Ch 4 – NUR304 – Adult Health – Flashcards

The Registered Nurse will: - Derive the diagnosis based on the assessment - Validate the diagnosis in a manner that facilitates development of expected outcomes and measures - Identify actual or potential risks the patient as well as identify potential barriers to health - Use a standardize classification system, when available in naming diagnosis

A statement of client health status that nurses can identify, prevent, or treat independently. It is stated in terms of human responses (biological, emotional, interpersonal, social or spiritual). Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable (NANDA, 2003, p. 263). Example: Ineffective tissue perfusion related to decreased cardiac output as evidenced by dusky color, capillary refill of 5 seconds, circumoral cyanosis.

Diagnosis is critical because it links the assessment step, which precedes it, to all of the steps that follow it. Assessment data must be comprehensive and accurate to make an accurate nursing diagnosis. The nursing diagnosis must be accurate because it is the basis for the goals and interventions you will plan and implement for your patients.

American Nurses Association and NANDA International

Collaborative problem (potential complication of childbirth: postpartum hemorrhage) Rationale: This is a potential problem that the nurse can help to prevent (e.g., by fundal massage); but if fundal massage is not effective, the physician must prescribe medication to prevent hemorrhage. This is a potential physiological complication associated with a medical diagnosis (childbirth).

Medical diagnosis: appendicitis (actual problem; nurse cannot treat independently; requires surgery and antibiotics)

Nursing diagnosis Rationale: The problem can usually be prevented by independent nursing interventions. Medication is sometimes prescribed, but not usually.

1. Actual nursing diagnosis 2. Risk (potential) nursing diagnosis 3. Possible nursing diagnosis 4. Syndrome nursing diagnosis 5. Wellness nursing diagnosis "Collaborative problems" is incorrect. Collaborative problems are a type of problem, but not a type of nursing diagnosis.

Wellness diagnosis

Actual diagnosis

Possible diagnosis

Risk diagnosis

Significant data (also called cues) are data that influence your conclusions about the client's health status (or that influence your choice of nursing diagnoses). A cue should alert you to look for other cues that might form a cluster (pattern) representing a nursing diagnosis.

A cue is recognized by the presence of data representing (1) a deviation from population norms (2) a change in usual health patterns that is not explained by developmental or situational changes (3) an indication of delayed growth and development (4) a change in usual behaviors in roles or relationships (5) a nonproductive or dysfunctional behavior

You might conclude that there is a patient strength, no problem, a wellness diagnosis, a possible problem, an actual nursing diagnosis, a risk (potential) nursing diagnosis s, a collaborative problem, or a medical diagnosis.

A cue is a fact (data). Inferences are conclusions (judgments, interpretations) that are based on the data. You can observe a cue directly, but not an inference. You cannot directly check the accuracy of an inference.

The more data and theoretical knowledge you have to support an inference, the more sure you can be that it is valid/accurate.

1. Analyzing and interpreting data (this includes identifying significant data, clustering cues, and identifying data gaps and inconsistencies) 2. Drawing conclusions about health status (this includes making inferences and identifying problem etiologies) 3. Verifying problems with the patient 4. Prioritizing the problems 5. Recording the diagnostic statements (it could be argued that this is not really a "part of" the diagnostic process) Students might also include "reflecting critically about your diagnostic reasoning," although it comes after the diagnostic process, strictly speaking.

● Did I identify all the significant data (cues)? ● Did I omit any important cues from the cluster? ● Did I include unnecessary cues that may have confused my interpretation? ● Did I try more than one way of grouping the cues? ● Did I consider the patient's social, cultural, and spiritual beliefs and needs? ● Did I identify all the data gaps and inconsistencies?

● Did I consider all the possible explanations for the cue cluster? ● Is this the best explanation for the cue cluster? ● Did I have enough data to make that inference? When there is insufficient data, you should suspend judgment until you gather more data. ● Did I look at patterns, not single cues? ● Did I consider behavior over time, not just isolated incidents? ● Did I jump to conclusions? Always take the time to carefully analyze and synthesize the data.

● Is the diagnosis relevant, and does it reflect the data? ● Does the diagnostic statement give a clear and accurate picture of the patient's problem or strength? ● When identifying the problem and etiology, did I look beyond medical diagnoses and consider human responses? ● Did I consider strengths and wellness diagnoses, as well as problems? ● Can I explain how the etiology relates to the problem—that is, how it would produce the problem response? ● Does the complete list of problems fully describe the patient's overall health status?

● Did the patient verify this diagnosis? ● When I verified the diagnosis, did I explain clearly enough? Am I certain that the patient understood my description of his health status? ● Did I obtain feedback from the patient, or did I just assume that he agreed? ● Did I keep an open mind, realizing that all diagnoses are tentative and subject to change as I acquire more data?

● Considering the whole situation, what are the most important problems? ● What aspects of the situation require the most immediate attention? ● Did I consider patient preferences when setting priorities? If not, was there a good reason?

- Places problems in order of importance - Does not mean that you must resolve one problem before attending to another - Determined by the theoretical framework you use ~~Maslow - Problems may be resolved any time or their prioritization may change - monitor and adjust

High priority: Life-threatening Medium priority: Not a direct threat to life, but may cause destructive physical or emotional changes Low priority: Requires minimal supportive nursing intervention

● Diagnostic label ● Definition ● Defining characteristics ● Related or risk factors

Diagnostic label. Succinct expression that symbolizes a pattern of associated cues. Usually reflects the problem response. Definition. Imparts a distinctive explanation, which distinguishes the label from similar nursing diagnoses. Defining characteristics. Recognizable indications that when organized into groups reflect an actual or wellness nursing diagnosis. Patient data. Similar to signs and symptoms. Related or risk factors. Description of clinical cues, conditions, and circumstances associated with the problem in some way (i.e., causing, contributing to the problem). Usually a part of the problem etiology.

● Basic two-part statement. Anxiety related to unknown outcome of surgery—or Pain (lower back) related to muscle strain and tissue inflammation. ● Basic three-part statement. Pain (lower back) related to muscle strain and tissue inflammation AMB states pain is 9 on a 1 to 10 scale. ● Basic two-part statement, using "secondary to" (create your own disease/pathology). Pain (lower back) related to muscle strain and tissue inflammation secondary to lifting heavy object using poor body mechanics. ● Statement with unknown etiology. Anxiety related to unknown etiology. Pain (abdominal) related to unknown etiology. ● Possible nursing diagnosis. Possible Anxiety related to unknown outcome of surgery. ● Risk nursing diagnosis. Risk for Anxiety related to unknown outcome of surgery.

C. Accurate Rationale: Data that are accurate and verifiable are essential to establishing the nursing diagnosis. Recall that nursing diagnoses may also be used to identify risks for problems or wellness concerns. As a result, "problem oriented" is not an appropriate response.

A. a problem or strength. C. a human response to disease, injury, or stressors. Rationale: A nursing diagnosis is 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 can be either a problem or strength. Human responses can be biological, emotional, interpersonal, social, or spiritual.

B. Potential Rationale: A collaborative problem is always a potential problem. If it becomes actual, then it is no longer a collaborative problem but a medical diagnosis requiring physician intervention.

A. Possible B. Actual C. Actual D. Possible E. Possible F. Risk Rationale: An actual nursing diagnosis is a problem response that exists at the time of the assessment. You will identify it by the signs and symptoms (cues) that are present. A possible nursing diagnosis 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. A risk nursing diagnosis describes a problem response that is likely to develop in a vulnerable patient if the nurse does not intervene to prevent it. (A) There is no data to support Deficient Knowledge. Data do indicate that he is not managing his diabetes effectively; however, there is nothing to indicate Deficient Knowledge or anxiety. Therefore, you need more data to know whether Deficient Knowledge and/or anxiety are present. (B) There are cues to support Biochemical Alteration and Fatigue: "He is losing weight and complains of feeling very tired most of the time" and "his fasting glucose levels have been over 150 mg/dL for the majority of days" (C) Weight loss and his wife's statement about his eating are cues that support actual Imbalanced Nutrition: less than body requirements. (D) The data do show chronically elevated glucose, but you need more data to determine whether that is caused by ineffective management of his therapeutic regimen. (E) Data indicate fatigue, but we do not know that he is anxious nor that he is not sleeping well. More data is needed to make or rule out this diagnosis. (F) Data indicate neuropathy, which is a risk factor for Impaired Physical Mobility. There are no data that support actual Impaired Physical Mobility.

● Problem. Describes the client's health status (or a human response to a health problem) and identifies a response that needs to be changed. ● Etiology. Contains the factors that cause, contribute to, or create a risk for the problem. ● Symptom. An organic or functional condition indicating the presence of disease.

priority

identify, prevent, or treat independently

disease, illness, or injury and sometimes symptoms such as pain and constipation (which are also nursing diagnoses)

A. Human response patterns

1. Label 2. Definition 3. Defining characteristics 4. Related or risk factors

False Rationale: In 1980, the ANA published Nursing: Social Policy Statement, which characterized nursing as "the diagnosis and treatment of human response to actual or potential health problems" (ANA, 1980). As a result of this definition and the work of the nursing diagnosis task force, most state's nurse practice acts began to designate nursing diagnosis as an exclusive responsibility of registered professional nurses.

You may think of coherence as meaning "understandable" or "sticking together as a whole." It also has the meaning of "logical consistency." You should at least have answered that it means that the diagnoses, interventions, and outcomes would be understandable when they are documented. A better answer would mention that the interventions and outcomes are related to the diagnoses in some way.

You do not have enough information to make that inference. The study results and findings showed only that nurses charter better quality assessments. This does not necessarily mean that their assessment techniques improved. It could as easily mean that having the nursing diagnosis available when they charted their assessments helped them better remember which assessments they made, or that the diagnosis reminded them of the need to document a focused assessment for it.

Yes, you could safely make this inference, based on the summary of the study. The summary tells you that the researchers themselves concluded that using nursing documentation led to better documentation of interventions. Notice that it does not say that nursing diagnoses led to better interventions—only to better documentation of them.

4) Neither is made on the basis of client symptoms (defining characteristics) Rationale: A risk nursing diagnosis is used when a client is more susceptible (vulnerable) to the problem but does not have supporting data (e.g., signs and symptoms) that the problem exists, and risk factors are present. A possible nursing diagnosis is used when the nurse's intuition and experience make him or her suspect the diagnosis may be present, but again there are no (or minimal) supporting data and no increased vulnerability. Intuition is used for a possible nursing diagnosis, but not for a risk diagnosis. Collaborative problems, not nursing diagnoses, require physician intervention; so this option is not true for either a risk or a possible nursing diagnosis.

1) Acute Pain Rationale: Using a patient preferences framework, highest priority would be given to whatever the client thinks is most important, which most often would be pain. The nurse would, of course, be concerned about mobility, body image, and tissue perfusion. If using another framework (e.g., the potential for permanent injury), the nurse might be most concerned about Ineffective Tissue Perfusion.

4) Decreased urine output Rationale: Defining characteristics are signs and symptoms (cues) of a problem. Decreased urine output is the most obvious defining characteristic for Deficient Fluid Volume. Increased metabolic rate could contribute to Deficient Fluid Volume, but not directly. Some medications might cause (be the etiology of) Deficient Fluid Volume, but they would not be a defining characteristic. History of falls is seemingly unrelated to Deficient Fluid Volume, although the falls and the Deficient Fluid Volume might both be symptoms of a medical diagnosis.

2) Potential Rationale: "Risk for" indicates a potential problem. Risk for Deficient Fluid Volume is a potential nursing diagnosis. Potential nursing diagnoses are designed to identify a patient health problem that could progress to become an actual problem. Based on the nurse's knowledge of acute pancreatitis, she knows that pancreatitis places the client at risk for Deficient Fluid Volume. Actual nursing diagnoses identify problems that already exist. They help detect changes in the client's health status. Possible nursing diagnoses help obtain more data to confirm or eliminate a suspected nursing diagnosis. Wellness diagnoses help assess the client's wellness practices.

1) Interpret patient data Rationale: The diagnostic reasoning process allows the nurse to make sense of patient data for planning and providing quality nursing care. The broad steps in diagnostic reasoning occur generally in this order: analyze and interpret data, draw conclusions about health status, verify problems with the patient, and prioritize problems. Of course the steps overlap, and the nurse may move back and forth between them.

3) Identify significant data Rationale: The steps occur generally in this order, keeping in mind that they overlap and that the nurse may move back and forth between them: identify significant data, cluster cues, identify data gaps and inconsistencies, make inferences, and identify problem etiologies. It would be counterproductive to cluster cues before identifying significant data because the cue clusters would be unmanageable and might not reveal problems. (They would have large amounts of both normal and abnormal data in them.) It is easier to identify data gaps and inconsistencies after cues are clustered; however, it is sometimes evident when you are identifying significant cues. You should make inferences based on the cue clusters you create.

a. A risk nursing diagnosis The data (cues, defining characteristics) suggest that the client is at risk for constipation.

b. Fluid volume excess related to compromised regulatory mechanism Maslow's hierarchy of human needs places survival needs as a priority. Fluid volume excess can lead to pulmonary edema, impaired gas exchange, and respiratory failure. Fluid volume excess is therefore life-threatening and would be a high priority when ranking problems according to problem urgency.

c. The defining characteristics Defining characteristics are the signs and symptoms that allow the nurse to identify a client problem.

a. dehydration b. immobility c. constipaption