Nursing Process: Diagnosis Flashcards by Rhianne Grace

Second step of the Nursing Process

Diagnosis

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Interpret & analyze clustered data.

A. ASSESSMENT
B. DIAGNOSIS
C. PLANNING
D. IMPLEMENTATION
E. EVALUATION

B. DIAGNOSIS

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Identify client’s problem and strengths.

A. ASSESSMENT
B. DIAGNOSIS
C. PLANNING
D. IMPLEMENTATION
E. EVALUATION

B. DIAGNOSIS

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Formulate Nursing Diagnosis

NANDA — North American Nursing Diagnosis Association

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NANDA means

North American Nursing Diagnosis Association

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The conclusion you make during this phase affect the entire plan of care.

Diagnosis

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Made by a physician refers to a pathophysiologic response that are fairly uniform from one client to another.

Medical Diagnosis

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TRUE OR FALSE?

Nursing diagnosis is directive of nursing intervention.

TRUE

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TRUE OR FALSE?

Nursing diagnosis is an actual, not a potential

FALSE

Nursing diagnosis is either actual or potential

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TRUE OR FALSE?

Nursing diagnosis is not only within the scope of nursing practice

FALSE

Within the scope of nursing practice

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NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

MAIN FOCUS: The impact of disease, trauma or life changes upon patient and families (human responses)

NURSING DIAGNOSIS

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NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

MAIN FOCUS: Disease, trauma, and pathophysiology

MEDICAL DIAGNOSIS

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NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

MAIN FOCUS: Problems with functioning independently (ADL)

NURSING DIAGNOSIS

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NURSING DIAGNOSIS OR MEDICAL
DIAGNOSIS?

MAIN FOCUS: Quality of life issues (pain, ability to do desired activities, but to a lesser extent than nursing – they often refer this problem to other disciplines.

MEDICAL DIAGNOSIS

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NURSING DIAGNOSIS OR MEDICAL
DIAGNOSIS?

MAIN FOCUS: Quality of life issues (pain, ability to do desired activities)

NURSING DIAGNOSIS

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NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

MAIN FOCUS: Allows opportunity to ramble and get off track.

MEDICAL DIAGNOSIS

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NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

PRIMARY MANAGER OF THE PROBLEM: They may use other resources such as physical therapy or physician expertise, but the nurse accepts primary responsibility for monitoring status and allocating resources.

NURSING DIAGNOSIS

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NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

PRIMARY MANAGER OF THE PROBLEM: Physician or Advanced Practice Nurse

MEDICAL DIAGNOSIS

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NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

DEFINITIVE DIAGNOSIS: Authority to diagnose is within the nursing domain

NURSING DIAGNOSIS

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NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

DEFINITIVE DIAGNOSIS: Nursing is required to seek physician or APN diagnosis

MEDICAL DIAGNOSIS

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NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

RESPONSIBILITIES: Identification of the factors, anticipating complications

NURSING DIAGNOSIS

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NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

RESPONSIBILITIES: Monitoring to detect and report early signs and symptoms or potential complications or change in status.

NURSING DIAGNOSIS

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NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

RESPONSIBILITIES: Initiating actions within the nursing domain to prevent or minimize the problems and their potential complications.

NURSING DIAGNOSIS

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NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS?

RESPONSIBILITIES: Identification of signs, symptoms, and risk factors

MEDICAL DIAGNOSIS

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NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS? RESPONSIBILITIES: Early detection of actual or potential problem.

MEDICAL DIAGNOSIS

NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS? RESPONSIBILITIES: Initiation of a comprehensive plan to prevent, correct, or control the problems (nurse is the primary manager of the problems)

MEDICAL DIAGNOSIS

NURSING DIAGNOSIS OR MEDICAL DIAGNOSIS? RESPONSIBILITIES: Implementing medical orders (physician or APN is primary manager of the problem.

NURSING DIAGNOSIS

Focuses on the physical, psychosocial & spiritual needs of the client

NURSING DIAGNOSIS

Address actual existing problems

MEDICAL DIAGNOSIS

Focuses on the physical condition of the client

MEDICAL DIAGNOSIS

Address actual & potential problems

NURSING DIAGNOSIS

Not validate with the client

MEDICAL DIAGNOSIS

Validate with the client, if possible

NURSING DIAGNOSIS

Uses individualized goals & interventions

NURSING DIAGNOSIS

Uses standardized goals & treatments

MEDICAL DIAGNOSIS

May not be resolve

MEDICAL DIAGNOSIS

Usually resolvable

NURSING DIAGNOSIS

Within the scope of nursing practice

NURSING DIAGNOSIS

Within the scope of medical practice

MEDICAL DIAGNOSIS

Identify responses to health and illness

NURSING DIAGNOSIS

Focuses on curing pathology

MEDICAL DIAGNOSIS

Can change from day to day

NURSING DIAGNOSIS

Stays the same as long as the disease is present

MEDICAL DIAGNOSIS

TYPES OF DIAGNOSIS

Actual Risk Wellness/ Health Promotion Possible Syndrome

A type of nursing diagnosis that is present or existing problem that may or may not necessitate immediate concern.

Actual Nursing Diagnosis

PES Approach

P – Problem E – Etiology S – signs and symptoms

A type of nursing diagnosis that relates to clients’ preparedness to implement behaviors to improve their health condition

Health Promotion Diagnosis

A type of nursing diagnosis that is client problem that is present at the time of the nursing assessment.

Actual Nursing Diagnosis

PRS Approach

P – Problem R – Risk Factors S – signs and symptoms

A type of nursing diagnosis that is assigned by a nurse’s clinical judgement to describe a cluster of nursing diagnoses that have similar interventions.

Syndrome Diagnosis

Domains of NANDA

Domain 1: Health Promotion. Domain 2: Nutrition. Domain 3: Elimination and exchange. Domain 4: Activity/rest. Domain 5: Perception/cognition. Domain 6: Self-perception. Domain 7: Role Relationships Domain 8: Sexuality Domain 9: Coping/Stress Tolerance Domain 10: Life Principles Domain 11: Safety/Protection Domain 12: Comfort Domain 13: Growth/Development

Domain 2 Classes

Class 1: INGESTION * Insufficient breast milk * Ineffective breastfeeding * Imbalanced nutrition: less than body requirements Class 2: DIGESTION Class 3: ABSORPTION Class 4: METABOLISM Class 5: HYDRATION

3 components of NANDA

o The problem and its definition o The etiology o The Defining Characteristics

The standardized NANDA names for the diagnoses are called

Diagnostic labels

relationship) between a problem and its related or risk factors is called

Nursing Diagnosis

Are words that have been added to some NANDA labels to give additional meaning to the diagnostic statement,

Qualifiers

Inadequate in amount, quality, or degree; not sufficient;

Deficient

Made worse, weakened, damage, reduced, deteriorated

Impaired

Lesser in size, amount, or degree

Decrease

FUNDAMENTAL PRINCIPLES AND RULES OF DIAGNOSTIC REASONING

Know your qualifications and limitations. Keep an open mind. Making diagnoses involve comparing your patient’s cues (signs and symptoms) with the “textbook picture” of the diagnoses you suspect. Name problems by using the labels that most closely match assessment cues. When you suspect a specific problem, look for other signs, symptoms, and risk factors commonly associated with the problem. Include problems from patient’s perspective Patients often present complaining of two or more related problems.

TRUE OR FALSE? People have the right to be assessed by a qualified health care professional.

TRUE

TRUE OR FALSE? Although you may feel that you have the knowledge to do an assessment and diagnose the problems, you should not determine (for your patient and your own legal protection) whether you have the authority to do so.

FALSE Although you may feel that you have the knowledge to do an assessment and diagnose the problems, you must determine (for your patient and your own legal protection) whether you have the authority to do so.

TRUE OR FALSE? Keeping an open mind prevents you from seeing problems from a broad perspective, a common critical thinking error.

FALSE Prevents you from seeing problems from a narrow perspective, a common critical thinking error.

TRUE OR FALSE? You make a definitive diagnosis, when your patient’s data closely match the “textbook picture” of the diagnosis you suspect.

TRUE

TRUE OR FALSE? Diagnosis is based on recognizing when patient cues match the signs and symptoms or defining characteristics of a specific diagnosis.

TRUE

TRUE OR FALSE? “More than one cue, more likely its TRUE. More than one source, more likely of course.”

TRUE

TRUE OR FALSE? Patients know themselves best and must not be included in the diagnostic process.

FALSE Patients know themselves best and must be included in the diagnostic process.

TRUE OR FALSE? Often one problem creates another.

TRUE

Diagnostic process involves

critical thinking skills of analysis and synthesis.

The separation into components, that is, the breaking down of the whole into its parts

Analysis

The putting together of parts into the whole

Synthesis

Analysis is also what type of reasoning

Deductive Reasoning

Synthesis is also what type of reasoning?

Inductive Reasoning

ANALYZING DATA includes

1. Compare data against standards (identify significant cues). 2. Cluster the cues (generate tentative hypotheses). 3. Identify gaps and inconsistencies.

STEPS ON HOW TO MAKE DEFINITIVE DIAGNOSIS

1. Analyzing data 2. Identifying health problems, risks, and strengths 3. Formulating diagnostic statements

A cue is considered significant if it does any of the following:

- Point to negative or positive change in a client’s health status or pattern. - Varies from norms of the client population. - Indicates a developmental delay.

TRUE OR FALSE? Sources of conflicting data include measurement error, expectations and inconsistent or unreliable reports.

TRUE

IDENTIFYING HEALTH PROBLEMS, RISKS, AND STRENGTHS

- Determining problems and risk - Determining strengths

After grouping and clustering the data, the nurse and client together identify problems that support tentative actual, risk, and possible diagnoses.

Determining problems and risk

Establish the client’s strengths, resources, and abilities to cope

Determining strengths

Which one is correct? 1. Needs suctioning because she has many secretions. 2. High Risk for Aspiration related to excessive or secretions.

Option 2 Write the diagnosis in terms of the person’s response rather than nursing need.

Which one is correct? 1. Altered Sexuality Patterns related to change in body image 2. Altered Sexuality Patterns caused by change in body image.

Option 1 Use “RELATED TO” rather than “DUE TO” or “CAUSED BY” to connect the two parts of the statement.

Which one is correct? 1. High Risk for trauma related to inadequately maintained skin traction. 2. High Risk for trauma related to hazards of skin traction.

Option 1 Write the diagnosis in LEGALLY advisable terms.

Which one is correct? 1. Impaired social interaction related to confinement to home. 2. Confinement to home related to impaired social interaction.

Option 1 Avoid reversing the parts.

Which one is correct? 1. Altered Parenting related to poor bonding with child. 2. Altered Parenting related to prolonged separation from child.

Option 2 Write the diagnosis WITHOUT value judgements.

Which one is correct? 1. Withdrawn behavior related to inability to engage in satisfying personal relationships. 2. Social isolation related to inability to engage in satisfying personal relationships.

Option 1 Avoid including signs & symptoms of illness in the first part of the statement.

Which one is correct? 1. Stress Incontinence related to impaired muscle tone of the urinary bladder. 2. Stress incontinence related to inability to control urine.

Option 2 Be sure that the two parts of the diagnosis do not mean the same thing.

Which one is correct? 1. Knowledge Deficit (Prenatal Diet) 2. Knowledge Deficit (Pregnancy)

Option 1 Express the problems and related factors in terms that can be changed.

Which one is correct? 1. High Risk for trauma related to dizziness. 2. Fatigue related to dizziness.

Option 1 State the diagnosis CLEARLY & CONCISELY.

The client’s response to a problem

Problem Statement

What’s causing/ contributing to the client’s problem

Etiology

What’s the evidence of the problem

Defining Characteristics

GUIDELINE FOR WRITING A NURSING DIAGNOSTIC STATEMENT

1. State in terms of problem, not a need or intervention 2. Non-self-Incriminating 3. Use non-judgmental statement 4. Both elements of the statement do not say the same thing 5. Cause and effect are correctly stated 6. Use nursing terminology rather than medical terminology to describe the client’s response.

Which one is wrong and which one is correct? Fluid replacement r/t fever Deficient fluid volume r/t fever

Wrong: Fluid replacement r/t fever Correct: Deficient fluid volume r/t fever

Which one is wrong and which one is correct? Impaired skin integrity r/t improper positioning Impaired skin integrity r/t immobility

Wrong: Impaired skin integrity r/t improper positioning Correct: Impaired skin integrity r/t immobility

Which one is wrong and which one is correct? Spiritual distress r/t strict rules necessity church attendance Spiritual distress r/t inability to attend church services secondary to immobility.

Wrong: Spiritual distress r/t strict rules necessity church attendance Correct: spiritual distress r/t inability to attend church services secondary to immobility.

Which one is wrong and which one is correct? Risk for ineffective airway clearance r/t pneumonia. Risk for ineffective airway clearance r/t to accumulation of secretions in lungs.

Wrong: Risk for ineffective airway clearance r/t pneumonia. Correct: Risk for ineffective airway clearance r/t to accumulation of secretions in lungs.

Which one is wrong and which one is correct? Impaired skin integrity r/t ulceration of sacral area Risk for impaired skin integrity r/t immobility

Wrong: Impaired skin integrity r/t ulceration of sacral area Correct: Risk for impaired skin integrity r/t immobility

Which one is wrong and which one is correct? Pain related to serve headache Severe headache r/t fear of addiction to narcotics

Wrong: Pain related to serve headache Correct: severe headache r/t fear of addiction to narcotics