the nursing diagnosis chapter 12 – Flashcards

the results of the assessment and collecting data now I analyze and interpret the data and get my diagnosis. identify patterns validate diganosis formulate the diagnostic statement

analyze data identify patient strengths identify patients normal functional level and indicators of actual or potential dysfunctions. Formulating in my head a diagnostic statement.

I identify patterns validate the diagnosis formulate nursing diagnostic statement.

name of the diagnosis as listed in the taxonomy. it describes problem using as few words as possible, ie: Stress, Urinary Incontinence, Anxiety, self care deficit.

also called modifiers are words used to give additional meaning to the the nursing diagnosis. They describe changes in condition, state of patient, ie Anticipatory: realize ahead of time compromised: made vulnerable to threat Decreased: lessened, lesser in size, amount, or degree

use, analyze, and synthesize the cues. Make sure cues are clustered together in order to get pattern

when there is a lack of cues, I haven't gathered enough information

after selecting the diagnosis validate it with the patient. Normally they will agree but may be in denial but document the problem and status. You validate in 2 stages.

1.the cue clusters I have interpreted are compared with norms for the patient. 2. nursing diagnosis is evaluated for its nursing research base. For each diagnosis discuss with patient etc.

write the label of the actual, risk, wellness, or possible nursing diagnostic process.

actual nursing diagnosis risk nursing diagnosis possible nursing diagnosis wellness diagnosis

3 part statement to include: label, related factors, and defining characteristics. IE Acute pain related to surgical trauma and inflammation as evidenced by grimacing and verbal reports of pain

2 part statement including diagnostic label and risk factors, IE risk for Infection related to surgery and immunosuppression.

2 part statement including diagnostic label and related factors unknown. IE Possible self-esteem disturbance related to unknown etiology

1 part statement includes diagnostic label. IE Readiness for enhanced spiritual well-being.

"risk for caregiver role strain R/T addiction." no defining characteristics

impaired skin Integrity R/T immobility secondary to pneumonia AEB unable to ambulate length of hall without assistance. Put it after etiology and secondary to.

looks at patient holistically, patient is the center. May have multiple medical diagnosis. From these multiple diagnosis he will have multiple nursing diagnosis.

his medical diagnosis is polio my nursing diagnosis are what is affecting him due to the polio, ie impaired walking, fatigue, risk for injury, risk for falls, activity intolerance, chronic pain. Dont put interventions.

Diagnosing would include identifying the client's strengths (past effective coping) and potential health problems (risk for impaired skin integrity; risk for injury due to excessive activity) and validating the nursing diagnosis with the client (urinary incontinence). Assisting the client with ambulation would occur in the implementation stage

The appropriately written nursing diagnosis is "ineffective airway clearance related to inability to clear secretions." "Ineffective health maintenance related to unhealthy habits" is incorrect because it shows value judgments by the nurse. "Ineffective breathing pattern related to dyspnea" is incorrectly written because the "related to" statement essentially restates the nursing diagnosis. "Ineffective therapeutic regimen management due to smoking" is incorrect because the clause "due to" implies a direct cause-and-effect relationship