Funda week 7 8 9 10 Flashcards
is the pivotal step of the nursing process in which the nurse interprets assessment
data,
identify client strengths and health problems and formulates diagnostic statements.
DIAGNOSIS
is a clinical judgment concerning human response to health conditions/life
processes,
or a vulnerability for that response, by an individual, family, group, or community.
provides the basis for the selection of nursing interventions to achieve outcomes for which
the nurse has accountability
Nursing diagnosis
are developed based on data obtained during the
nursing assessment and enable the nurse to develop the care plan.
Nursing diagnoses
is made
by the physician or advance health care practitioner that deals more with the disease, medical
condition, or pathological state only a practitioner can treat.
medical diagnosis
is the principal organization for
defining, distribution and integration of standardized nursing diagnoses worldwide.
It’s purpose is to define, refine and promote a
taxonomy of nursing diagnostic terminology of general use to professional nurses.
North American Nursing Diagnosis Association (NANDA)
is a classification system or set of categories arranged on the basis of a single
principle or set of principles.
taxonomy
is a client problem that is present at the time of the nursing assessment.
It is based on the presence of associated signs and symptoms.
Actual Diagnosis
a clinical judgment that a problem does not exist, but the presence
of risk factors indicates that a problem is likely to develop unless nurses intervene.
Risk nursing diagnosis
- which concerns the motivation and desire to increase wellbeing and to move closer to a person’s own optimum health potential. These diagnoses use
terms related to a patient’s readiness for specific health behaviors.
Health promotion diagnosis
a clinical judgment concerning with a cluster of problem or risk
nursing diagnoses that are predicted to present because of a certain situation or event.
They, too, are written as a one-part statement requiring only the diagnostic label.
Syndrome diagnosis
identifies one or more probable causes of
the health problem, gives direction to the required nursing therapy and enables the nurse to
individualize the client’s care
is linked with the problem statement with the phrase
“related to“.
Etiology (related factors and risk factors)
are the cluster of signs and symptoms that indicate the presence
of a particular diagnostic label.
defining characteristics
involves comparing patient data against standards, clustering the cues,
and identifying gaps and inconsistencies.
Analyzing Data
In this decision-making step after data analysis, the nurse together with the client, identify
problems that support tentative actual, risk, and possible diagnoses. It involves
determining whether a problem is a nursing diagnosis, medical diagnosis, or a collaborative
problem. It is also at this stage is wherein the nurse and the client identify the client’s
strengths, resources, and abilities to cope.
❖ Identifying Health Problems, Risks, and Strengths
is the last step of the diagnostic process wherein
the nurse creates diagnostic statements.
Formulation of diagnostic statement
is a deliberative, systematic phase of the nursing process that involves decision
making and problem solving. It includes setting priorities, establishing goals, identifying desired
client outcomes, and determining specific nursing interventions.
Planning
is the process of establishing a preferential sequence for address nursing
diagnoses and interventions. In this step, the nurse and the client begin planning which nursing
diagnosis requires attention first. Diagnoses can be ranked and grouped as to having a high,
medium, or low priority.
Setting priorities
are broad statements about the client’s status.
Goals
are the more specific, observable criteria used to evaluate whether the
goals have been met.
Desired outcomes
The phase in which the nurse implements the nursing interventions.
Purpose: To assist the client to meet desired goals/outcomes; promote wellness; prevent illness
and disease; restore health; and facilitate coping with altered functioning. The phase in which the
nurse implements the nursing interventions.
IMPLEMENTING
A planned, ongoing, purposeful activity in which clients and health care professionals
determine the client’s progress toward achievement of goals/outcomes and the effectiveness of
the nursing care plan.
EVALUATING
are subjective data or objective data that can be directly observed by the nurse; that
is, what the client says or what the nurse can see, feel, smell or measure.
cues
are the nurse’s interpretation or conclusions made based on the cues.
inference
is the systematic and continuous collection, organization, validation, and
documentation of data.
assessment
