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26 Cards in this Set
- Front
- Back
Nursing Diagnosis
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Nursing diagnosis, the second step of the nursing process, is a term used to classify health problems within the domain of nursing. Diagnosis means “to distinguish” or “to know.” A nursing diagnosis is a clinical judgement about individual, family, or community responses to acutal and potential health problems or life processes. It is a statement that describes the client's actual or potential response to a health problem that the nurse is licensed and competent to treat. Impaired skin integrity, risk for infection, and deficient knowledge are examples of nursing diagnosis.
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Wellness Diagnosis
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Statement of effective functioning
NANDA - “A clinical judgement about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness.” 2 cues must be present Desire for increased wellness Effective present status or function Diagnostic statements for wellness nursing diagnosis are one part, containing the label only. The label begins with “Potential for Enhanced,” followed by the higher-level wellness that the individual or group desires (eg, Readiness for Enhanced Family Processes). |
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Actual Nursing Diagnosis
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An actual nursing diagnosis represents a problem that has been validated by the presence of major defining characteristics. This type of nursing diagnosis has four components: label, definition, defining characteristics, and related factors.
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High-Risk Nursing Diagnosis
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NANDA defines a risk nursing diagnosis as “a clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation.”
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Syndrome Nursing Diagnosis
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Syndrome nursing diagnosis are an interesting development in nursing diagnosis. They comprise a cluster of predicted actual or high-risk nursing diagnosis related to a certain event or situation.
Syndrome nursing diagnosis usually are one-part diagnostic statements with the etiologic or contributing factors contained in the diagnostic label (eg, Rape Trauma Syndrome). |
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Nursing Diagnosis: Analysis
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Principles
problem identification begins with gathering and clustering data the recognition of abnormal data is essential before you can recognize abnormal data, you must know what is normal authority and ability to diagnose a health problem depends on your nursing knowledge |
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Steps of diagnostic reasoning
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After the assessment is done, bring related data together (clustering)
Identify positive and negative data If one piece of data suggests a problem, do a focus assessment |
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Nursing Diagnosis
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A statement of the client's current or high risk health problems which nurse's can change in the direction of health
Identifies cause and signs and symptoms By virtue of our nursing education we are capable and licensed to treat these problems |
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Components of Diagnostic Statements
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Wellness diagnosis - statement of effective functioning
NANDA - "a clinical judgement about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness." 2 cues must be present Desire for a higher level of wellness Effective present status or function |
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High Risk Nursing Diagnosis
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A clinical judgement that an individual, family or community is more vulnerable to develop the problem than others in the same or similar circumstances.
Diagnostic Statement Statement of risk or high risk Diagnostic label (etiology) Risk factor |
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Actual Nursing Diagnosis
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Diagnostic label (Client Problem)
Etiology - probable cause of the problem Defining characteristics - signs and symptoms |
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Syndrome Nursing Diagnosis
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Diagnostic label
NANDA has approved five syndrome diagnosis: Disuse syndrome Rape trauma syndrome Post - trauma syndrome Relocation stress syndrome Impaired environmental interpretation syndrome Made up of a cluster of actual or high risk nursing diagnosis that are predicted to be present because of a specific event or situation |
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Nursing Diagnosis Associated with Disuse Syndrome
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Impaired physical immobility
High risk for: altered respiratory function venous thrombosis constipation infection injury Activity intolerance body image disturbance self-care deficits impairment of skin integrity powerlessness |
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Nursing Diagnosis Associated with Rape Trauma Syndrome
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Anxiety
Fear Grieving Pain High risk for: sleep/rest disturbances altered sexuality patterns |
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Documentation of Nursing Diagnosis
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Diagnostic statement is very disciplined - the label cannot be modified in any way.
Precise terminology is used to aid communication, research and reimbursement Nursing Diagnosis is the problem and we are building the care plan to solve that problem. |
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Wellness Diagnosis
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One part statement
Contains the label only Example: Potential for enhanced... |
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High Risk Nursing Diagnosis
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Statement of degree of risk
"high risk" or "risk" Diagnostic labels - client problems a situation a nurse can treat Statement of the risk factors those situations which increase the vulnerability of the client to the problem Ex: High risk for activity intolerance r/t enforced bedrest |
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Actual Nursing Diagnosis
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Diagnostic Label - problem
describes client's situation/condition is unhealthy May be changed by nursing Include any qualifiers that clarify the problem |
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Etiology/cause
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identifies why the problem exists
may be: pathological maturational treatment related situational unknown linked to the problem by term "related to" - R/T legal issue don't use "caused by" (medical diagnosis) because that is not in our scope of practice. Can use "secondary to" to further describe the etiology. |
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Defining characteristics
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positive data that supports the problem
data may be subjective or objective validated data joined to the diagnostic statement by "as evidenced by" or "a.e.b." |
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PES Format
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P = Problem
E = Etiology S = Symptoms Ex: Ineffective breathing pattern r/t accumulation of fluid in lungs s/t CHF a.e.b. c/o dyspnea, RR = 32, O2 Sat 88%, etc. |
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Syndrome Diagnosis
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One part diagnostic statement
etiology or contributing factors for Dx is contained in the diagnostic label could consider cluster of diagnoses individually, but syndrome diagnosis says it all |
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Collaborative Problem
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Certain physiological complications that nurses monitor to detect onset or changes in client status
Nurses monitor them using MD prescribed interventions to minimize the complication or event. |
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Nursing Diagnosis vs. Collaborative Problem
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Nursing Diagnosis
a statment of the client's high risk or actual health problem which nurses by virtue of their education and experience are licensed to treat Collaborative Problem certain physiological complications that nurses monitor to detect the onset or a change in status. Doctor's prescribe the definitive treatment. Nurse use prescribed treatment and interventions that are in the domain of nursing. |
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Validating an Actual Nursing Dx
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Carpenito's criteria
determine that major defining characteristics are present defining characteristics refer to clinical cues (objective and subjective) signs and symptoms must be present 80-100% of time |
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Case Study
Mr. B. has been on enforced bedrest for 2 weeks. When the doctor finally decides he can ambulate, he finds that walking to the bathroom causes dyspnea and a rapid pulse. VS: 98.6-100-26-150/70 Baseline: 98.8-80-18-130/68 P and R do not return to baseline by 3 min. (standard recovery) |
Activity intolerance related to compromised oxygen transport secondary to prolonged bedrest of 2 weeks a.e.b. dyspnea and a rapid pulse when walking to the bathroom that do not return to baseline within 3 min. P100, RR26
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