Chapter 17: Nursing Diagnosis Flashcards Preview

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Flashcards in Chapter 17: Nursing Diagnosis Deck (35)
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1
Q

Medical Diagnosis

A
  • identification of a disease through diagnostic findings.

- Stays constant as the condition remains.

2
Q

Nursing Diagnosis

A

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

3
Q

The nursing diagnostic process is unique in that

A

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

4
Q

Diagnostic conclusions include

A
  • problems treated primarily by nurses (nursing diagnosis)

- problems requiring treatment by several disciplines (collaborative problems)

5
Q

Medical Diagnosis is identification of disease conditions based on

A
  • specific evaluation of physical S&S
  • patients medical hx
  • results of diagnostic test/procedures
6
Q

What is the purpose of nursing diagnostic statements?

A
  • 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
7
Q

What are the three types of nursing diagnosis?

A
  1. actual diagnosis
  2. risk diagnosis
  3. health promotion diagnosis
8
Q

Actual Diagnosis

A

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

9
Q

Risk Diagnosis

A
  • response to health conditions that may develop in a vulnerable patient, family or community.
  • there are no defining characteristics because they have not occurred.
10
Q

Health Promotion Diagnosis

A

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

11
Q

What are the elements of a nursing diagnosis?

A
  1. problem focused diagnosis
  2. related factor (etiology)
  3. defining characteristics (AEB)
12
Q

Problem focused diagnosis

A

clinical judgement concerning an undesirable response to a health condition

13
Q

Related factor (etiology)

A
  • causative factor for the diagnosis

- individualized for a particular patient

14
Q

Defining Characteristics (as evidenced by)

A

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

15
Q

Diagnostic reasoning involves

A

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

16
Q

Data Clustering

A

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

17
Q

Clinical Criteria

A

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

18
Q

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

A

the name of the nursing diagnosis

  • stated in as few words as possible
  • include “descriptors”
19
Q

What are descriptors for nursing diagnoses?

A

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

20
Q

Related Factors include 4 categories:

A
  1. Pathophysiological (biological or psychological)
  2. Treatment-related
  3. Situational (environmental or personal)
  4. Maturational
21
Q

Nursing Diagnostic Process

A

F. 17-2 p. 230

22
Q

The nursing diagnosis focus may be

A

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”

23
Q

The Nursing Diagnosis is state in what format?

A

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

24
Q

Cultural Relevance to the Nursing Diagnosis

A
  • consider patients cultural diversity

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

25
Q

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

A
  • 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?
26
Q

Concept mapping

A
  • graphically represents the connections between concepts (nursing diagnosis) and ideas that are related to patient health problems
  • focus is on the patient
27
Q

Concept mapping promotes

A

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

28
Q

Concept mapping incorporates

A
  • clinical reasoning
  • intuition
  • past experiences with patients
  • patterns seen in similar situations
  • reference to institutional standards and procedures
29
Q

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

A
  • errors in data collection
  • errors in interpretation and analysis of data
  • errors in data clustering
  • errors in the diagnostic statement
30
Q

Errors in interpretation and analysis of data

A

validate that measureable, objective physical findings support subjective data

31
Q

Errors in data clustering

A

an incorrect nursing diagnosis affects quality of patient care

32
Q

Errors in diagnostic statement

A

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

33
Q

Where should you document the nursing diagnosis?

A

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

34
Q

When documenting the nursing diagnosis, the nurse should…

A
  • Place the highest-priority nursing diagnosis first.

- note date and time of the nursing diagnosis entry

35
Q

Accurate documentation assures

A

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