1229 Exam 2: Nursing Diagnosis Flashcards
Nursing Assessment
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
Purpose of the Nursing Assessment
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
Steps that Constitute a Nursing Assessment
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
Subjective Data
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.
Objective Data
Observable & measurable data
Can be seen, heard, or felt by someone other than the patient
Can be validated
Also called signs or overt data
Sources of Data
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
Observation
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
Helpful Questions
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?
Four Methods to Collect Data
Inspection
Palpation
Percussion
Auscultation
Nursing Assessment
Does not duplicate medical assessments
Focus on the patient’s responses to health problems
Medical Assessment
Target data pointing to pathological conditions
Focused Assessment
The nurse gathers data about a specific problem that has already been identified
Emergency Assessment
To identify life threatening problems
Time-Lapsed Assessment
Is scheduled to compare a patient’s current status to baseline data obtained earlier
Nursing Diagnosis vs. Medical Diagnosis
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
Steps in the Nursing Diagnosis Process
Recognizing Significant Data
Recognize Patterns or Clusters
Identifying Strengths and Problems
Identifying Potential Complications
Parts of Nursing Diagnosis Statements
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)
Nursing Diagnosis Statements
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
Guidelines for Writing Nursing Diagnosis
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
Guidelines continued…
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
Purpose of Nursing Diagnosis
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
Purpose continued…
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
In your book:
Page 257
Page 255
Pages 252-254
