Ch 15: Diagnosing Flashcards
What is the purpose of diagnosing (3) Process Factors Aids
- identify how a person, group community response to actual/potential health and life processes
- Identify factors that contribute to/cause health problems (ethologies)
- Identify resources or strengths that a person, group, community can draw on to prevent or resolve problems
What is the basis of your nursing diagnosis
Define a health problem
Basis of the nursing diag:
-The nursing interprets/analyzes that are gathered from the assessment identifies patient strengths and health problems
Health problem: condition than Sessa Tate intervention to prevent/resolve disease/illness or promote coping/wellness
What is a nursing diagnosis(what do they identify) what does it derive from and what is it not
What is the purpose of a nursing diagnosis
Nursing diagnosis identify health problems
- problems derived from medical diagnoses
- nursing diagnosis are NOT medical diagnosis
Purpose of a nursing diagnosis is to prevent complications
As a nursing concern:
why do we want to identify human responses
what are examples of human responses
What is vital for us to anticipate and for what reason?
When should you begin interventions what do you not want to wait for
We want to identify human responses to see the impacts on patient’s lives and promote optimal functioning, independence, QOL
Examples of human responses: signs and symptoms treatment
Anticipate possible complications to prevent problems
 begin interventions EARLY if SIGNS AND SYMPTOMS indicating immediate treatment
DO NOT WAIT UNTIL FINAL DIAG
In the picture chart: what is done duringdiagnosing
Interpret/analyze patient data
Identify strengths and h problems
Formulate and validate nursing diagnosis
Develop prioritized list of nursing diagnosis
Detect and refer signs and symptoms indicating problem
How are nursing diagnosis written how does nurse treat nursing diagnosis
Give examples of problems/issues
Why are early evidence based interventions included
Nursing diagnosis written to describe patient problems/issues
Nurse treats INDEPENDENTLY
(I.e: activity, pain/comfort, tissue integrity, profusion)
Early evidence based interventions used to:
-prevent and manage problems and complications

What are the 3 types of nursing diagnosis and briefly describe each
What is a collaborative problem known as?
- Nursing diagnosis
- treated INDEPENDENTLY
- Describes patient problems - Medical diagnosis
- pathologic
- describes problem physician direct primary treatment - Collaborative problem
- physician prescribed nurse prescribed interventions
A collaborative problem aka “ potential complication”
Differentiate medical diagnosis from a nursing diagnosis
Focus
Treatment approach Dr directs? N treat
How long do each last?
Medical diagnosis
- Focus is pathologic condition (disease)
- Direct primary treatment
- remains the same as long as disease is present
Nursing diagnosis:
- focuses on patients response to health problem
-  describe problem treated IDEPENDENTLY
- change from day today FaceTime patients response
Describe collaborative problems
-  definition
- Role of physician/role of nurse
- Who is responsible
- what does interdelegate
- where do treatments come from
Give example
collaborative problems = potential complication
- physiologic complications a nurse monitors to detect onset or changes in status
- physician prescribed
- nurse interventions
- collaborative problems primarily responsibility of NURSE
-  nurse Delegates medical orders to achieve goals
- treatment from any disciplinary
EXAMPLE:
-infection related to stage three ulcer
➡️ nurse treats skin applies barrier for infection

how do you correctly diagnose health problems
(Four steps)
What is possible sometimes is you’re completing a care plan and what do you have to do after you gather the information
- Be familiar with nursing diagnosis (NANDA) and other health problems
- Trust clinical experience/judgment but be willing to ask for help if more qualifications needed
- respect your clinical intuition but increase frequency of observations and search for cues
- Recognize personal bias and keep open mind
Sometimes you gather information as you complete a care plan then you support a diagnosis

What does the very best nursing diagnosis include
What must you be, do, accept when doing diagnosis
The very best nursing diagnosis includes a partnership between patients, families groups and communities
You must keep an open mind, listen carefully and take suggestions to create diagnosis
Give the four steps of data interpretation and analysis
- Recognize significant data,
compare to standards - Recognize patterns are clusters
➡️ cluster of information will point to existing problem - Identify strengths and problems/potential complications
• Family involvement?
• patient problem areas
• problems patient will likely experience
• strengths: self motivation? - Reaching conclusions
• actual v potential? Possible prob?
What are the parts of a nursing diagnosis
3 letters
P- roblem
- THE LABEL OF THE NURSING DIAG
- could be areas wanting improvement
E- tiology (R/T)
-what caused problem
-🚫 BE MED DIAG

S-&s (defining characteristics) (AEB)
- PROVE IT
- subjective/objective data signaling problem
When you think about the problem and signs and symptoms How do you determine what your defining characteristics are
When thinking about problem in the signs and symptoms (defining characteristics)
You’re AEB MUST PROVE PROBLEM!
What is another way to describe the ethology (R/T) statements
What can your etiologies not be
The ideology is the causative problem (what is causing the problem) how you go there
Etiologies🚫 be a medical diagnosis
What can you not do to your diagnosis (problem/label)
You cannot alter the NANDA Nursing diagnosis
What are the types of nursing diagnosis (3)
What is a syndrome
- in syndromes, what occurs together
-  How are the best address
- Problem focused (actual)
-  undesirable human response to health condition/life process - Risk (potential)
- concerning VULNERABILITY - Health promotion
- motivation and desire to increase well-being. Want to improveSyndromes: a clinical judgment concerning specific cluster of nursing diagnoses that occur together that are best addressed together through similar interventions
Guidelines for writing nursing diagnosis:
How do you phrase a nursing diagnosis
how do you not want to phrase
What does the problem statement indicate
where does the problem go what comes before it
What should be identified (populations/conditions)

Phrase nursing diagnosis as problem or alteration in health state
- 🚫 do not phrase as need of patient
Problem statement should indicate what is unhealthy
Problem comes before etiology
Identify any at risk populations or associated conditions
How should diagnosis be written (terms)
What language is used
 what do you want to avoid using in the problem statement
 what should the problem Suggest what should etiology direct
Diagnosis written in legal advisable terms
Use nonjudgmental (matter of fact) language
Avoid using in problem statement:
- UNCHANGEABLE 
- define characteristics
- medical diagnosis
- Problem statement should suggest patient outcomes
- Etiologies should direct nursing measures (interventions)
Where do you document a nursing diagnosis
How is the EHR used:
- View what
- decide/document based on
- What does it facilitate
- what is made
- done
Document nursing diagnosis in the patient record (EHR)
EHR used:
- View ongoing risks/problems
- decide on and document new diagnosis based on assessment findings
- facilitate communication with nurse and other team members
- use diagnosis to make decisions about mutual goals
- determine and document when diagnosis are resolved
What are a few benefits of nursing diagnoses
Limitations
BENEFITS?
Individualized patient care
Is a standard language for all to understand within healthcare
Helps seek funding and reimbursement
LIMITATIONS?
- misdiagnosis
- restricting
What are few errors in writing nursing diagnosis
Writing to patient’s needs instead of problem or Health alteration
Legally inadvisable statements
Problem as signs and symptoms
Problem or Etiology that cannot be changed
Environmental factors instead of problem
Reversing clause (Contradicting)
Having both clauses say the same thing
Including judgment using medical diagnosis
How does a premature diagnosis occur
How does a erroneous diagnosis occur
Routine diagnosis
Premature diagnosis: due to incomplete database
Erroneous diagnosis due to faulty data analysis
Routine diagnosis: not individualized to unique patient needs
Omission
What does the Etiology direct and why
Etiologies direct nursing interventions because they are causing the problem
What is considered first When beginning to make a nursing diagnosis
The defining characteristics (signs and symptoms) are considered first when making a diagnosis
What does it mean to say interdisciplinary problem
Interdisciplinary involves other people other than the physician such as nutritionists, respiratory therapist, physical
