DIAGNOSIS Flashcards
Refers to the reasoning process
Diagnosing
A statement or conclusion regarding the nature of a phenomenon
Diagnosis
standardized names for diagnosis called diagnostic labels
NANDA names
The client’s problem statement, consisting of diagnostic label plus etiology (causal relationship)
Nursing Diagnosis
“… a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community” (Herdman & Kamitsuru, 2014, p. 464).
Official NANDA Definition
What are the 3 components of NANDA nursing diagnosis
- Problem and its Definition
- Etiology
- Defining Characteristics
Describes the client’s health problem or response for which nursing therapy is given.
Problem (Diagnostic Label)
Inadequate in amount, quality, or degree; not sufficient; incomplete.
Deficient
Made worse, weakened, damaged, reduced, deteriorated.
Impaired
Lesser in size, amount, or degree.
Decreased
Not producing the desired effect.
Ineffective
To make vulnerable to threat.
Compromised
Uses the critical thinking skills of analysis and synthesis.
Diagnostic Process
The separation into components (deductive reasoning).
Analysis
Putting together parts into the whole (inductive reasoning).
Synthesis
Steps in the Diagnostic Process?
- Analyzing data
- Identifying health problems, risks, and strengths
- Formulating diagnostic statements
Steps in the Diagnostic Process
1. Analyzing data
2. Identifying health problems, risks, and strengths
3. Formulating diagnostic statements
- Compare data against standards (identify significant cues).
- Cluster the cues (generate tentative hypotheses).
- Identify gaps and inconsistencies.
Analyzing Data
Nurses compare client data to standards and norms to identify significant and relevant cues
Comparing Data with Standards
Data clustering is a process of determining the relatedness of facts and identifying patterns.
Clustering Cues
- Skillful assessment minimizes gaps and inconsistencies in data.
- Inconsistencies must be clarified before a valid pattern can be established.
Identifying Gaps and Inconsistencies in Data
- Problems that support tentative actual, risk, and possible diagnoses are identified.
- Establishing the client’s strengths, resources, and abilities to cope.
Identifying Health Problems, Risks, and Strengths
what are the Formulating Diagnostic Statements
Basic Two-Part Statements and Basic Three-Part Statements (PES Format)
Basic Two-Part Statements
- the Statement of the client’s response (NANDA label).
Problem
Basic Two-Part Statements
- Factors contributing to or probable causes of the responses.
Etiology
Basic Three-Part Statements (PES Format)
1. Problem (P): Statement of the client’s response (NANDA label).
2. Etiology (E): Factors contributing to or probable causes of the response.
3. Signs and Symptoms (S): Defining characteristics manifested by the client.
Health promotion diagnoses and syndrome nursing diagnoses consist of a NANDA label only.
One-Part Statements
Guidelines in Writing a Diagnosis Statement
* Evaluating the Quality of the Diagnostic Statement:
* Verify hypotheses and recognize that all diagnoses are tentative until verified.
* Build a good knowledge base and acquire clinical experience.
* Consult resources when in doubt.
* Base diagnoses on patterns over time rather than isolated incidents.
* Improve critical thinking skills.
