Kozier Ch 12 Diagnosing Unit 3 The Nursing Process - Fundamentals Of Nursing + Nclex Review? (Elisa)

Front 1

What are the 3 key steps to Diagnosing?

Back 1

-analyze data
-identify health problems, risk, and strengths.
-formulate diagnostic statements
(slide 1)page 200 fig 12-1)

Front 2

What does Diagnosing refers to?

Back 2

-the reasoning process
(slide 2, p.200)

Front 3

Define Diagnosis?

Back 3

-a statement or conclusion regarding the nature of a phenomenon


(slide 2, p.200)

Front 4

What are Diagnostic labels?=

Back 4

-standardized NANDA names

(slide 2, p.200)

Front 5

Define Nursing diagnosis

Back 5

- problem statement consisting of diagnostic label plus etiology
(slide 2, p.200)

Front 6

What are the 4 Types of Nursing Diagnoses?

Back 6

-Actual diagnosis
-Health promotion diagnosis
-Risk diagnosis
-Wellness diagnosis
(slide 3,4, p.200,201)

Front 7

What are the 2 components of Actual diagnosis?

Back 7

-Problem presents at the time of assessment
-Presence of associated signs and symptoms
EX. Ineffective breathing pattern and anxiety.
(slide 3, p.200)

Front 8

What are the 2 components of Health promotion diagnosis?

Back 8

-Preparedness to implement behaviors to improve their health condition
-Example: Readiness for Enhanced Nutrition
(slide 3, p.201)

Front 9

What are the 2 components of Risk diagnosis?

Back 9

-Problem does not exist
-Presence of risk factors (problem likely to develop)
EX. Risk for infection
(slide 4, p.201)

Front 10

What is Wellness diagnosis?

Back 10

-Describes human responses to levels of wellness in individual, family, or community
Example: Readiness for Enhanced Family Coping
(slide 4, p.201)

Front 11

What are the 3 Components of a Nursing Diagnosis ?

Back 11

-Problem statement (diagnostic label)
- Etiology (related factors and risk factors)
- Defining characteristics
(slide 5, p.201)

Front 12

What is a Problem statement (diagnostic label)?

Back 12

-Describes the client’s health problem or response
-Qualifiers (NANDA labels) added to give additional meaning
(slide 5, p.201)

Front 13

Describe Etiology

Back 13

-(related factors and risk factors)
-Identifies one or more probable causes of the health problem
-defines diagnostic label more clearly
(slide 5, p.202)

Front 14

What are Defining characteristics?

Back 14

-Cluster of existing signs and symptoms indicates “actual” diagnosis (clients have signs and symptoms).
-Cluster of factors that cause client to be more vulnerable to a problem indicates “risk for” diagnosis (no subjective or objective data exist at present).
(slide 6, p.202)

Front 15

Nursing Diagnosis is A statement of nursing judgment based on…?

Back 15

- education, experience, expertise and license to treat
(slide 7, p.202)

Front 16

Nursing Diagnosis Describes…?

Back 16

-human response, the client’s physical, sociocultural, psychological, and spiritual responses to an illness or health problem
(slide 7, p.202)

Front 17

Nursing Diagnosis Changes when…?

Back 17

-client’s responses change
(slide 7, p.202)

Front 18

Nursing Diagnosis is an…?

Back 18

-Independent nursing functions
(slide 7, p.202)

Front 19

Who makes the Medical Diagnosis?

Back 19

-Made by a physician
(slide 8, p.202)

Front 20

What does the Medical Diagnosis Refers to?

Back 20

a disease process
(slide 8, p.202)

Front 21

When does the Medical Diagnosis change?

Back 21

Remains the same as long as the disease process is present
(slide 8, p.202)

Front 22

What is Dependent nursing functions?

Back 22

(physician-prescribed therapies and treatments)
(slide 8, p.202)

Front 23

What are Collaborative Problems?

Back 23

-Type of potential problem that nurses manage using both independent and dependent (physician-prescribed) interventions
(slide 9, p.202)

Front 24

What do Collaborative Problems Require?

Back 24

-monitoring of client’s condition and prevention of potential complications
(slide 9, p.202)

Front 25

When do Collaborative Problems Occur?

Back 25

-when a particular disease or treatment is present
(slide 9, p.202)

Front 26

Describe -Analyze data in the 3 key Steps in Diagnostic Process

Back 26

---Compare data against standards (standard, norm)
---Cluster cues (generate tentative hypothesis)
---Identify gaps and inconsistencies (validate data)
(slide 10, p.203-204)

Front 27

After you Analyze data what are the last 2 steps of the 3 key Steps in Diagnostic Process?

Back 27

-Identify health problems, risks, and strengths
-Formulate diagnostic statements
(slide 10, p.204-206)

Front 28

When Writing Nursing Diagnoses what is included in the Basic Two-Part Statement?

Back 28

-Problem (P)
-Etiology (E)
(slide 11, p.207)

Front 29

When Writing Nursing Diagnoses what is included in the Basic Three-Part Statement?

Back 29

-Problem (P)
-Etiology (E)
-Signs and symptoms (S)
(slide 11, p.207)

Front 30

When Writing Nursing Diagnoses what is included in the One-Part Statement?

Back 30

-Wellness (readiness for enhanced)
-Syndrome
(slide 12, p.208)

Front 31

When Writing Nursing Diagnoses what are some Variations?

Back 31

-Unknown etiology
-Complex factors
-Possible
-Secondary
-Other additions for precision
(slide 12, p.208)

Front 32

What are 6 things to remember to Avoid Errors in Diagnostic
Reasoning?

Back 32

-Verify data
-Build a good knowledge base, acquire clinical experience
-Have a working knowledge of what is “normal”
-Consult resources
-Base diagnoses on patterns
-Improve critical-thinking skills
(slide 13, p.209)

Front 33

Describe the Evolution of Nursing Diagnoses

Back 33

-First taxonomy was alphabetical
-Later version based on “human response patterns”
-Taxonomy II has three levels
Domains
Classes
Nursing diagnoses
-Process for acceptance of new and modified labels reviewed biannually
-NIC
-NOC
(slide 14 p. 210)

Front 34

What is NIC?

Back 34

(nursing interventions classification)
(slide 14 p. 210)

Front 35

What is NOC?

Back 35

(nursing outcomes classification)
(slide 14 p. 210)

Front 36

The nurse is conducting the diagnosing phase (nursing diagnosis) of the nursing process for a client with a seizure disorder. Which step exists between data analysis and formulating the diagnostic statement?

A. Assess the client’s needs.
B. Delineate the client’s problems and strengths.
C. Determine which interventions are most likely to succeed.
D. Estimate the cost of several different approaches.

Back 36

A. Gathering data about client needs is assessment.
*B. Correct. In diagnosing, data from assessment are analyzed and problems, risks, and strengths are identified before diagnostic statements are established.
C. Interventions are established in the planning phase and carried out in the implementation phase of the nursing process.
D. Cost is an important consideration but would be estimated in the planning phase.

Front 37

In the diagnostic statement “Excess Fluid Volume related to decreased venous return as manifested by lower extremity edema (swelling),” the etiology of the problem is which of the following?

A. Excess fluid volume
B. Decreased venous return
C. Edema
D. Unknown

Back 37

A. Excess Fluid Volume is the nursing diagnosis.
*B. Correct. Because the venous return is impaired, fluid builds up in lower extremities, resulting in swelling. Therefore, decreased venous return is the cause (etiology) of the problem.
C. Edema of the lower extremity is the sign/symptom or critical attribute.
D. The cause (impaired venous return) is known.

Front 38

Which of the following nursing diagnoses contains the proper components?

A. Risk for Caregiver Role Strain related to unpredictable course of illness
B. Risk for Falls related to tendency to collapse when having difficulty breathing
C. Impaired Communication related to stroke
D. Sleep Deprivation secondary to fatigue and a noisy environment

Back 38

*A. Correct. States the relationship between the stem (Caregiver Role Strain) and the cause of the problem.
B. The diagnostic statement here says the same thing as the related factor (falls and collapse).
C. It is inappropriate to use medical diagnoses such as stroke within a nursing diagnosis statement.
D. Option D is vague. The statement must be specific and guide the plan of care (fatigue may be a result of sleep deprivation and does not direct intervention).

Front 39

A collaborative (multidisciplinary) problem is indicated instead of a nursing or medical diagnosis:

A. If both medical and nursing interventions are required to treat the problem.
B. When independent nursing actions can be utilized to treat the problem.
C. In cases where nursing interventions are the primary actions required to treat the problem.
D. When no medical diagnosis (disease) can be determined.

Back 39

*A. Correct. A collaborative (multidisciplinary) problem is indicated when both medical and nursing interventions are needed to prevent or treat the problem.
B. If nursing care alone can treat the problem (in this case, independent nursing actions), a nursing diagnosis is indicated.
C. If nursing care alone can treat the problem (whether that care involves independent or dependent nursing actions), a nursing diagnosis is indicated.
D. If medical care alone can treat the problem, a medical diagnosis is indicated.

Front 40

A client’s disease is identified by which of the following?

A. Medical diagnosis
B. Nursing diagnosis
C. Nursing process
D. Collaborative diagnosis

Back 40

Answer: A

Rationale: A medical diagnosis identifies and labels a disease. A nursing diagnosis describes responses to disease processes. The nursing process is a way of thinking—a systematic approach to problem identification and care planning. A collaborative diagnosis is a special kind of client problem, not a nursing or medical problem. It describes the complications that might occur as a
result of the client’s disease process.

Front 41

What kind of nursing diagnosis describes an altered health status that may occur if certain
nursing interventions are not ordered?

A. Actual
B. Potential
C. Possible
D. Probable

Back 41

Answer: B

Rationale: A potential nursing diagnosis describes an altered health status for which there are no symptoms present, but which may occur if certain nursing interventions are not ordered. An actual problem exists when the health status has been validated and is occurring.
A possible problem is one that may be present, but there is insufficient data to confirm or rule it out. “Probable” is not a term to describe problem status.

Front 42

Identify the (underlined) part of this nursing diagnosis: “Impaired Skin Integrity:
(Excoriation)r/t prolonged exposure to ammonia 2o urinary incontinence.”

A. Cue
B. Problem
C. Etiology
D. Contributing factor

Back 42

Answer: B

Rationale: A nursing diagnosis consists of two phrases linked by “r/t”. The first phrase is the client’s problem; the second is the etiology (cause) of the problem. A problem is a human response to a stressor such as illness or unmet needs. Cues are the signs and symptoms that form the pattern and allow you to identify the problem. The etiology is the factor(s) causing or contributing to the problem—the second part of the diagnostic statement. “Contributing
factor” is NANDA-I language for “etiology.”

Front 43

What is the (underlined) part of this nursing diagnosis? “Impaired Skin Integrity:
Excoriation r/t (prolonged exposure to ammonia) 2o urinary incontinence.”

A. Cue
B. Problem
C. Etiology
D. Diagnostic label

Back 43

Answer: C

Rationale: The etiology is the factor(s) causing or contributing to the problem—the second part of the diagnostic statement. Cues are the signs and symptoms that form the pattern and allow you to identify the problem. The problem is a human response to a stressor such as
illness or unmet needs—the first part of the diagnostic statement. Diagnostic labels are the standardized NANDA-I labels for problems.