Chapter 15 Flashcards
What is the purpose of diagnosing in the nursing process
- identify how a person responds to actual or potential health processes
- identify factors that contribute to or cause health problems
- identify resources or strengths that the person can draw on to prevent or resolve the issues
what is the difference between a nursing diagnosis and a medical diagnosis
nursing - actual or potential health problems that can be prevented or resolved by independent nursing interventions
medical - identify diseases
what is a data cluster
a grouping of patient data or cues that point to the existence of a health problem
what is an actual diagnosis
a patient problem that is present at the time of the nursing assessment based on signs and symptoms
what is a risk diagnosis
a clinical judgement that a problem does not exists, but the presence of risk factors indicates that a problem is likely to develop
what is health promotion nursing diagnoses
a clinical judgment concerning motivation and desire to increase well-being and to actualize human health
what is a possible nursing diagnosis
these are statements - not a diagnosis describing a suspected problem for which additional data is needed to confirm
what is Etiology
the factors that are maintaining the unhealthy state or response (the causes)
what are the guidelines for writing nursing diagnoses
- should be a patient problem rather than a need
- make sure the patient problem precedes the etiology and the two are R/T
- consider when at-risk conditions should be identified
- nursing diagnosis should follow the etiology and be linked by “as manifested by or “as evidenced by”
- write in legally advisable terms
- use nonjudgmental language
- avoid defining characteristics or medical diagnosis
What are the components of a nursing diagnosis
PED
problem - describe the problem
Etiology - identify factors
defining characteristics - subjective and objective data
