased stimulationfrom (or interest orengagement in)recreational or leisureactivities

Risk for Imbalanced

Reports a habit of lifethat is characterizedby a low physicalactivity level

Decrease mobility

Inactivity/Insufficientphysical activity

Problemin activity

Impaired

Wandering

ImpairedPhysicalmobility

Risk forconstipation

Sedentarylifestyle


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PREFACE

What is ?is a tool/pathway to help nurse to assess patient in order to screen all "possible nursing diagnoses" and "possible collaborative

problems" which may be experienced by patient.Sequences in are follows:

a. Assessment for vital sign

b. Assessment for safetyc. Assessment for specific circumstancesd. Assessment for body functione. Assessment for psychologyf. Assessment for cognitive, perception and sensoryg. Assessment for spiritual and religiosityh. Assessment for behaviori. Assessment for sexualityj. Assessment for socialk. Assessment for infant/childl. Assessment for caregiver, family, communitym. Assessment for environmentn. Additional assessment for risk diagnoseso. Assessment for wellness diagnosesp. Assessment for data that belong to collaborative problems and nursing diagnosesq. Assessment for data that only belong to collaborative problems

How to use ?1. If possible, nurses need to assess patient based on the sequence in , however, it is depend on client's situations and

circumstances2. When nurse has found "possible nursing diagnoses" or "possible collaborative problems", it is suggested that nursea. Learn more about those diagnoses or collaborative problems from reliable sources before nurse can determine the most accurate

of nursing diagnoses or collaborative problemsb. Look at "The map of Nursing Diagnoses Based on NANDA-I 2007-2008" to find the relationship among nursing diagnoses in

order to continue the assessment in more focus/detail3. Nurse need to remember that not all data can be screened by , in this situation, nurse can use the book with the tittle "The Fast

method of Formulating Nursing Diagnoses" to track the possible nursing diagnoses based on the data that have been found from theprevious assessment

Note:The use of which requiring approvals and/or license fees are listed bellow:

1. An author or company requests use in an audiovisual material2. A software developer or computer based-patient record vendor request use of3 T l ti i th l

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PREFACE

CONTENT

Assessment for vital signAssessment for safety

Assessment for specific circumstances

Assessment for body function

Assessment for psychology

Assessment for cognitive, perception and sensory

Assessment for spiritual and religiosity

Assessment for behavior

Assessment for sexuality

Assessment for social

Assessment for infant/child

Assessment for caregiver, family, community

Assessment for environment

Additional assessment for risk diagnoses

Assessment for wellness diagnoses

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CONTENTS


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