Diagnosing (ch 13) Flashcards
Health problem
A condition that needs an intervention to prevent or resolve a disease/illness or to promote coping and wellness.
Purpose of diagnosing?
- Identify how and individual, group, or community responds to actual or potential health/life processes.
- ID factors that contribute to or cause health problems. (Etiology)
- ID resources or strengths the individual, group, or community can use to prevent/resolve probs.
Purpose of diagnosis (easier definition)
To clarify the exact nature of the problems and risk factors you need to achieve the overall expected outcomes if care.
Nursing diagnosis
Actual or potential health problems that can be prevented or resolved by independent nursing interventions.
Nursing diagnosis may change from day to day as patients responses change.
Medical diagnosis
ID diseases and physician directs the primary treatment.
Collaborative problems
“Certain physiologic complications that nurses monitor to detect onset or change in status”
Nurses manage collaborative problems using physician prescribed and nursing interventions to minimize the complication of the event.
Diagnostic error
Erroneously labeling selected patient health patterns as unhealthy while failing to detect an actual unhealthy behavior
Standard
Norm. A generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category.
Data cluster
Grouping of data patient or cues that points to the existence of a patient health problem.
*nursing diagnoses should always be derived from clusters of significant data rather than from a single cue.
Actual nursing diagnosis
Problem that has been validated by the presence of major definitions characteristics.
Risk nursing diagnosis
Clinical judgements that an individual, family, or community is more vulnerable to develop the problem than others in a similar situation.
Possible nursing diagnosis
Statement describing a suspected problem for which additional data are needed.
*Additional data is used to confirm or rule out the suspected problem
Wellness diagnosis
Clinical judgement about an individual, group, community in transition from a specific level of wellness.
Two Cues must be present
1. Desire for higher level of wellness
2. Effective present status or function
Syndrome nursing diagnosis
Comprise a cluster of actual or risk nursing diagnosis that are predicted to be present because of a certain event or situation.
(Examples: rape-trauma, post-trauma)
PES
Stands for?
Problem.- what is unhealthy? this suggests patient outcomes
Etiology- physiologic, psychological,sociologic, spiritual and environmental factors believed to be related to the problem as the Cause or contributing factor. *etiology directs nursing intervention.
Signs and symptoms- signal the existence of the actual or potential health problem.
Three activities required to Predict, Prevent, Manage, and Promote
- Predict the most common and most dangerous complications and take immediate action to (a)prevent and (b) manage if unable to prevent
- Look for evidence of risk factors. If ID’d, aim to reduce/control them= preventing the problems.
- In all situations encourage behaviors that promote optimum functioning, independence, & sense of well being.
Diagnosis begins after the nurse has?
Collected and recorded the patient data
What is the difference between a medical and nursing diagnosis?
Medical: describe problem for which the physician directs the primary care
Nursing: describes problems treated by the nurse within the scope of independent nursing practice
To write a diagnostic statement for a collaborative problem..
focus on the potential complications of the problem
Focus of nursing diagnosis
monitoring human responses to actual or potential health problems
Focus of collaborative problem
monitoring pathophysiologic responses of body organs or systems
Focus of Medical diagnosis
correcting or preventing pathology of specific organs or body systems
Cue
significant data or data that influence this analysis, should raise a red flag
Your best source of information?
an aware patient
NANDA describes five types of nursing diagnosis
Actual Risk Possible Wellness Syndrome
Two cues must be present for a wellness diagnosis
- desire for higher level of wellness
- effective present status or function
The diagnostic statement of wellness diagnosis is one part statement that contains the label Readiness for Enhanced, followed by?
desired higher level of wellness-related factors are not included
Defining characteristics
subjective or objective data that signal the existence of the actual or potential health problem
The nursing diagnosis statement is written in terms of?
patient problem, alteration in health state, or patient strength for which nursing provides the primary therapy
The use of nursing diagnoses also allows the patients to be?
informed and willing participants in their care
nursing diagnosis is a powerful tool for?
indiviualizing patient care and ensures that nurses’ energies are being used in the most efficient way to meed to the patients’ needs
