1229 Exam 2: Nursing Diagnosis

Question 1

Nursing Assessment

Answer 1

the systematic and continuous collection, validation, and communication of patient data or information.
Assessment is the 1st step you are learning about the nursing process

Question 2

Purpose of the Nursing Assessment

Answer 2

Appraisal of health status
Identification of health problems
Establishment of database for nursing intervention
Nurses in different areas of specialty use different physical assessment techniques

Question 3

Steps that Constitute a Nursing Assessment

Answer 3

1) Make a judgment about a patients health satis, the ability to manage his/her own care, and the need for nursing
2) Refer the patient to a MD or other health care provider, if necessary
3) Plan & Deliver individualized, holistic nursing care that draws on the patients strengths

Question 4

Subjective Data

Answer 4

Information perceived only by the patient
Cannot be validated by another person
Examples: “I feel nervous.” “I felt a little chill.” “I am nauseated.”
Also called symptoms or covert data
What the patient tells you in their own words; usually in quotations.

Question 5

Objective Data

Answer 5

Observable & measurable data
Can be seen, heard, or felt by someone other than the patient
Can be validated
Also called signs or overt data

Question 6

Sources of Data

Answer 6

Patient
Family & Significant Others
Patient Record: 
  -Medical history, physical exam, & progress notes.
  -Consultations
  -Lab Reports & Diagnostic Studies
  -Reports of therapies by other HCPs
**Other health care professionals
**Nursing & other health care literature

Question 7

Observation

Answer 7

Is a key nursing skill for both methods of data collection
Observation is the conscious & deliberate use of the five senses to gather data
You must work on this each time you see a patient

Question 8

Helpful Questions

Answer 8

1) What are your symptoms?
2) When did they start?
3) Were you doing anything different than usual when they began?
4) What makes your symptoms better/worse?
5) Are you taking anything (medications, OTC, etc.) for your symptoms?

Question 9

Four Methods to Collect Data

Answer 9

Inspection
Palpation
Percussion
Auscultation

Question 10

Nursing Assessment

Answer 10

Does not duplicate medical assessments

Focus on the patient’s responses to health problems

Question 11

Medical Assessment

Answer 11

Target data pointing to pathological conditions

Question 12

Focused Assessment

Answer 12

The nurse gathers data about a specific problem that has already been identified

Question 13

Emergency Assessment

Answer 13

To identify life threatening problems

Question 14

Time-Lapsed Assessment

Answer 14

Is scheduled to compare a patient’s current status to baseline data obtained earlier

Question 15

Nursing Diagnosis vs. Medical Diagnosis

Answer 15

Nursing

• Focus on unhealthy responses to health & illness
• Describe problems treated by nurses within their scope of independent nursing practice
• Diagnosis may change from day to day as the patient’s response changes

Medical

• Identify diseases
• Describe problems for which the physician directs the primary treatment
• Diagnosis stays the same for as long as the disease is present

Question 16

Steps in the Nursing Diagnosis Process

Answer 16

Recognizing Significant Data
Recognize Patterns or Clusters
Identifying Strengths and Problems
Identifying Potential Complications

Question 17

Parts of Nursing Diagnosis Statements

Answer 17

Problem Statement - is to describe the health state or health problem of the patient as clearly and concisely as possible
Etiology - identifies the physiologic, psychological, sociological, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor
Defining Characteristics - subjective and objective data that signal the existence of the problems (actual or potential)

Question 18

Nursing Diagnosis Statements

Answer 18

Are written as either a 2 part statement listing the problem and its cause.
Can be written as a 3 part statement that also includes the problem’s defining characteristics

Question 19

Guidelines for Writing Nursing Diagnosis

Answer 19

1) Phrase the nursing diagnosis as a patient problem or alteration in health state rather than as a patient need
2) Check to make sure that the patient problem precedes the etiology and that the two are linked by the phrase “related to.” (r/t)
3) Defining characteristics, when included in the nursing diagnosis, should follow the etiology statement and be linked by the phrase “as manifested by or “as evidence by” (AEB)
4) Write in legally advisable terms

Question 20

Guidelines continued…

Answer 20

5) Use nonjudgmental language
6) Be sure the problem statement indicated what is unhealthy about the patient or what the patient wants to change
7) Avoid using defining characteristics, medical diagnoses (BIG NO NO), or something that cannot be changed in the problem statement
8) Re-read the diagnosis to make sure the problem statement suggests patient outcomes and that the etiology will direct the selection of nursing measures

Question 21

Purpose of Nursing Diagnosis

Answer 21

Identify how an individual, group, or community responds to actual or potential health and life process
Identify factors that contribute to or cause health problems
Identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems
In the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from the nursing assessment

Question 22

Purpose continued…

Answer 22

The data helps to identify strengths and health problems
Health problems are conditions that necessitated intervention to prevent or resolve disease/illness or to promote coping and wellness
Actual or potential problems that can be prevented by independent nursing interventions are termed NURSING DIAGNOSIS
The nurse formulates, validates, and lists nursing diagnoses for each patient
Nursing Diagnosis provide basis for selecting nursing interventions that will achieve valued patient outcomes for which the nurse is responsible

Question 23

In your book:

Answer 23

Page 257
Page 255
Pages 252-254