the nursing diagnosis chapter 12

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main points in diagnosing are
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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
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during the assessment I am doing in order to get to my nursing diagnosis
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analyze data identify patient strengths identify patients normal functional level and indicators of actual or potential dysfunctions. Formulating in my head a diagnostic statement.
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with the info from the assessment how do I do the diagnosis
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I identify patterns validate the diagnosis formulate nursing diagnostic statement.
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what is the diagnostic label
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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.
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What are descriptors
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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
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cue clustering
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use, analyze, and synthesize the cues. Make sure cues are clustered together in order to get pattern
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premature closure
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when there is a lack of cues, I haven’t gathered enough information
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how to validate a diagnosis
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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.
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2 stages of validating the diagnosis
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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.
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How do I formulate the diagnostic statement
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write the label of the actual, risk, wellness, or possible nursing diagnostic process.
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What are the types of nursing diagnosis
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actual nursing diagnosis risk nursing diagnosis possible nursing diagnosis wellness diagnosis
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Example of an Actual nursing diagnosis
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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
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Example of Risk nursing diagnosis
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2 part statement including diagnostic label and risk factors, IE risk for Infection related to surgery and immunosuppression.
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Example of Possible nursing diagnosis
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2 part statement including diagnostic label and related factors unknown. IE Possible self-esteem disturbance related to unknown etiology
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Example of a wellness diagnosis
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1 part statement includes diagnostic label. IE Readiness for enhanced spiritual well-being.
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example of nursing risk diagnosis
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“risk for caregiver role strain R/T addiction.” no defining characteristics
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adding a medical diganosis
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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.
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explain mind map
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looks at patient holistically, patient is the center. May have multiple medical diagnosis. From these multiple diagnosis he will have multiple nursing diagnosis.
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concept map
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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.
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what does the nursing diagnose include
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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
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a good example of a diagnosis
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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

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