Ch 12 - Nursing Diagnosis

Front 1

Nursing Diagnosis

NANDA Def

Back 1

a clinical judgment about individual, family or community responses to actual or potential health/life processes

a nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable

Front 2

Nursing Diagnosis

purpose

Back 2

both the label and the action

to identify problems and synthesize the information gathered during the nursing assessment

Front 3

Taxonomy

Back 3

classification system

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NANDA Taxonomy

Back 4

3 levels:
Domains
Classes
Nursing Diagnosis

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Nursing Diagnosis - NANDA 1973

Back 5

at the first conference, 86 nursing diagnoses alphabetically listed and published for RN usage

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Nursing Diagnosis - NANDA 2007

Back 6

accepted 188 nursing diagnoses for clinical use and testing

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Medical Diagnosis

Back 7

describes a disease or pathology of specific organs or body systems

physician focuses on treating the underlying pathology

Front 8

Nursing Diagnosis

Back 8

describes and actual risk, or wellness human response to a health problem that nurses are responsible for treating independently

Front 9

Nursing Diagnosis

Back 9

describe the client's response for to the disease process, developmental stage, or life process and provide a convenient way to communicate nursing therapies or conventions

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A nurse cannot:

Back 10

diagnose a medical disease and is not licensed to treat such a problem

RN's must take care to identify client problems w/in their scope, practice abilities and education

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When identifying problems from assessment data...

Back 11

nurses determine whether they can address such problems legally and independently

Front 12

Collaborative Health Problems

Back 12

actual or potential physiologic complications that can result from disease, trauma, treatment or diagnostic studies for which nursed intervene in collaboration with personal of other disciplines

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Formulate a Nursing Diagnosis by:

Back 13

*analyzing collected data
*identifying the client's strengths
*identifying the client's normal functional level and indicators of actual or potential dysfunction
*formulating a diagnostic statement in relation to this synthesis

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In the Diagnosis Phase, the nurse:

Back 14

*identifies patterns
*validates the diagnosis
*formulates the nursing diagnosis statement

Front 15

Diagnostic Label

Back 15

the name of the ND as listed in the taxonomy
- describes the essence of the problem using as few words a possible

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Descriptors

Back 16

describe changes in condition, state of the client, of some qualification of the specific nursing diagnosis

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Risk Factors

Back 17

environmental factors and physiological, psychological, genetic, or chemical elements that increase the vulnerability of an individual, family, or community to an unhealthful event

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If Risk Factors are not Addressed:

Back 18

a potential problem may become and actual problem

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Cues

Back 19

pieces of info collected during the nursing assessment

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Cluster

Back 20

formed by several relate cues which are then interpreted and validated

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Cue Clustering

Back 21

goes beyond systems

brings together cues that, if viewed separately, would not convey the same meaning

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Cue Clustering - Purpose

Back 22

to take individual cues and group them to derive meaning

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Problems in Cue Clustering

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expect to use a variety of reference materials to develop cue clustering skills

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Premature Closure

Back 24

lack of adequate cues when forming a nursing diagnosis

selecting a diagnosis before analyzing pertinent information

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Cluster Interpretation

Back 25

intellectual activity requiring nurses to see the whole picture and to attach meaning to the cluster, looking at the pattern the cluster suggests

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correct nursing diagnosis statements

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all the cues supporting the defining characteristics for the diagnosis are present

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Problems in Cluster Interpretations

Back 27

Analysis of cue clusters can be impeded by incorrect clustering of data and misinterpretation of cue clusters

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Validation

Back 28

after selecting the Nursing diagnosis, the nurse should validate it with the client
- legitimizes the diagnosis and helps to discover its significance for the client

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Diagnostic Validation occurs in 2 stages

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Stage 1: clue clusters that have been interpreted are compared with norms for the client and clients in general
Stage 2: the specific nursing diagnosis is evaluated for its nursing research base

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Problems in Diagnostic Validation

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can occur because of a nurse's limited experience, lack of a knowledge base about the nursing diagnosis,or insufficient characteristics of a diagnosis

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Actual Nursing Diagnoses

3-Part Statements

Back 31

describe a human response to a health problem that is being manifested
1-Diagnostic Label
2-Defining Characteristics
3- Related Factors

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Nursing Diagnosis Terms

Back 32

- as manifested by
- as evidenced by
- related to

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Risk Nursing Diagnosis

Back 33

describes human responses to health conditions/ life processes that may develop in a vulnerable individual, family, or community
- supported by risk factors that contribute to increased vulnerability

Front 34

Wellness Nursing Diagnosis

Back 34

a diagnostic statement that describes the human response to levels of wellness in an individual, family or community that have a potential for enhancement to a higher state

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Possible Nursing Diagnosis

Back 35

made when not enough evidence supports the presence of the problem but the nurse thinks that it is highly probable and wants to collect more info