Chapter 17 — Nursing Diagnosis

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The nurse identified that the patient has pain on a scale of 7, he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. Write a three-part nursing diagnostic statement using the PES format.
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Correct Answer(s): P, acute pain; E, related to incisional trauma; S, evidenced by pain reported at 7, with guarding, and restricted turning and positioning. The PES format stands for: P (problem), E (etiology or related factor), and S (symptoms or defining characteristics).
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Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) A) Anxiety related to fear of dying B) Fatigue related to chronic emphysema C) Need for mouth care related to inflamed mucosa D) Risk for infection
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Correct Answer(s): A, D The diagnosis “Anxiety related to fear of dying” is stated correctly, with the related factor being the patient’s response to a health problem. Risk for infection is a risk factor for an at-risk diagnosis. In all cases the related factor or risk factor is a condition for which the nurse can implement preventive measures. Fatigue related to chronic emphysema is incorrect since chronic emphysema is a medical diagnosis. Need for mouth care related to inflamed mucosa is not a NANDA-I-approved nursing diagnosis.
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A nurse reviews data gathered regarding a patient’s pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. This is an example of the nurse avoiding an error in: A) Data collection. B) Data clustering. C) Data interpretation. D) Making a diagnostic statement.
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Correct Answer(s): C In the review of data, the nurse compares defining characteristics for the two nursing diagnoses and selects one based on the interpretation of data. Making a diagnostic statement is incorrect because the nurse has not included a related factor.
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The nursing diagnosis readiness for enhanced communication is an example of a(n): A) Risk nursing diagnosis. B) Actual nursing diagnosis. C) Health promotion nursing diagnosis D) Wellness nursing diagnosis.
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Correct Answer(s): C A patient’s readiness for enhanced communication is an example of a health-promotion diagnosis because it implies the patient’s motivation and desire to strengthen his health.
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In the following examples, which nurses are making nursing diagnostic errors? (Select all that apply.) A) The nurse who listens to lung sounds after a patient reports “difficulty breathing” B) The nurse who considers conflicting cues in deciding which diagnostic label to choose C) The nurse assessing the edema in a patient’s lower leg who is unsure how to assess the severity of edema D) The nurse who identifies a diagnosis on the basis of a single defining characteristic
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Correct Answer(s): C, D When the nurse assesses edema without knowing how to assess the severity, the nurse fails to validate her assessment findings of edema, either by using a scale to measure the severity or by asking a colleague to validate her findings. In identifying a diagnosis on the basis of a single defining characteristic, the nurse prematurely closes clustering, which can lead to an inaccurate diagnosis. By listening to lung sounds after the patient reports “difficulty breathing” the nurse validates findings to make an accurate diagnosis. The nurse interprets cue clusters to make an accurate diagnosis when considering conflicting cues to make a diagnosis.
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A nurse is reviewing a patient’s list of nursing diagnoses in the medical record. The most recent nursing diagnosis is diarrhea related to intestinal colitis. This is an incorrectly stated diagnostic statement, best described as: A) Identifying the clinical sign instead of an etiology. B) Identifying a diagnosis based on prejudicial judgment. C) Identifying the diagnostic study rather than a problem caused by the diagnostic study. D) Identifying the medical diagnosis instead of the patient’s response to the diagnosis.
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Correct Answer(s): D In this example intestinal colitis is a medical diagnosis and thus an incorrect diagnostic statement.
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A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order. _____ 1. Considers context of patient’s health problem and selects a related factor _____ 2. Reviews assessment data, noting objective and subjective clinical criteria _____ 3. Clusters clinical criteria that form a pattern _____ 4. Chooses diagnostic label
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Correct Answer(s): 2, 3, 4, 1
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Match the activity on the left with the source of diagnostic error on the right: Activity a. Nurse listens to lungs for first time and is not sure if abnormal lung sounds are present. b. After reviewing objective data, nurse selects diagnosis of fear before asking patient to discuss feelings. c. Nurse identifies incorrect diagnostic label. d. Nurse does not consider patient’s cultural background when reviewing cues. e. Nurse prepares to complete decision on diagnosis and realizes that clinical criteria are grouped incorrectly to form a pattern. Source of Diagnostic Error __ 1. Collecting data __ 2. Interpreting __ 3. Clustering __ 4. Labeling
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Correct Answer(s): 1 a, 2 b and d, 3 e, 4 c. Choice a is an example of lack of skill, an error in collecting data. Choice b is an example of using an insufficient number of cues, an error in interpretation. Choice c is an example of not accurately identifying the problem, a labeling error. Choice d is an example of not incorporating cultural information into the diagnostic process, an error in interpretation. Choice e is an example of incorrect clustering, a clustering error.
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Review the following list of nursing diagnoses and identify those stated incorrectly. (Select all that apply.) A) Acute pain related to lumbar disk repair B) Sleep deprivation related to difficulty falling asleep C) Constipation related to inadequate intake of liquids D) Potential nausea related to nasogastric tube insertion
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Correct Answer(s): A, B, D Acute pain related to lumbar disk repair uses a medical diagnosis as a related factor. Sleep deprivation related to difficulty falling asleep uses a clinical sign rather than a treatable etiology such as “excess noise in environment.” Potential nausea related to nasogastric tube insertion uses a diagnostic study as the etiology. None of the etiologies can be managed or treated by nursing intervention.
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The nurse completed the following assessment: 63-year-old female patient has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2 to 3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37° C, pulse 82 and regular, blood pressure 128/72. Which of the following data form a cluster, showing a relevant pattern? (Select all that apply.) A) Vital sign results B) Abdominal distention C) Age of patient D) Change in bowel elimination pattern E) Abdominal pain F) No past history of hospitalization
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Correct Answer(s): B, D, E The presence of abdominal pain, distention, and a change in bowel elimination pattern forms a cluster, suggesting an elimination problem.
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The nurse completed the following assessment: 63-year-old female patient has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2 to 3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37° C, pulse 82 and regular, blood pressure 128/72. Which additional data do you collect to add to the cluster of information?
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Correct Answer(s): The best way to understand the answer to this question is to have a list of NANDA-I nursing diagnoses and their defining characteristics. For example, the nursing diagnosis of constipation is a possible choice. Examples of additional defining characteristics for which the nurse might assess include checking the quality of bowel sounds, palpating the abdomen for a possible mass, observing the character of any stool that is passed, asking the patient if she is passing flatus.
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The nurse in a geriatric clinic collects the following information from an 82-year-old patient and her daughter, the family caregiver. The daughter explains that the patient is “always getting lost.” The patient sits in the chair but gets up frequently and paces back and forth in the examination room. The daughter says, “I just don’t know what to do because I worry she will fall or hurt herself.” The daughter states that, when she took her mother to the store, they became separated, and the mother couldn’t find the front entrance. The daughter works part time and has no one to help watch her mother. Which of the data form a cluster, showing a relevant pattern? (Select all that apply.) A) Daughter’s concern of mother’s risk for injury B) Pacing C) Patient getting lost easily D) Daughter working part time E) Getting up frequently
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Correct Answer(s): B, C, E Pacing, getting lost, and hyperactivity are a cluster of defining characteristics that point to the diagnostic label of wandering.
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Which of the following are examples of collaborative problems? (Select all that apply.) A) Nausea B) Hemorrhage C) Wound infection D) Fear
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Correct Answer(s): B, C Hemorrhage and wound infection are collaborative problems, actual or potential physiological complications. Nurses typically monitor for these to detect changes in a patient’s status. Nausea and fear are both NANDA-I approved nursing diagnoses.
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Two nurses are having a discussion at the nurses’ station. One nurse is a new graduate who added, “Patient needs improved bowel function related to constipation” to a patient’s care plan. The nurse’s colleague, the charge nurse says, “I think your diagnosis is possibly worded incorrectly. Let’s go over it together.” A correctly worded diagnostic statement is: A) Need for improved bowel function related to change in diet. B) Patient needs improved bowel function related to alteration in elimination. C) Constipation related to inadequate fluid intake. D) Constipation related to hard infrequent stools.
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Correct Answer(s): C Constipation related to inadequate fluid intake is an accurate NANDA-I approved nursing diagnosis with an appropriate etiology. Need for improved bowel function related to change in diet is a goal with an etiologic factor. Patient needs improved bowel function related to alteration in elimination is a goal with a diagnostic statement. Constipation related to hard infrequent stools is a nursing diagnostic label with a clinical sign.
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The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the care plan, which diagnoses will not include defining characteristics? A) Risk for aspiration B) Acute confusion C) Readiness for enhanced coping D) Sedentary lifestyle
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Correct Answer(s): A A risk diagnosis does not have defining characteristics, but instead risk factors. Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem.
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Nursing Diagnosis
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a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. **what makes it unique is having patients involved in the process (if/when possible)**
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Sources of Diagnostic Errors in Collecting Data
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– Lack of knowledge or skill – Inaccurate data – Missing data – Disorganization
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Sources of Diagnostic Errors in Interpreting/Analyzing Data
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– Inaccurate interpretation of cues – Failure to consider conflicting cues – Using an insufficient number of cues – Using unreliable or invalid cues – Failure to consider cultural influences or developmental stage
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Sources of Error in Clustering Data
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– Insufficient cluster of cues – Premature or early closure – Incorrect clustering
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Errors in Labeling Data
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– Wrong diagnostic label selected – Evidence that another diagnosis is more likely – Condition a collaborative problem – Failure to validate nursing diagnosis with patient – Failure to seek guidance
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Sources of Diagnostic Errors
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Collecting data, data clustering, labeling data, interpreting/analyzing data
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Nursing Diagnosis Format (example)
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AT RISK OF ________ (ex INJURY), RELATED TO ___________ (ex DIZZINESS), AS EVIDENCED BY ____________ (ex HISTORY OF PREVIOUS FALLS). – use of BOTH subjective and objective data help to form nursing diagnosis.
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Collaborative Problem
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an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s status.
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Data Cluster
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a set of signs or symptoms gathered during assessment that you group together in a logical way. ex: nurse reports symptoms of: “patient wincing when incision palpated,” “patient acknowledges discomfort over incision,” “patient rates discomfort at 7 on scale of 0 to 10,” “pain increases with movement.” Analyzing data: pattern of a comfort problem.
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Defining characteristics
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found within data clusters; patterns of data that contain the clinical criteria that are observable and verifiable.
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Clinical Criterion
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either an objective or subjective sign, symptom, or risk factor that when analyzed with other criteria, leads to a diagnostic conclusion.
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Related Factor
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a condition, historical factor, or etiology that gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis; needed to individualize and formulate a nursing diagnosis.
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Types of Nursing Diagnoses (3)
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actual diagnoses, risk diagnoses, and health promotion diagnoses
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Actual Diagnosis
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type of nursing diagnosis; describes human responses to health conditions or life processes that exist in an individual, family, or community. Defining characteristics support the diagnostic judgement. ex. wandering, impaired social interaction, stress urinary incontinence.
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Risk Diagnosis
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type of nursing diagnosis; describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. – do NOT have related factors or defining characteristics because they have not occurred yet; instead they have risk factors. ex.: risk for lonliness, risk for acute confusion
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Health Promotion Diagnosis
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a clinical judgment of a person’s, family’s or community’s motivation, desire, and readiness to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors such as nutrition and exercise. – can be used in any health state, do not require current levels of wellness. ex: readiness for enhanced family coping, readiness for enhanced nutrition
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Diagnostic Label
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the name of the nursing diagnosis as approved by NANDA International; describes the essence of a patient’s response to health conditions in as few words as possible.
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Etiology
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related factor of a nursing diagnosis; always within the domain of nursing practice and a condition that responds to nursing interventions.

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