Nursing Diagnosis/Analyze Cues Flashcards
Why is a nursing diagnosis/patient problem made?
When a nurse identifies a health-related problem or the potential to develop a problem based on patient data
Which step of the nursing process is making a diagnosis?
The second step of the nursing process
And the 2nd and 3rd step of the CJMM process
What is a medical diagnosis?
Identification of a disease condition based on specific evaluation of physical signs and symptoms, a patient’s medical history, and the results of diagnostic tests and procedures
What is a nursing diagnosis / nursing problem identification?
A clinical judgement made by a nurse to describe a patient’s response or vulnerability to health conditions or life events that a nurse is licensed and competent to treat
Which categories are we looking at when identifying the nursing problem / nursing diagnosis?
Pathophysiological
Treatment-related
Personal
Environmental
Maturational (**Erickson and Maslow)
Define collaborative problems
A problem that requires both medicine and nursing interventions to treat
What would make a physiological problem not be a collaborative problem?
If a nurse can prevent the onset of a complication or provide the primary treatment for it, then it is a nursing problem
What is a problem-focused nursing problem statement?
Identify an undesirable human response to existing problems or concerns of a patient
What is a risk problem nursing problem statement?
Diagnoses that apply when there is an increased potential or vulnerability for a patient to develop a problem or complication
What is a health promotion nursing problem statement?
Identify the desire or motivation to improve health status through a positive behavioral change
Order of critical thinking and the nursing process/CJMM
Assess patient’s health status
Validate data with other sources
Interpret and analyze meaning of data
Data clustering/patterns
Look for assessment findings and related factors
Identify patient needs
Formulate nursing diagnosis and collaborative problems
What is a data cluster?
A set of assessment findings/defining characteristics
How should you find a data cluster?
By comparing a patient’s data with info that is consistent with normal, healthy patterns
What does data interpretation involve?
- Placing a label on your data pattern or cluster to clearly identify a patient’s health problem
- Comparing the data in a cluster with the data standard
- Recognizing data in a logical cluster or revealing the nursing problems(s), how a patient is responding to a health condition or life process
Components of a nursing diagnosis statement:
Diagnostic label
Related factors (etiology)
Major assessment findings (as evidenced by - cues)
How should you keep in mind cultural relevance when using the nursing process?
Must consider your patients’ cultural diversity
Including ethnicity, values, beliefs, language, and health practices
Type of nursing problem that is always applied to vulnerable populations?
Risk problem
How do diagnoses/nursing problems affect the planning process?
- They direct it and help select the nursing interventions to achieve desired outcomes for patients
- Demonstrate your accountability for patient care
How should you prioritize nursing problems?
*Using Maslow’s model, starting at the base
Define priority setting
The ordering of nursing diagnoses or patient problems to establish a preferential order for nursing interventions
How are priorities of patient care categorized?
Priorities are either high, intermediate or low importance
How does a nurse determine which priorities are high, intermediate, or low importance?
Using Maslow’s hierarchy of needs
Which types of problems fall into each category of patient care?
- High priorities are immediate needs (ABC’s)
- Intermediate priorities are nonemergent and not life threatening
- Low importance priorities are not always directly related to a specific illness/prognosis, but affect a patient’s long term wellbeing
What is the difference between a goal and an expected outcome?
A goal is broad and is an ultimate outcome
Expected outcomes are the measurable changes the patient achieves to reach a goal
What is the SMART acronym used for?
To correctly write out an outcome for a goal of care
What are the 5 levels of Maslow’s hierarchy of needs?
Physiological
Safety
Love/belonging
Esteem
Self-actualization
Explain what each aspect of the SMART acronym stands for
Singular
Measurable
Attainable
Realistic
Timed
*What is an independent nursing intervention?
*An intervention that a nurse initiates in response to a nursing problem, without supervision, direction, or orders
Example of an independent nursing intervention
Turning a patient
What is a dependent nursing intervention?
Health care provider-initiated interventions that require an order from a health care provider
Example of a dependent nursing intervention
Giving a patient pain medication
What is a collaborative/interdependent intervention?
Require combined knowledge, skill, and expertise of multiple healthcare providers
