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
Nursing Diagnosis or Medical Diagnosis?
- refers to disease processes
Medical Diagnosis
T or F
Use nursing terminology rather than medical terminology to describe the client’s response.
True
T or F
Make sure that both elements of the
statement says the same thing.
False
both elements of the statement DO NOT say the same thing
Nursing Diagnosis domain includes health states that
nurses are ______ and ___________
educated, licensed to
treat
Step in Analyzing Data
process of determining the RELATEDNESS OF FACTS and determining whether any PATTERNS ARE PRESENT, whether the DATA REPRESENTS ISOLATED INCIDENTS
and the DATA ARE SIGNIFICANT
Clustering Cues
Adding a _______ _____ to the general response or NANDA label to make it more precise
second part
3 types of statement in Formulating Diagnostic Statement
a. basic two-part statement
b. basic three-part statement
c. one-part statement
Step in Analyzing Data
include final check to ensure that data are COMPLETE and CORRECT
Identifying gaps and inconsistencies of data
Nursing Diagnosis describes a ______________: deviations from health, presence of risk factors and areas of
enhanced personal growth
continuum of health states
clinical judgment that a problem does not exist, but the presence of risk factors indicate that a problem is likely to develop unless nurses intervene
Risk Nursing Diagnosis
Nursing Diagnosis or Medical Diagnosis?
- refers to a condition that only physician can treat
Medical Diagnosis
Nursing Diagnosis or Medical Diagnosis?
- made by PHYSICIAN
Medical Diagnosis
Nursing Diagnosis or Medical Diagnosis?
- statement of NURSING JUDGEMENT
Nursing Diagnosis
Type of POTENTIAL PROBLEM that nurses manage using both independent and physician-prescribed interventions
COLLABORATIVE PROBLEMS
T or F
Word the problem so that it is legally advisable
False
Word the STATEMENT
consist of a NANDA label only
ONE-PART STATEMENT
Step where you establish the CLIENT’S STRENGTHS,
RESOURCES, and ABILITIES TO COPE
Identifying Health Problems, Risks, & Strengths
defining characteristics manifested by the client
Signs and symptoms (S)
diagnostic label in Nursing Diagnosis
Problem (P)
T or F
Word the diagnosis specifically and precisely to provide answer for planning nursing intervention.
False
to provide PROBLEM not answer
client problem that is present at the time of nursing assessment
Actual Nursing Diagnosis
Nursing Diagnosis or Medical Diagnosis?
- nursing actions – primarily dependent
Medical Diagnosis
T or F
Be sure that cause & effect are correctly stated.
True
Step where you determine whether the client’s problem is a nursing diagnosis or a collaborative
problem
Identifying Health Problems, Risks, & Strengths
Using ______ ______ when there are too many etiologic factors
complex factors
Step where you compare data with standards
Analyzing Data
Nursing Diagnosis or Medical Diagnosis?
- refers to a condition that nurses by virtue of their education, experience, and expertise are licensed to treat
Nursing Diagnosis
T or F
Use nonjudgmental statements.
True
describes human responses to levels of wellness in an individual, family or community that have
readiness for enhancement
Wellness Diagnosis
identifies one or more probable causes of a health problem, gives direction to the required nursing
therapy & enables the nurse to individualize the client’s care
Etiology (related factors & risk factors)
Step in Analyzing Data
possible sources of inconsistencies: measurement error, expectations and inconsistent or unreliable reports
Identifying gaps and inconsistencies of data
T or F
State in terms of a need, not a problem.
False
in terms of a PROBLEM, not a NEED
client’s preparedness to implement behaviors to improve health condition
Health Promotion Diagnosis
Interpret assessment data
DIAGNOSING
