Fundamentals: Chapter 17 Flashcards
What is a medical diagnosis?
the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the patient’s medical history and the results of diagnostic tests and procedures.
What is a nursing diagnosis?
a CLINICAL judgement about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat.
Who is licensed to make a medical diagnosis?
a physician
What is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s status?
collaborative problem
Why is selecting the correct nursing diagnosis essential?
accurate diagnosis of patient problems ensures that the nurse selects more effective and efficient nursing interventions
What is a set of signs or symptoms gathered during assessment that you group together in a logical way?
data cluster
What are the clinical criteria that are observable and verifiable?
defining characteristics
What is an objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a diagnostic conclusion?
clinical criterion
What is a condition, historical factor, or etiology that gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis?
related factor
What are the three types of nursing diagnosis?
actual nursing diagnosis
risk diagnosis
health promotion diagnosis
Describe an actual nursing diagnosis
human responses to health conditions or life processes that EXIST in an individual, family, or community
Describe a risk nursing diagnosis
human responses to health conditions or life processes that MAY develop in a VULNERABLE individual, family, or community.
What is the main difference between an actual nursing diagnosis and a risk nursing diagnosis?
risk diagnosis do not have related factors or defining characteristics because they have not occurred
What are categories of risk factors?
Environmental
Physiological
Psychological
Genetic
Chemical
Describe a health promotion nursing diagnosis
a clinical judgment of a person’s, family’s, or community’s motivation, desire and readiness to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors
What are the two components of a nursing diagnosis?
NANDA-I diagnostic label
Related Factor (etiology)
What is a diagnostic label?
the name of the nursing diagnosis as approved by NANDA International
Why is a diagnostic label used?
it describes the essence of a patient’s response to health conditions in as few words as possible
How does a nurse identify related factors?
use the patient’s assessment data
What are the four categories of related factors for NANDA-I diagnosis?
Pathophysiological (biological or psychological)
Treatment-related
Situational (environmental or personal)
Maturational
How do nursing interventions effect the medical diagnosis?
They do not change a medical diagnosis. Interventions must be directed at behaviors or conditions that the nurse is able to treat or manage
What does PES stand for?
Problem (label)
Etiology (related factor)
Symptoms (defining characteristics)
What is the cause of not being able to validate data?
an inaccurate match between clinical cues and nursing diagnosis
What causes errors in data clustering?
data is clustered prematurely, incorrectly, or not at all
List 12 ways to reduce errors in diagnostic statements:
- Identify the patient’s response, not the medical diagnosis
- Identify a NANDA-I diagnostic statement, not the symptom
- Identify a treatable etiology, not a clinical situation sign or chronic problem that is not treatable through nursing intervention
- Identify the problem caused by the tx or dx study, not the tx or study itself
- Identify the pt response to the equipment, not the equipment itself
- Identify the patient’s problems, not your problems with nursing care
- Identify the patient problem, not the nursing intervention
- Identify the patient problem, not the goal of care
- Make professional judgments, not prejudicial judgments
- Avoid legally inadvisable statements
- Identify the problem and etiology to avoid circular statement
- Identify only one patient problem in the dx statement
KEYS: PATIENT-CENTERED DIAGNOSIS; COMPLETE DX BEFORE PLANNING/IMPLEMENTATION
What makes a nursing diagnosis unique from a medical diagnosis?
the patient can be involved in the diagnostic process
