Nursing Process - Diagnosis Flashcards
It is based on the presence of associated s/sx
Actual Nursing Diagnosis
It describes the client’s health problem/status
or response for which nursing therapy is
given and is SPECIFIC
Problem statement/diagnostic label
Using the word ________, to describe either the problem or the etiology require more data about the client’s problem or etiology
possible
It composes of P r/t E
BASIC TWO-PART
NURSING DIAGNOSIS
Step where you identify problems that support TENTATIVE ACTUAL, RISK AND POSSIBLE DIAGNOSIS
Identifying Health Problems, Risks, & Strengths
Identify client strengths & problems
DIAGNOSING
statement of the client’s health state or response
Problem (P)
comprises a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain situation or event
Syndrome Nursing Diagnosis
wellness diagnoses & syndrome diagnoses
ONE-PART STATEMENT
NANDA diagnostic label + etiology = ?
Nursing diagnosis
Step in Analyzing Data
Skillful assessment minimizes gaps and inconsistencies of data
Identifying gaps and
inconsistencies of data
3 Purposes of Nursing Diagnosis
- Helps identify nursing priorities and helps direct nursing intervention based on identified priorities
- Helps the formulation of expected outcomes
- Helps identify how a client or group response to actual or potential help and life processes
Writing _______ ________ when defining
characteristics are present but the nurse
does not know the cause or contributing
factors
unknown etiology
Using _______ __
to divide the etiology
into two parts
secondary to
Nursing Diagnosis or Medical Diagnosis?
- describes HUMAN RESPONSE, a client’s physical, socio-cultural, psychological & spiritual responses to an illness or a health problem
Nursing Diagnosis
Present when a particular disease or treatment is present
COLLABORATIVE PROBLEMS
In comparing data with standards you should identify _________?
significant cues
clusters of signs & symptoms that indicate the presence of a particular diagnostic label
Defining characteristics
A clinical judgment about individual, family, or community responses to actual or potential health problems/ life processes (NANDA International in Kozier, 2012)
Nursing Diagnosis
3 Steps of Diagnostic Process
- Analyzing Data
- Identifying Health PRisks, & Strengths
- Formulating Diagnostic Statement
factors contributing to or probable causes of the responses
Etiology (E)
5 Kinds of Nursing Diagnoses based on STATUS
- Actual diagnosis
- Health promotion diagnosis
- Risk nursing diagnosis
- Wellness diagnosis
- Syndrome diagnosis