Diagnosis Flashcards
- The second phase of the nursing process
- Pivotal step in the nursing process
Diagnosing
In the diagnosing phase, the nurse uses __________ to interpret assessment data and identify client strengths and problems.
critical thinking skills
Activities preceeding the diagnosing phase are directed toward formulating the __________
nursing diagnoses
Refers to the reasoning process
Diagnosing
Statement or conclusion regarding the nature of a phenomenon
Diagnosis
Contains a diagnostic phrase or diagnostic label followed by an etiology phase
Nursing Diagnosis
Statement of the client’s problem
Diagnostic Phrase
Causal relationship between the client’s problem or risk factors
Etiology
- Responsible for making nursing diagnoses
- Accountable for analyzing data to determine diagnoses or issues
Professional Nurses (registered nurses)
Are not educated to diagnose or treat diseases such as diabetes mellitus
Generalist Nurses
Nursing diagnoses describe a continuum of health states:
- (1) __________ from health
- (2) presence of __________
- (3) areas of enhanced __________
(1) deviations
(2) risk factors
(3) personal growth
- Is also known as a problem-based diagnosis
- Is a client problem that is present at the time of the nursing assessment
- Based on the presence of associated signs and symptoms
Actual Nursing Diagnosis
- Client’s preparedness to implement behaviors
- Willingness to learn about health maintenance
- Willingness to change health practices
Health Promotion Diagnosis
- Clinical judgement that a problem does not exist
- Presence of risk factors indicates that a problem is likely to develop unless nurses intervene
Risk Nursing Diagnosis
- Clinical nursing judgement when a client has several similar nursing diagnoses
Syndrome Diagnosis
- Describes the client’s health problem and client’s health status
- Directs the formation of client goals and described outcomes
Problem Statement / Diagnostic Label
- Added to the nursing diagnosis to provide additional meaning to the diagnostic statement
Qualifiers
- Identifies one or more probable causes of the health problem, gives direction to nursing therapies, and enables individualization of client’s care
- Clarifies the meaning of the diagnosis
Etiology
- Cluster of signs and symptoms that indicate the presence of a particular diagnostic label
- Client’s signs and symptoms
Defining Characteristics
- Provides a way to describe the client’s area of concern
- Clinical judgement that concerns a human response to a health condition that nurses, by virtue of thier education, experience, and expertise, are licensed to treat
Nursing Diagnosis
- Made by a physician
- Refers to a condition that only a physician can treat
- Refer to the disease processes: specific pathophysiologic responses that are fairly uniform from one client to another
Medical Diagnosis
Nursing diagnoses relate primarily to the nurse’s ___________, which are the areas of healthcare that are unique to nursing and separate and distinct from medical management
independent functions
With regard to medical diagnoses, nurses are obligated to carry out physician-prescribed therapies and treatements, that is, __________
dependent functions
- A type of potential problem that nurses manage using both independent and physician-prescibed interventions
Collaborative Problem
- Is the separation into components of the diagnostic process
- Breaking down of the whole into its parts
Analysis
- Putting together of parts intot the whole (inductive reasoning)
Synthesis
The diagnostic process is used __________ by most nurses
continuously
The diagnostic process has three steps:
- Analyzing (1) __________
- Identifying (2) __________
- Formulating (3) __________
(1) data
(2) health problems, risks, and strengths
(3) diagnostic statements
In the diagnostic process, analyzing involves the following steps:
1. Compare the data against (1) __________
2. Cluster the (2) __________
3. Identify (3) __________
(1) standards
(2) cues
(3) gaps and inconsistencies
Is generally a accepted measure, rule, model, or pattern
Standard / Norm
A process of determining the relatedness of facts and determining whether any patterns are present, whether the data represent isolated incidents, and whether the data are significant
Clustering Cues
- Are conflicting data
- Measurement error, expectations, and inconsistent or unreliable reports
Inconsistencies
The basic two-part diagnostic statements includes the following:
1. __________: the statement of the client’s response
2. __________: factors contributing to or probable causes of the responses
Problem (P)
Etiology (E)
The two parts of the diagnostic statement are joined by the words (1) _______ rather than (2) _______
(1) related to
(2) due to
For a nursing diagnosis that contains the word “__________”, the nurse must add words to indicate the problem more specifically.
“specify”
TRUE OR FALSE
Write diagnostic statements as they would be stated in normal conversation
e.g., Potential for infection
TRUE
The basic three-part nursing diagnosis statement
PES Format
The PES Format for diagnostic statements include the following:
1. __________: statement of the client’s response
2. __________: factors contributing to or probable causes of the response
3. __________: defining characteristics manifested by the client
(1) Problem (P)
(2) Etiology (E)
(3) Signs & Symptoms (S)
The PES format cannot be used for _________ because the client does not have signs and symptoms of the diagnosis
risk diagnoses
To minimize long problem statements, the nurse lists the __________ on the care plan below the nursing diagnosis, grouping the subjective (S) and objective (O) data.
signs and symptoms
Some diagnostic statements, such as health promotion diagnoses and syndrome nursing diagnoses, consist of a __________ only.
nursing diagnosis label (one-part statements)
Writing __________ when the defining characteristics are present but the nurse does not know the cause or contributing factors
unknown etiology
(Non-adhereance to medical regimen related to UNKNOWN ETIOLOGY)
Using the phrase __________ when there are too many etiologic factors or when they are too complex to state in a brief phrase.
complex factors
(Chronic pain related to COMPLEX FACTORS)
When the nurse believes that more data are needed about the client’s problem or etiology, the word ________ is inserted.
possible
(Alteration in throught processes POSSIBLY related to unfamiliar surroundings)
Using __________ to divide the etiology into two parts, following a pathopysiologic or disease process or medical diagnoses
secondary to
(Impaired skin integrity related to decreased peripheral circulation SECONDARY to diabetes)
Adding a __________ to the general response or nursing diagnosis label to make it more precise
second part
(Altered skin integrity [LEFT LATERAL ANKLE] related to decreased peripheral circulation)
