Nursing Process-Diagnosis

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Medical Diagnosis

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is 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 and procedure

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Nursing diagnosis

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

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Nursing diagnosis is a statement that describes what?

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the client's actual or potential response to a health problem that the nurse is licensed and competent to treat

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Nursing diagnoses provides what?

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

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A classification system for nursing defines what?

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the body of knowledge for which nursing is held accountable

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The use of standard formal nursing diagnostic statements serves several purpose such as

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1. Nursing diagnoses offer a language to promote understanding between nurses about clients' health problems so as to facilitate communication and care planning. 2. Nursing diagnoses distinguish the nurse's role from that of the physician. 3. Nursing diagnoses help nurses to focus on the role of nursing in client care

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Diagnostic process include what?

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decision-making steps, including gathering the assessment database, validating data, analyzing and interpreting data, identifying client needs, and formulating nursing diagnosis

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The diagnostic process is what?

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dynamic and requires the nurse to reflect on existing assessment data and health care needs of the client

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Data analysis involves what?

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recognizing patterns or trends, comparing them with standards, and coming to a reasoned conclusion about the client's response to a health problem

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Clinical criteria are what?

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objective or subjective signs and symptoms, clusters of signs and symptoms, or risk factors

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Accuracy means what?

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achieved when all characteristics are evaluated, nonrelevant ones are eliminated, and relevant ones are confirmed

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Before finalizing a nursing diagnosis, the nurse does what?

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identifies the client's general health care needs or problem

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When identifying the client's general problem, the nurse does what?

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considers all assessment data and focuses on pertinent, relevant, and abnormal data

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It is important to do what before assigning a nursing diagnosis?

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review the assessment data to indentify client needs and not to focus solely on the client's illness or medical diagnosis

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Actual Nursing Diagnosis describes what?

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

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An actual nursing diagnosis is a what?

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judgment that is supported by defining characteristics (manifestations, signs, and symptoms) that cluster in patters of related cues or inferences

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Risk Nursing Diagnosis descibes what?

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

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The key assessment for risk nursing diagnosis is what?

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is the presence of data revealing risk factors that support the client's vulnerability

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Wellness nursing diagnosis describes what?

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

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Diagnostic Label is what?

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the name of the nursing diagnosis as approved by NANDA International

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Diagnostic label describes what?

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the essence of a client's response to health conditions in as few words as possible

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Examples of diagnostic descriptors include

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compromised, decreased, deficient, delayed, effective, imbalanced, impaired, and increased

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Related factors are what?

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causative or other contributing factors that have influenced the client's actual or potential response to the health problem and can be changed by nursing interventions

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Related factors include four categories

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pathophysiological (biological or psychological), treatment-related, situational (envirnmental or personal), and maturational

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The "related to" phase does what?

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identifies the etiology or cause of the client's response to health conditions/life processes

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The inclusion of the "related to" phase requires the nurse to what?

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to use critical thinking skills to individualize the diagnosis to ensure appropriate interventions are chosen

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The etiology or cause of the nursing diagnosis must be what?

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withing the domain of nursing practice and a condition that responds to interventions

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Nursing interventions ___ change a medical diagnosis

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cannot

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Nursing interventions can be what?

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directed at behavior or conditions that a nurse can treat or manage

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Example of a definition of a diagnostic label

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Impaired physical mobility is the "limitation in independent, purposeful physcial movement of the body or of one or more extremeties

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What are risk factors?

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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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the risk factors help what?

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in selecting the correct risk diagnosis, similar to the manner in which defining characteristics help in the formulation of actual nursing diagnosis

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Sources of Diagnostic Error: Collecting

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1. Lacking of knowledge or skill
2. Inaccurate data
3. Missing data
4. Disorganization

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Sources of Diagnostic Error: Interpreting

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1. Inaccurate interpretation of cues
2. Failure to consider conflicting cues
3. Using an insufficient number of cues
4. Using unreliable or invalid cues
5. Failure to consider cultural influences or developmental stage

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Sources of Diagnostic Error: Clustering

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1. Insufficient cluster of cues
2. Premature or early closure
3. Incorrect clustering

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Sources of Diagnostic Error: Labeling

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1. Wrong diagnostic label selected
2. Evidence exists that another diagnosis is more likely
3. Condition is a collaborative problem
4. Failure to validate nursing diagnosis with client
5. Failure to seek guidance

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Suggestions to help avoid errors in formulating nursing diagnosis

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1. Identify the client's response, not the medical diagnosis 2. Identify a NANDA International diagnostic statement rather than the symptom. 3. Indentify a treatable etiology rather than a clinical sign or chronic problem 4. Identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself

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Continued: Suggestions to help avoid errors in formulating nursing diagnosis

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5. Identify the client response to the equipment rather than the equipment itself. 6. Identify the client's problems rather than the nurse's problem. 7. Identify the client problem rather than the nursing intervention. 8. Identify the client problem rather than the goal

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Continued: Suggestions to help avoid errors in formulating nursing diagnosis

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9. Make professional rather than prejudicial judgments 10. Avoid legally inadvisable statements. 11. Identify the problem and etiology. 12. Identify only one client problem in the diagnostic statement

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Collabrative problems

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are actual or potential physiological complications that can result from disease, trauma, treatment, or diagnostic studies for which nurses intervene in collaboration with personnel of other health care discipline

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The formulated nursing diagnoses provide what?

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direction for the planning process and the selection of nursing interventions to achieve the desired outcomes

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NANDA International has developed what?

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a nursing diagnosis taxonomy, a classification system, to provide a structure for nursing practice