Chapter 17: Nursing Diagnosis Flashcards
Medical Diagnosis
- identification of a disease through diagnostic findings.
- Stays constant as the condition remains.
Nursing Diagnosis
clinical judgement concerning a human response to health conditions based on information that the nurse is licensed to treat
The nursing diagnostic process is unique in that
clinical judgement about an individual, family or community that a nurse is licensed and competent to treat: acute pain, nausea and physical deficits.
Diagnostic conclusions include
- problems treated primarily by nurses (nursing diagnosis)
- problems requiring treatment by several disciplines (collaborative problems)
Medical Diagnosis is identification of disease conditions based on
- specific evaluation of physical S&S
- patients medical hx
- results of diagnostic test/procedures
What is the purpose of nursing diagnostic statements?
- provide precise definition to a patient problem using a common language
- allows nurses to communicate what they do among themselves with other disciplines and the public
- distinguishes the nurse’s role from physician or other health care provider
- helps nurses focus on their scope of practice
- fosters the development of nursing knowledge
- promotes creation of practice guidelines that reflect the essence of nursing
What are the three types of nursing diagnosis?
- actual diagnosis
- risk diagnosis
- health promotion diagnosis
Actual Diagnosis
response to an existing condition in a patient, family or community
Risk Diagnosis
- response to health conditions that may develop in a vulnerable patient, family or community.
- there are no defining characteristics because they have not occurred.
Health Promotion Diagnosis
clinical judgement of a person’s, family’s or community’s motivation and readiness to increase human health potential.
What are the elements of a nursing diagnosis?
- problem focused diagnosis
- related factor (etiology)
- defining characteristics (AEB)
Problem focused diagnosis
clinical judgement concerning an undesirable response to a health condition
Related factor (etiology)
- causative factor for the diagnosis
- individualized for a particular patient
Defining Characteristics (as evidenced by)
subjective and/or objective assessment cues/data such as patient behavior or physical signs that support the diagnostic statement.
Diagnostic reasoning involves
using the assessment data gathered on a patient to logically explain a clinical judgement - the nursing diagnosis.
Data Clustering
a set of signs or symptoms gathered during your assessment that share a common thread.
Clinical Criteria
objective or subjective data that when analyzed with other criteria, leads to a diagnostic conclusion.
Diagnostic label (B 17-2 pg. 228-9)
the name of the nursing diagnosis
- stated in as few words as possible
- include “descriptors”
What are descriptors for nursing diagnoses?
compromised, decreased, deficient, delayed, impaired, imbalanced.
Related Factors include 4 categories:
- Pathophysiological (biological or psychological)
- Treatment-related
- Situational (environmental or personal)
- Maturational
Nursing Diagnostic Process
F. 17-2 p. 230
The nursing diagnosis focus may be
an actual or potential response to a problem rather than on the physiological event, complication or disease.
ex) “acute pain related to incisional trauma” NOT “acute pain related to cholecystectomy”
The Nursing Diagnosis is state in what format?
PES
(P)roblem: nursing diagnosis
(E)tiology: R/T
(S)ymptoms: AEB
Cultural Relevance to the Nursing Diagnosis
- consider patients cultural diversity
- cultural awareness and sensitivity improve your accuracy in making nursing diagnoses
What are examples of interview questions in regards to cultural relevance?
- What do you expect from your hospital stay to help maintain some of your cultural practices?
- What do you believe will help or fix the problem?
- What worries you the most about this problem?
- Will being in the hospital affect your ability to practice your religion?
Concept mapping
- graphically represents the connections between concepts (nursing diagnosis) and ideas that are related to patient health problems
- focus is on the patient
Concept mapping promotes
critical thinking - key concepts are linked by organizing and analyzing information
Concept mapping incorporates
- clinical reasoning
- intuition
- past experiences with patients
- patterns seen in similar situations
- reference to institutional standards and procedures
What are the sources of diagnostic errors? (read pp. 234-36)
- errors in data collection
- errors in interpretation and analysis of data
- errors in data clustering
- errors in the diagnostic statement
Errors in interpretation and analysis of data
validate that measureable, objective physical findings support subjective data
Errors in data clustering
an incorrect nursing diagnosis affects quality of patient care
Errors in diagnostic statement
reduce errors by selecting appropriate, concise and precise language using NANDA terminology
Where should you document the nursing diagnosis?
Document in the written plan of care or in the electronic record.
When documenting the nursing diagnosis, the nurse should…
- Place the highest-priority nursing diagnosis first.
- note date and time of the nursing diagnosis entry
Accurate documentation assures
clear communication with other health care professionals and assures relevant and appropriate nursing interventions have been selected
