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25 Cards in this Set

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NANDA
North American Nursing Diagnosis Association
Diagnosis
statement or conclusion reguarding RN Dx
Types of Diagnosis:
WARPS
Wellness
Actual
Risk
Possible
Syndrome
Wellness
i.e Readiness to enhance
Actual
problem is present at time of assesment
Risk
problem does not exist yet but has the potential unless RN intervenes
Possible
evidence about health problem but incomplete or unclear
i.e Possible Social Isolation
(single, elderly widow)
Syndrome
associated with a cluster of other diagnoses
i.s. Bedridden: Risk for injury, fall, constipation
RN Dx:
PES
problem define
etiology(related to)
signs and symptoms
Qualifiers:
Words with meaning for Dx
Deficient
Impaired
Decreased
Ineffective
Compromised
RN Dx Example
Acute pain related to tissue distention and edema AEB verbal reports, guarding behavior, and change in vital signs.
Nursing vs Medical Diagnoses
Nursing: judgement
Medical: disease process
Independent functions
RN based
Dependent functions
MD gives orders for RN to follow
Collaborative problems
potential problem managed by RN and MD
Collaborative problems Example
RN Dx: Activity Intolerance
MD Dx: Myocardial Infarction
Coll: Potential Complication of MI: CHF
Dx Process:
AIF
Analyze Data
Identify health Problem
Form Dx Statement
Analyze Data
compare with norms
cluster data
id inconsistancies
Identify Health Problem
gather data and conclude a statement
Types of Statements:
2 part: P. E(related to)
3 part: P.E(related to). S(AEB)
2-part: P problem E etiology
3-part: P problem E etiology
S sign/symptom
Two Part Example
Constipation related to prolonged laxative
Three Part Example
Situational Low Self-Esteem related to feeling of rejection by husbands AEB hypersensitivity to criticism; states"I don't know if I can manage by myself."
Collaborative Problems
Disease/Situation
Complication
Related to
Collaborative Problems Example
Potential complication of childbirth: hemorrhage related to bladder distention, retained placental fragments
Guidelines for RN dx
state problem
legally advisable
nonjudgemental
cause/effect are related
RN terminology