151-Wk5 Nursing Assessment And Diagnosis- Brianna Lange

Front 1

Nursing Process

Back 1

A problem-solving approach to indentifying, diagnosing, and treating the health issues of clients

Front 2

Steps of the Nursing Process

Back 2

1. Assessment
-the gathering and analysis of information about client's health status
2. Diagnosis
-identify client's problems
3. Planning
-indivualized for each client
4. Implementation
- actual performance of planned interventions
5. Evaluation
-of both the client's response and whether the interventions were effective

Front 3

cue

Back 3

information obtained through the use of the senses

Front 4

inference

Back 4

judgement or interpretation of cues

Front 5

subjective data

Back 5

client's verbal descriptions of their health problems

Front 6

objective data

Back 6

observations or measurements of a client's health status

Front 7

sources of data

Back 7

-client
-family and significant others
-health care team
-medical records
-literature
-nurse's experience

Front 8

phases of client interview

Back 8

Orientation Phase
-introductions, purpose of interview, assurance of confidentiality
Working Phase
-gather information about client's health status
Termination Phase

Front 9

assessment data validation

Back 9

the comparison of data with another source to determine data accuracy

Front 10

Steps of Data Analysis

Back 10

1. Recognize a pattern or trent by cues
2. Compare with normal standards
3. Make a reasoned conclusion

Front 11

medical diagnosis

Back 11

identification of a disease condition on the basis of specific evaluation of physical signs, symptoms, medical history, and results of diagnostic tests/procedures

Front 12

nursing diagnosis

Back 12

determines health problems within the domain of nursing

Front 13

collaborative problem

Back 13

an actual or potential physiological complication that is monitored to detect the onset of changes in a client's status

Front 14

clinical criteria

Back 14

objective or subjective signs and symptoms, clusters of signs and symptoms, or risk factorsthat lead to a diagnostic conclusion

Front 15

risk nursing diagnosis

Back 15

responses to health conditions or life processes that may develop in a vulnerable individual, family, community

Front 16

health-promotion nursing diagnosis

Back 16

clinical judgement of a person's, family's, or community's motivation to increase well-being and actualize human health potential

Front 17

wellness nursing diagnosis

Back 17

describes level of wellness in an individual, family, or community that can be enhanced

Front 18

diagnostic label

Back 18

describes the essence of a client's response to health conditions

Front 19

sources of diagnostic errors

Back 19

1. Errors in data collection
-accuracy, confidence, competence important
2. Errors in interpretation and analysis of data
-ensure database is accurate, complete
3. Errors in Data Clustering
-occurs when data clustered prematurely, incorrectly or not clustered at all
4. Errors in Diagnostic Statement
-ensure language is precise
5. Errors in Documentation