Nursing Process: Nursing Diagnosis – Flashcards

is bases on the presence of associated signs and symptoms - is a pt problem that is present at the time of the nursing assessment

a clinical judgment that a problem does not exist

are the cluster of signs and symptoms that indicate the presence of a particular diagnostic label

any piece of information or data that influences decisions

It helps us view the pt in a holistic approach - must analyze the data before a nursing diagnosis can be made

pt S/S that must be present to validate a nursing diagnosis

the casual relationship between a problem and its related or risk factors - Nurses should write the etiology when (a) it clarifies the problem statement, (b) it can be concisely stated, and (c) it helps to suggest nursing actions.

interpretations or conclusions made based on cues or observed data

Self-actualization - morality,creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts Esteem - self-esteem, confidence, achievement, respect of others, respect by others Love/belonging - friendship, family, sexual intimacy Safety - security of: body, employment, resources, morality, the family, health, property Physiological - breathing, food, water, sex, sleep, homeostasis, excretion

North American Nursing Diagnosis Association - purpose is to define, refine, and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses - A group of nurses who review and approved new nursing diagnoses

NANDA Label (the problem) - (P) Etiology (r/t) The cause of the problem or its Risk Factors (r.f.) - (E) Defining Characteristics (a.e.b.) (signs and symptoms - (S) - The PES format can create very long problem statements, sometimes making the problem and etiology unclear - To minimize long problem statements, the nurse can record the S/S in the nursing notes instead of on the care plan - It is to list the S.S on the care plan below the nursing diagnosis, grouping the subjective (S) and objective (O) data - Ex: "noncompliance" (Diabetic Diet) related to unresolved anger about diagnosis as manifested by S --"I forget to take my pills." "I can't live w/out sugar in my food" O --Weight 98 kg (215lb) (gain of 4.5 kg [10 lb]) Blood pressure 190/100

the process of establishing a preferential order for nursing strategies

this is related to the etiology

factors that cause a client to be vulnerable to developing a health problem

(NANDA) describes human responses to levels of wellness in an individual, family, or community that have a readiness for enhanccement

with regard to medical diagnoses, physician-prescribed therapies and treatments nurses are obligated to carry out

is a statement or conclusion regarding the nature of a phenomenon

title used in writing a nursing diagnosis; taken from the North American Nursing Diagnosis Association (NANDA) standardized taxonomy of terms - when the word "specify" follows a NANDA label, the nurse states the area in which the problem occurs - Ex: Deficient Knowledge (Medications) or Deficient Knowledge (Dietary Adjustments)

any activity undertaken for the purpose of achieving a higher level of health and well-being

areas of health care unique to nursing, separate and distinct from medical management

an ideal or fixed standard; an expected standard of behavior of group members

provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable - the nurse's clinical judgement about individual, family, or community responses to actual and potential health problems/life processes to provide the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable - is a statement of nursing judgement and refers to a condition that nurses, by virtue of their education, experience, and expertise, are licensed to treat - describe the human response, a pt's physical, sociocultural, psychological, and spiritual responses to an illness or a health problem - Nursing diagnoses relate primarily to nurse's independent functions

words that have been added to some NANDA labels to give additional meaning to the diagnostic statement Ex: - Deficient: inadequate in amount, quality, or degree; not sufficient; incomplete - Impaired: made worse, weakened, damaged, reduced, deteriorated - Decreased: lesser in size, amount, or degree - Ineffective: not producing the desired effect - Compromised: to make vulnerable to threat

a generally accepted rule, model, pattern, or measure

a diagnosis that is associated with a cluster of other diagnoses

is a classification system or set of categories arranged based on a single principle or set of principles

refers to the reasoning process - is the second phase of the nursing process

Status refers to the actuality or potentiality of the diagnosis or the categorization of the diagnosis *Kinds of Nursing Diagnosis* 1. *Actual Diagnosis* (Ex. Ineffective Breathing Pattern and Anxiety) 2. *Health Promotion Diagnosis* (Readiness for Enhanced; Readiness for Enhanced Nutrition) 3. *Risk Nursing Diagnosis* - (Risk for Infection) to describe the client's heath status 4. *Wellness Diagnosis* - Readiness for Enhanced (Ex. wellness diagnoses would be Readiness for Enhanced Spiritual Well-Being or Readiness for Enhanced Family Coping)

(1) *Problem (Diagnostic Label) and Definition* - The problem statement or diagnostic label, describes the client's health problem or response for which nursing therapy is given - Describes client's health status - Purpose of the diagnostic label is to direct the formation of client goals and desired outcomes - When the word "specify" follows a NANDA label, the nurse states the area in which the problem occurs - For Ex: Deficient Knowledge (Medications) or Deficient Knowledge (Dietary Adjustment) (2) *Etiology (Related Factors and Risk Factors)* - Identifies one or more probable causes of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client's care (3) *Defining Characteristics* - For actual nursing diagnoses, the defining characteristics are the pt's S/S - For risk nursing diagnoses, no subjective and objective signs are present - Factors that cause the pt to be more vulnerable to the problem form the etiology of a risk nursing diagnosis

is made by a physician and refers to a condition that only a physician can treat. - Medical diagnoses refer to disease processes--specific pathophysiologic responses that are fairly uniform from one pt to another.

is a type of potential problem that nurses manage using both independent and physician-prescribed interventions - are present when a particular disease or treatment is present - (Ex: a statement of collaborative problems is "Potential complications of pneumonia: atelectasis, respiratory failure, pleural effusion, pericarditis, and meninitis")

for a collaborative problem focus mainly on monitoring the client's condition and preventing development of the potential complication

uses the critical thinking skills of analysis and synthesis - In critical thinking, a person reviews data and considers explanations before forming an opinion *Diagnostic process has three steps:* - Analyzing data - Identifying health problems, risks, and strengths - Formulating diagnostic statements

the separation into components, that is, the breaking down of the whole into its parts (deductive reasoning)

the opposite, that is, the putting together of parts into the whole (inductive reasoning)

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

*Considered significant if it does any of the following* - Points to negative or positive change in a pt's health status or pattern - Varies from noms of the pt population. The pt may consider a pattern - Indicates a developmental delay. To identify significant cues, the nurse must be aware of the normal patterns and changes that occur as the person grows and develops

is a process of determining the relatedness of facts and determining whether any patterns are present, whether the data represent isolated incident, and whether the data are significant - This is the beginning of synthesis - Data clustering involves making inferences about the data

Inconsistencies are conflicting data. Conflicting data include measurement error, expectations, and inconsistent or unreliable reports

After data are analyzed, the nurse and client can together identify strengths and problems. This is primarily a decision-making process. - A client's strengths can be found in the nursing assessment record (health, home life, education, recreation, exercise, work, family and friends, religious beliefs, and sense of humor, for example), the health examination, and the client's records.

1. *Problem (P)*: statement of the client's response 2. *Etiology (E):* factors contributing to or probable causes of the responses - The two parts are joined by the words "related to" rather than "due to". The phrase "due to" implies that one part causes or is responsible for the other part - The phrase "related to" merely implies a relationship - For NANDA labels that contain the word "Specify," the nurse must add words to indicate the problem more specifically - Ex: "Noncompliance" (Specify) would be "Noncompliance" (Diabetic Diet) related to denial of having disease.

1. *Problem (P)*: statement of the client's respone 2. *Etiology (E)*: factors contributing to or probable causes of the response 3. *Signs and symptoms (S)*: defining characteristics manifested by the client - This format cannot be used for risk diagnoses because the pt does not have S/S of the diagnosis

1. Writing "unknown etiology" when the defining characteristics are present but the nurse does not know the cause of contributing factors 2. Using the phrase "complex factors" when there are too many etiologic factors or when they are too complex to state in a brief phrase 3. Using the word "possible" to describe either the problem or the etiology 4. Using "secondary to" to divide the etiology into two parts, thereby making the statement more descriptive and useful - The part following "secondary to" is often a pathophysiologic or disease process or a medical diagnosis 5. Adding a second part to NANDA makes it more precise (Ex. the diagnosis Impaired Skin Integrity does not indicate the location of the problem) More specific (Ex: Impaired Skin Integrity (Left Lateral Ankle) related to decreased peripheral circulation

Potential Complication - "Potential Complication of Head Injury": increased intracranial pressure

- Verify -Build a good knowledge base and acquire clinical experience - Have a working knowledge of what is normal - Consult resources - Base diagnoses on patterns--that is, on behavior over time---rather than on an isolated incident - Improve critical thinking skills

In 1982, NANDA accepted the "nine patterns of unitary man" (based on the nursing models of Sr. Callista Roy and Martha Rogers) In 1984, NANDA renamed the "patterns of unitary man" as "human response patterns" based more on the work of Marjorie Gordon - Taxonomy II has three levels: domains, classes, and nursing diagnoses - Taxonomy coded according to seven axes: diagnostic concept, subject of diagnosis, judgment, location, age, time, and status of diagnosis. - Diagnoses are now listed alphabetically by concept, not by first word - System includes classifications of nursing interventions & nursing outcomes - Research groups are examining what nurses do from these three different perspectives (diagnoses, interventions, and outcomes)