Chapter 17: Nursing Diagnosis

Question 1

Medical Diagnosis

Answer 1

• identification of a disease through diagnostic findings.

- Stays constant as the condition remains.

Question 2

Nursing Diagnosis

Answer 2

clinical judgement concerning a human response to health conditions based on information that the nurse is licensed to treat

Question 3

The nursing diagnostic process is unique in that

Answer 3

clinical judgement about an individual, family or community that a nurse is licensed and competent to treat: acute pain, nausea and physical deficits.

Question 4

Diagnostic conclusions include

Answer 4

• problems treated primarily by nurses (nursing diagnosis)

- problems requiring treatment by several disciplines (collaborative problems)

Question 5

Medical Diagnosis is identification of disease conditions based on

Answer 5

• specific evaluation of physical S&S
• patients medical hx
• results of diagnostic test/procedures

Question 6

What is the purpose of nursing diagnostic statements?

Answer 6

• provide precise definition to a patient problem using a common language
• allows nurses to communicate what they do among themselves with other disciplines and the public
• distinguishes the nurse’s role from physician or other health care provider
• helps nurses focus on their scope of practice
• fosters the development of nursing knowledge
• promotes creation of practice guidelines that reflect the essence of nursing

Question 7

What are the three types of nursing diagnosis?

Answer 7

1. actual diagnosis
2. risk diagnosis
3. health promotion diagnosis

Question 8

Actual Diagnosis

Answer 8

response to an existing condition in a patient, family or community

Question 9

Risk Diagnosis

Answer 9

• response to health conditions that may develop in a vulnerable patient, family or community.
• there are no defining characteristics because they have not occurred.

Question 10

Health Promotion Diagnosis

Answer 10

clinical judgement of a person’s, family’s or community’s motivation and readiness to increase human health potential.

Question 11

What are the elements of a nursing diagnosis?

Answer 11

1. problem focused diagnosis
2. related factor (etiology)
3. defining characteristics (AEB)

Question 12

Problem focused diagnosis

Answer 12

clinical judgement concerning an undesirable response to a health condition

Question 13

Related factor (etiology)

Answer 13

• causative factor for the diagnosis

- individualized for a particular patient

Question 14

Defining Characteristics (as evidenced by)

Answer 14

subjective and/or objective assessment cues/data such as patient behavior or physical signs that support the diagnostic statement.

Question 15

Diagnostic reasoning involves

Answer 15

using the assessment data gathered on a patient to logically explain a clinical judgement - the nursing diagnosis.

Question 16

Data Clustering

Answer 16

a set of signs or symptoms gathered during your assessment that share a common thread.

Question 17

Clinical Criteria

Answer 17

objective or subjective data that when analyzed with other criteria, leads to a diagnostic conclusion.

Question 18

Diagnostic label (B 17-2 pg. 228-9)

Answer 18

the name of the nursing diagnosis

• stated in as few words as possible
• include “descriptors”

Question 19

What are descriptors for nursing diagnoses?

Answer 19

compromised, decreased, deficient, delayed, impaired, imbalanced.

Question 20

Related Factors include 4 categories:

Answer 20

1. Pathophysiological (biological or psychological)
2. Treatment-related
3. Situational (environmental or personal)
4. Maturational

Question 21

Nursing Diagnostic Process

Answer 21

F. 17-2 p. 230

Question 22

The nursing diagnosis focus may be

Answer 22

an actual or potential response to a problem rather than on the physiological event, complication or disease.
ex) “acute pain related to incisional trauma” NOT “acute pain related to cholecystectomy”

Question 23

The Nursing Diagnosis is state in what format?

Answer 23

PES
(P)roblem: nursing diagnosis
(E)tiology: R/T
(S)ymptoms: AEB

Question 24

Cultural Relevance to the Nursing Diagnosis

Answer 24

• consider patients cultural diversity

- cultural awareness and sensitivity improve your accuracy in making nursing diagnoses

Question 25

What are examples of interview questions in regards to cultural relevance?

Answer 25

- What do you expect from your hospital stay to help maintain some of your cultural practices? - What do you believe will help or fix the problem? - What worries you the most about this problem? - Will being in the hospital affect your ability to practice your religion?

Question 26

Concept mapping

Answer 26

- graphically represents the connections between concepts (nursing diagnosis) and ideas that are related to patient health problems - focus is on the patient

Question 27

Concept mapping promotes

Answer 27

critical thinking - key concepts are linked by organizing and analyzing information

Question 28

Concept mapping incorporates

Answer 28

- clinical reasoning - intuition - past experiences with patients - patterns seen in similar situations - reference to institutional standards and procedures

Question 29

What are the sources of diagnostic errors? (read pp. 234-36)

Answer 29

- errors in data collection - errors in interpretation and analysis of data - errors in data clustering - errors in the diagnostic statement

Question 30

Errors in interpretation and analysis of data

Answer 30

validate that measureable, objective physical findings support subjective data

Question 31

Errors in data clustering

Answer 31

an incorrect nursing diagnosis affects quality of patient care

Question 32

Errors in diagnostic statement

Answer 32

reduce errors by selecting appropriate, concise and precise language using NANDA terminology

Question 33

Where should you document the nursing diagnosis?

Answer 33

Document in the written plan of care or in the electronic record.

Question 34

When documenting the nursing diagnosis, the nurse should...

Answer 34

- Place the highest-priority nursing diagnosis first. | - note date and time of the nursing diagnosis entry

Question 35

Accurate documentation assures

Answer 35

clear communication with other health care professionals and assures relevant and appropriate nursing interventions have been selected