Ch 12 Diagnosing – Flashcards

seconds step in nursing process purpose- identify how a person, group, or community responds to actual or potential health problem, identify factors that contribute to or cause health problems (etiologies), identify resources or strengths that the person, group, or community can draw on to prevent or resolve problems nurse intreprets and analyzes data gathered from nursing asessment data helps nurse identify patient strengths and health problems

condition that necessitates intervention to prevent or resolve disease or illness or to promote coping and wellness

Recognizing safety and infection-transmission risks and addressing these immediately. Identifying human responses—how problems, signs and symptoms, and treatment regimens impact on patients' lives—and promoting optimum function, independence, and quality of life Anticipating possible complications and taking steps to prevent them Initiating urgent interventions—you do not want to wait to make a final diagnosis if there are signs and symptoms indicating the need for immediate treatment.

assessment: collecting data, identifying cues and making inferences, validating data, clustering related data, reporting and recording data clinical reasoning- analyzing, synthesizing, reflecting, drawing conclusions diagnosis- creating a list of suspected problems, naming actual and potential problems/diagnosis determining risk factors that must me managed

significant information that is helpful in making decisions denote significant data and data that influence this analysis "raise a red flag"

groups of patient data or cues that points to the existence of a patient health problem help form nursing diagnosis ex- woman recovering from gall bladder surgery Ineffective coping related to refusal to eat, preferring bed rest, reporting increasing discomfort, crying

actual or potential problems that can be prevented or resolved by independent nursing intervention provide basis for selecting nursing interventions that will achieve valued patient outcomes focus on unhealthy to health can change from day to day as the patient's responses change clinical judgment about individual, family, or community responses to actual or potential health problems ex- pain and comfort, tissue integrity and perfusion problems

In the presence of known problems, predict the most common and most dangerous complications and take immediate action to (a) prevent them, and (b) manage them in case they cannot be prevented. Whether problems are present or not, look for evidence of risk factors (things that evidence suggests contribute to health problems). If you identify risk factors, you aim to reduce or control them, thereby preventing the problems themselves. In all situations, ensure that safety and learning needs are met, and promote optimum function and independence.

identify diseases describes problems for which the physician directs the primary treatment as long as the disease is present

medical- myocardial infarction nursing- fear, altered health maintenance, deficient knowledge, altered tissue perfusion

managed by using physician-prescribed and nursing-prescribed interventions certain physiologic complications that nurses monitor to detect onset of changes in status PC (potential problem): ______ related to _______ ex- PC: paralytic ileus related to anesthesia

needed to implement each step of the nursing process nursing diagnoses best used by nurses who have strong interpersonal and communication skills

Pain (alteration in comfort) related to inflammation as evidence by patient reporting on scale of 8 to 10 Risk for alteration in circulation related to immobility (no evidence- risk diagnosis have 2 parts

labeling selected patient health problems as unhealthy

norm generally accepted rule or pattern data can be compared too

changes in patient's usual health patterns that are unexplained deviation from appropiate population norm behavior that is nonproductive behavior that indicates a developmental lag or evolving dysfunctional pattern

Recognizing significant data: Comparing data to standards to see what is abnormal Recognizing patterns or clusters Identifying strengths and problems Identifying potential complications Reaching conclusions Prioritize!

no problem- no nursing response needed, reinforce health habits possible problem- collect more data to confirm actual or potential nursing diagnosis- evaluate care designed before planning and implementing clinical problem other than nursing diagnosis

problem- what is unhealthy about the patient (ex- bathing self care deficit) etiology- factors maintaining to the unhealthy state (what is causing the problem) (ex- RELATEDTO fear of falling in the tub and obesity) Defining characteristics- identifies subjective and objective data that signal existence of problem; cues (ex- manifested by strong body and urine odor, unclear hair)

smoking cigarettes

Actual- problem has been validated by major defining factors Risk- clinical judgements that there is a vulnerablity to develop the problem Possible- suspected problem, need additional data to confirm or rule out Wellness- clinical judgements about transition from a level of wellness to a higher level of wellness Syndrome- cluter of actual or risk diagnoses that are predicted related

Actual problems have all 4 components- ex- Label- imbalanced nutrition- more than body requirements Definition—intake exceeds metabolic requirements Defining characteristics-eats 5 large meals a day, snacks throughout the day, eats when stressed Related factors: excessive caloric intake, minimal physical activity each day

Individualizing patient care Defining domain of nursing to health care administrators, legislators, and providers Seeking funding for nursing and reimbursement for nursing services

Writing diagnosis in terms of needs and response; ex needs assistance with bathing related to bed rest- bathing self care deficit related to immobility Making legally inadvisable statements - do not use due to Identifying as a problem a patient response that is not necessarily unhealthy; ex mild anxiety related to impending surgery Identifying as a problem signs and symptoms of illness; ex cough related to long history of smoking- ineffective airway clearance related to 20 year history of smoking Identifying as a patient problem or etiology that cannot be changed Identifying environmental factors rather than patient factors as a problem; ex- deficient knowledge related to alteration in parenting- impaired parenting related to knowledge deficit

D. Imbalanced Nutrition related to insufficient funds in meal budget

b, d, f. The purposes of diagnosing are to identify how an individual, group, or community responds to actual or potential health and life processes; identify factors that contribute to or cause health problems (etiologies); and identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems. In the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from the nursing assessment, identifies patient strengths, and identifies resources the patient can use to resolve problems. The nurse assesses and collects patient data in the assessment step and develops a care plan in the planning step of the nursing process.

b, c, f. Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent nursing interventions, such as impaired gas exchange, ineffective airway clearance, or risk for septic shock. Bronchial pneumonia and infection are medical diagnoses, and "potential complication: sepsis" is a collaborative problem.

b. When a possible problem exists, such as situational low self-esteem related to effects of stroke, the nurse must collect more data to confirm or disprove the suspected problem. The conclusion "no problem" means no nursing response is indicated. When an actual problem exists, the nurse begins planning, implementing, and evaluating care to prevent, reduce, or resolve the problem. A clinical problem other than nursing diagnosis requires that the nurse consult with the appropriate health care professional to work collaboratively on the problem.

b."Related to prescribed bedrest" is the etiology of the statement. The etiology identifies the contributing or causative factors of the problem. "Risk for Impaired Skin Integrity" is the problem, and "as evidenced by reddened areas of skin on the heels and back" are the defining characteristics of the problem.

d. Nursing Problem, because it describes a problem that can be treated by nurses within the scope of independent nursing practice. Collaborative and interdisciplinary problems require a teamwork approach with other health care professionals to resolve the problem. A medical problem is a traumatic or disease condition validated by medical diagnostic studies.

b. A clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation is a Risk nursing diagnosis.

d. Each of the four diagnoses is a correctly written two-part diagnostic statement that includes the problem or diagnostic label and the etiology or cause