Nursing Diagnosis Flashcards
Definition of Nursing Diagnosis
A nursing diagnosis is a statement of the high risk or actual problems in the client’s health status that the nurse is licensed and competent to treat
3 Major Components of analysis phase
Analysis and interpretation of data
-validation and clustering
Identification of problem/health care needs
Formulation of nursing diagnosis statement
Nursing Diagnosis Statement
Focus: helping client to achieve a maximal level of wellness and highest level of independence
Nursing Diagnosis vs Medical Diagnosis
Medical Diagnosis deals with disease or medical condition or pathology
Nursing diagnosis deals with human response to bio-psycho-social stressors and/or health problems that a nurse is licensed and competent to treat
Advantages of Nursing Diagnosis - client
individualization of care, appropriate selection of interventions, establishment of goals
Sources of Error
- error in data collection
- error in data analysis
- clustering errors
- incorrect diagnostic statement
Related to (r/t)
- Educated guess
- in between problem and etiology to indicate relationship between them
- not medical diagnosis
- must be modifiable
- one of five categories: environmental, situational, psychological, pathophysical, and maturational
Advantages of Nursing Diagnosis- Nurse
facilitates communication, documentation, and continuity of care among health care providers
Nursing Diagnostic Statement Diagram
(Priority)(PT problem) r/t (etiology) e/b (signs/symptoms that come from assessment)
Ex) Pain r/t tissue damage e/b patient complains of pain at level of 7 out of 10