Ch 4 Funds 2 – Flashcards
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What is the diagnosis step of the nursing process?
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the second step; The phase in which you analyze your assessment data. Identify patterns in the data and draw conclusions about the client's health status, including strengths, problems, and factors contributing to the problems.
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What makes diagnosis critical?
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it links the assessment step, which precedes it, to all the steps that follow it.
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What does the term "nursing diagnosis" mean?
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*A formal diagnostic statement of the client's health status, containing both the problem & etiology. *The list of standardized terms (labels) used to write diagnostic statements. Those terms are problem labels; you must add a second part (etiology) in order to create a complete diagnostic statement.
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Which two nursing organizations have been responsible for making diagnosis a part of the professional nursing role?
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The ANA and NANDA
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What is a health problem?
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any condition that requires intervention to promote wellness or to prevent or treat disease or illness
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What is a nursing diagnosis?
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a statement of client health status that nurses can identify, prevent, or treat independently. It is stated in terms of human responses (reactions) to disease, injury, or other stressors, and it can be either a problem or a strength. Human responses can be biological, emotional, interpersonal, social, or spiritual. Human responses are complex and unique to each person.
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What is the NANDA-I official definition of nursing diagnosis?
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a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.
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What is a medical diagnosis?
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describes a disease, illness, or injury. Its purpose is to identify a pathology so that appropriate treatment can be given. A medical diagnosis is more narrowly focused than a nursing diagnosis. A medical diagnoses remains the same as long as a particular injury or pathology is present.
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What are three differences between medical and nursing diagnoses?
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*You cannot predict a patient's nursing diagnoses just by knowing his medical diagnoses or pathology. *A medical diagnosis, disease, or pathological condition can have any number of nursing diagnoses associated with it. *Clients with the same medical diagnosis may have different nursing diagnoses.
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What are collaborative problems?
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"certain physiologic complications [of diseases, medical treatments, or diagnostic studies] that nurses monitor to detect onset or changes in status."
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What characteristics do collaborative problems have?
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*All patients who have a certain disease or treatment are at risk for developing the same complications. *A collaborative problem is always a potential problem. *If you can prevent the complication with independent nursing interventions alone, it is not a collaborative problem. Collaborative problems require both a physician-prescribed and independent nursing interventions to prevent them or minimize the complications.
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What are the five types of nursing diagnoses?
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*Actual *Potential (Risk) *Possible *Syndrome *Wellness
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What is an actual nursing diagnosis?
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a problem response that exists at the time of the assessment. You identify it by the signs and symptoms (cues) that are present.
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What is a risk (potential) nursing diagnosis?
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describes a problem response that is likely to develop in a vulnerable patient if the nurse and patient do not intervene to prevent it. You will identify a risk diagnosis when the patient does not have signs or symptoms of the problem, but does have risk factors present that increase his vulnerability
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what is a possible nursing diagnosis?
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exists when your intuition and experience direct you to suspect that a diagnosis is present, but you do not have enough data to support the diagnosis. The main reason for including this type of diagnosis on a care plan is to alert other nurses to continue to collect data to confirm or rule out the problem.
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what is a syndrome nursing diagnosis?
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represents a collection of nursing diagnoses that usually occur together.
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what is a wellness diagnosis?
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when an individual, group, or community is in transition from one level of wellness to a higher level of wellness. A wellness diagnosis describes health status, but it is not a health problem. For you to make a wellness diagnosis, two conditions must be present: the client's present level of wellness is effective and the client wants to move to a higher level of wellness.
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what is diagnostic reasoning?
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the thinking process that enables you to make sense of it. Also referred to as analysis.
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what are the steps of the diagnostic reasoning process?
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analyze and interpret data, draw conclusions about health status, verify problems with the patient, prioritize the problems, and record the diagnostic statements.
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what 3 steps are used to analyze and interpret data?
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identify significant data, cluster data, identify data gaps
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what is significant data?
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also called cues; are data that influence your conclusions about the client's health status. A cue is usually an unhealthy response.
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what are five ways you can recognize cute?
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*a deviation from population norms *changes in usual health patterns are not explained by developmental or situational changes *indications of delayed growth and development *changes in usual behaviors in roles or relationships *non productive or dysfunctional behavior
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what is a cluster?
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a group of cues that are related to each other in some way. The cluster may suggest a health problem. You should always derive a nursing diagnosis from data clusters rather than from a single cue.
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what are the possible conclusions you can draw about a client's health status?
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*a patient strength *no problem or a wellness diagnosis *a possible problem *an actual nursing diagnosis *a risk (potential) nursing diagnosis *a collaborative problem *a medical diagnosis
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what is the difference between a cue and an inference?
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Cues are facts (or data), whereas inferences are conclusions (judgements, interpretations) that are based on the data. An inference is not a fact because you cannot directly check it's truth or accuracy.
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what is an etiology?
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consists of the factors that are causing or contributing to the problem. Etiologies may be pathophysiological, treatment-related, situational, social, spiritual, maturational, or environmental.
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what is prioritizing?
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prioritizing places the problems in order of importance, but it does not mean you must resolve one problem before attending to another.
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what theory is used for prioritizing problems?
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Moscow's hierarchy of human needs
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What criteria can you use to determine problem priority?
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*Maslow's Hierarchy of human needs *Problem urgency *Future consequences *Patient preference *Documenting priorities
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Describe a high priority problem urgency ranking.
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Assigned to problems that are life threatening or that could have a destructive effect on the client.
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Describe a medium priority problem urgency ranking.
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Assigned to problems that do not pose a direct threat to life, but that may cause destructive physical or emotional changes.
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Describe a low priority problem urgency ranking.
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Assigned to problems that require minimal supportive nursing intervention.
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what is computer assisted diagnosing?
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some expert systems allow you to enter assessment data, and the computer program will generate a list of possible problems. After you choose a problem, the computer will provide a screen with the definition and defining characteristics of the problem so you can compare them to the actual patient data. after you accept the diagnostic label, you complete the problem statement by choosing etiologies from the next computer screen.
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what three things should you think about when reflecting critically on your diagnostic reasoning?
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your theoretical knowledge, your self knowledge, and your analysis and conclusions
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what is a standardized language?
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one in which the terms are carefully defined and mean the same thing to all who use them
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what are standardized nursing languages?
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a comparatively recent attempt to bring such clarity to communication about nursing knowledge and nursing thinking
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what are the benefits of a uniform language?
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support electronic health records. Define, communicate, and expand nursing knowledge. Increase visibility of nursing interventions. Facilitate research to demonstrate the contribution of nurses to healthcare and influence health policy decisions. Improve patient care by providing better communication among nurses and other healthcare providers and facilitating the testing of nursing interventions.
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what is taxonomy?
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a system for classifying ideas or objects based on characteristics they have in common.
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what is a domain in the NANDA taxonomy?
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an area of activity, study, or interest.
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what is a class in the NANDA taxonomy?
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a subdivision of a domain.
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what are the components of a NANDA nursing diagnosis?
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the diagnostic label, the definition, the defining characteristics, related factors, risk factors
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what is the diagnostic label in a NANDA nursing diagnosis?
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a title or name. A word or phrase that represents a pattern of related cues and describes a problem or wellness response.
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what is the definition in a NANDA nursing diagnosis?
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explains the meaning of the label and distinguishes it from similar nursing diagnoses.
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what are defining characteristics in a NANDA nursing diagnosis?
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The cues (signs and symptoms) that allow you to identify a problem or wellness diagnosis.
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what are related factors in a NANDA nursing diagnosis?
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The cues, conditions, or circumstances that cause, precede, influence, contribute to, or are in some way associated with the problem.
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what are risk factors of a NANDA nursing diagnosis?
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events, circumstances, or conditions that increase the vulnerability of a person or group to a health problem
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how do I know which label to use?
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1.first, identify the broad topic or domain that seems to fit the cue cluster. 2.narrow your search to the class or most likely labels. 3.using a nursing diagnosis handbook, compare definitions and defining characteristics of the diagnostic labels to your cue cluster.
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what does a diagnostic statement consist of?
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a problem and an etiology linked by a connecting phrase
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What is a basic two-part statement?
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*used for actual, risk, and possible diagnoses. *format: (Problem/NANDA label) r/t (etiology/related factors)
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What is a basic three- part statement?
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*also called PES format (problem, etiology, & symptom) *ABE or AMB (as manifested by) *format: problem r/t etiology AMB signs or symptoms
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What is a one-part statement?
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Etiology can be omitted from: *syndrome diagnosis *wellness diagnosis *Very specific labels
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What are some variations to the basic two- & three -part statements?
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*"specify": you will see the word specify in some NANDA labels. *"secondary to": usually a pathophysiology or disease process. Makes clear that nurse is not responsible for that part.
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What is a two- part NANDA label?
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First part describes a general response; second part following a colon, makes it more specific.
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What is an unknown etiology?
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Sometimes you will be unable to identify the etiology but know the patients problem. Happens when you have some but not enough information.
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What is a complex etiology?
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Some problems have too many etiological factors to list, or the etiology is too complex to explain in a brief diagnostic statement. For such problems, You can replace the etiology with "complex factors"
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What is a collaborative problem?
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A potential problem; complication of a disease, test, or medical treatment.; the focus of nursing interventions is monitoring for & preventing the complication
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How does the Nursing Diagnosis relate to outcomes & interventions?
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As a general rule: the problem suggests goals, & the etiology suggests interventions.
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How does the problem suggest goals?
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From the problem, you can determine the patient outcomes for measuring the change in health status. The goals suggest assessments, which are actually a type of nursing interventions. If the problem is not an accurate statement of health status, then your goals & resulting assessments will be wrong.
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How does the etiology suggest interventions?
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The aim of nursing interventions is to alter the factors contributing to the problem. If the etiology is incorrect or incomplete, you might omit important nursing interventions.
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What guidelines can be used for judging the quality of diagnostic statements?
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1. Don't rely on the NANDA label definition alone. Compare patient data to defining characteristics of the label as well as to the definition. 2. Include both the problem & etiology, with "cause & effect" stated correctly. To check, read your statement backwards. 3. Be sure that the etiology doesn't merely restate the problem. 4. Avoid using medical diagnoses & treatments as etiological factors. Nursing interventions are directed at changing/removing the etiological factors. 5. Write the statement clearly. Should give a clear picture of the client's health. 6. Write the statement concisely. A wordy statement is likely to be unclear. 7. Be sure the statement is descriptive & specific. 8. State the problem as a patient response. 9. Use nonjudgmental language. 10. Avoid legally questionable language.
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What are some criticisms of the NANDA system?
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*labels are too abstract *diagnoses have not been researched
