Chapter 12 Flashcards
Nursing diagnosis
Describes patient problems nurses can treat independently
Medical diagnosis
Describes problems for which the physician directs the primary treatment
Collaborative problems
Managed by using physician-prescribed and nursing-prescribed interventions
Four Steps of Data Interpretation and Analysis
- Recognizing significant data: Comparing data to standards
- Recognizing patterns or clusters
- Identifying strengths and problems
- Identifying potential complications
- Reaching conclusions
Recognizing Significant Data
refers to the comparison of data to a standard or norm (e.g., normal blood pressure values).
Recognizing Patterns or Clusters
nursing diagnoses should always be derived from clusters of significant data rather than from a single cue
Reaching Conclusions
Four basic conclusions:
- No problem
- Possible problem
- Actual or potential nursing diagnosis
- Clinical problem other than nursing diagnosis
Problem
identifies what is unhealthy about patient
Etiology
identifies factors maintaining the unhealthy state
Defining characteristics
identify the subjective and objective data that signal the existence of a problem
Formulation of Nursing Diagnoses
- Problem
- Etiology
- Defining characteristics
Types of Nursing Diagnoses
- Actual
- Risk
- Possible
- Wellness
- Syndrome
Actual Nursing Diagnoses
- represent problems that have been validated by the presence of major defining characteristics
- has four components: label, definition, defining characteristics, and related factor.
Risk Nursing Diagnoses
are statements describing a suspected problem for which additional data are needed
Possible Diagnoses
if the nurse suspects that a disturbance of self-concept is also present but lacks the necessary defining characteristics
Wellness Diagnoses
- clinical judgments about a person, group, or community in transition from a specific level of wellness to a higher level of wellness.
- often more applicable on healthy patients
- two cues are a desire for high level of wellness and an effective present status or function
Syndrome Nursing Diagnoses
comprised of a cluster of actual or risk diagnoses that are predicted to be present because of a certain event or situation
Documentation of Diagnoses on EHR
goal is to enable the interdisciplinary team caring for the patient to more easily view the patient’s risks, health promotion possibilities, and actual long-term care problems.
Benefits of Nursing Diagnoses
- Individualizing patient care
- Defining domain of nursing to health care administrators, legislators, and providers
- Seeking funding for nursing and reimbursement for nursing services
Limitations of Nursing Diagnosis
- If used incorrectly, patient might be misdiagnosed.
- Nursing practice might be restricted.
Common Errors in Writing Nursing Diagnoses
- premature diagnoses based on incomplete data-base
- Wrong diagnoses resulting from an inaccurate database or a faulty data analysis
- Routine diagnoses resulting from the nurse’s failure to tailor data collection and analysis to the unique needs of the patient
- Errors of omission
