Chapter 17 Nursing Diagnosis

Front 1

a clinical judgement about individual, family, or community responses to actual and potential health problems or life processes. it describes an actual or potential health problem that the nurse is licensed and competent to treat.

Back 1

nursing diagnosis

Front 2

2nd step of nursing process

Back 2

nursing diagnosis

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NANDA

Back 3

North American Nursing Diagnosis Association

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NANDA-I

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North American Diagnosis Association International

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What is NANDA's purpose?

Back 5

responsible for developing a classification system of nursing diagnoses.

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What are four types of nursing diagnoses?

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risk nursing diagnosis; actual nursing diagnosis; wellness nursing diagnosis; heath promotion nursing diagnosis

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EX of nursing diagnosis:
acute pain

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Actual nursing diagnosis

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Ex of nursing diagnosis: risk for infection

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risk nursing diagnosis

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ex of nursing diagnosis:
readiness for enhanced comfort

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health promotion nursing diagnosis

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ex of nursing diagnosis:
readiness for enhanced coping related to successful cancer treatment

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wellness diagnosis

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describes human responses to health conditions or life processes that exist in an individual in an individual, family, or community.

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actual nursing diagnosis

Front 12

describes human responses to health conditions/life processes that will possibly develop in a vulnerable individual, family, or community.

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risk nursing diagnosis

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describes human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement.

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wellness nursing diagnosis

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What are 5 components of a nursing diagnosis?

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diagnostic label
related factors
definition
risk factors
support of diagnostic statement

Front 15

name of the nursing diagnosis as approved by NANDA International; describes the essence of a client's response to health conditions in as few words as possible; includes descriptors such as compromised, decreased, deficient, etc.

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Diagnostic Label

Front 16

a condition or etiology identified from the client's assessment data. it is associated with the client's actual or potential response to the health problem and can change by using nursing interventions; associated with the client's diagnosis.

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related factors

Front 17

describes the characteristics of the human response identified; approved by NANDA

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definition

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

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risk factors

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What are 4 sources of diagnostic errors?

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errors in data collection, errors in interpretation and analysis of data, errors in data clustering, errors in the diagnostic statement.

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which type of diagnostic error is this?
lack of knowledge or skill
inaccurate data
missing data
disorganization

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collecting

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which type of diagnostic error is this?
inaccurate interpretation of cues
failure to consider conflicting cues
using an insufficient number of cues

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interpreting

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which type of diagnostic error is this?
insufficient cluster of cues
premature or early closure
incorrect clustering

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clustering

Front 23

which type of diagnostic error is this?
wrong diagnostic label selected
evidence exists that another diagnosis is more likely
condition is a collaborative problem
failure to validate nursing diagnosis with client
failure to seek guidance

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labeling

Front 24

a nursing diagnosis is:
1. the diagnosis and treatment of human responses to health and illness
2. the advancement of the development, testing, and refinement of a common nursing language
3. a clinical judgment about individual, family, or community responses to actual and potential health problem or life processes.
4. the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history, and the results of diagnostic tests.

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3

Front 25

lisa reviews data she has regarding ms devines pain symptoms. she compares the defining characteristics for acute pain with those for chronic pain. in the end she selects acute pain as the correct diagnosis. this is an example of lisa avoiding an error in:
1. data collection
2. data clustering
3. data interpretation
4. making a diagnostic statement

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4

Front 26

one of the purposes of the use of standard formal nursing diagnostic statements is to
1. evaluate nursing care
2. gather information on client data
3. help nurses to focus on the role of nursing in client care
4. facilitate, understanding of client problems among health care providers

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4

Front 27

the nursing diagnosis "readiness for enhanced communication" is an example of
1. risk nursing diagnosis
2. actual nursing diagnosis
3. wellness nursing diagnosis

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3

Front 28

the nursing diagnosis hypothermia is an example of
1. risk nursing diagnosis
2. actual
3. wellness

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2

Front 29

the word "impaired" in the diagnosis impaired physical mobility is an example of a
1. descriptor
2. risk factor
3. related factor
4. nursing diagnosis

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1

Front 30

in the example listed below, which nurse is acting to avoid a data collection error?
1. the nurse ask a colleague to chart his or her assessment data.
2. the nurse considers conflicting cues in deciding the correct nursing diagnosis.
3. the nurse assessing the edema in a client;s lower leg is unsure of its severity and ask a co worker to check it with him or her.

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3

Front 31

unhappy and worried about health is not a scientifically based nursing diagnosis, and it can lead to error in
1. data collection
2. data clustering
3. medical diagnosis
4.diagnostic statement

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4

Front 32

casey is reviewing a clients list of nursing diagnoses for the medical record. the most recent diagnosis is "diarrhea related to intestinal colitis". this is an incorrectly state diagnostic statement, best described as
1. identifying the clinical sign instead of an etiology
2. identifying a diagnosis based on prejudicial judgment
3. identifying the diagnostic study rather than a problem caused by the diagnostic study
4. identifying the medical diagnosis instead of the client's response to the diagnosis.

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4

Front 33

which of the following are defining characteristics for the nursing diagnosis "impaired urinary elimination"? choose any that apply
1. nocturia
2. frequency
3. urine retention
4. inadequate urinary output
5. receiving intravenous fluids
6. sensation of bladder fullness

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