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26 Cards in this Set

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Nursing Diagnosis
Nursing diagnosis, the second step of the nursing process, is a term used to classify health problems within the domain of nursing. Diagnosis means “to distinguish” or “to know.” A nursing diagnosis is a clinical judgement about individual, family, or community responses to acutal and potential health problems or life processes. It is a statement that describes the client's actual or potential response to a health problem that the nurse is licensed and competent to treat. Impaired skin integrity, risk for infection, and deficient knowledge are examples of nursing diagnosis.
Wellness Diagnosis
Statement of effective functioning
NANDA - “A clinical judgement about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness.”
2 cues must be present
Desire for increased wellness
Effective present status or function
Diagnostic statements for wellness nursing diagnosis are one part, containing the label only. The label begins with “Potential for Enhanced,” followed by the higher-level wellness that the individual or group desires (eg, Readiness for Enhanced Family Processes).
Actual Nursing Diagnosis
An actual nursing diagnosis represents a problem that has been validated by the presence of major defining characteristics. This type of nursing diagnosis has four components: label, definition, defining characteristics, and related factors.
High-Risk Nursing Diagnosis
NANDA defines a risk nursing diagnosis as “a clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation.”
Syndrome Nursing Diagnosis
Syndrome nursing diagnosis are an interesting development in nursing diagnosis. They comprise a cluster of predicted actual or high-risk nursing diagnosis related to a certain event or situation.
Syndrome nursing diagnosis usually are one-part diagnostic statements with the etiologic or contributing factors contained in the diagnostic label (eg, Rape Trauma Syndrome).
Nursing Diagnosis: Analysis
problem identification begins with gathering and clustering data
the recognition of abnormal data is essential
before you can recognize abnormal data, you must know what is normal
authority and ability to diagnose a health problem depends on your nursing knowledge
Steps of diagnostic reasoning
After the assessment is done, bring related data together (clustering)
Identify positive and negative data
If one piece of data suggests a problem, do a focus assessment
Nursing Diagnosis
A statement of the client's current or high risk health problems which nurse's can change in the direction of health
Identifies cause and signs and symptoms
By virtue of our nursing education we are capable and licensed to treat these problems
Components of Diagnostic Statements
Wellness diagnosis - statement of effective functioning
NANDA - "a clinical judgement about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness."
2 cues must be present
Desire for a higher level of wellness
Effective present status or function
High Risk Nursing Diagnosis
A clinical judgement that an individual, family or community is more vulnerable to develop the problem than others in the same or similar circumstances.
Diagnostic Statement
Statement of risk or high risk
Diagnostic label (etiology)
Risk factor
Actual Nursing Diagnosis
Diagnostic label (Client Problem)
Etiology - probable cause of the problem
Defining characteristics - signs and symptoms
Syndrome Nursing Diagnosis
Diagnostic label
NANDA has approved five syndrome diagnosis:
Disuse syndrome
Rape trauma syndrome
Post - trauma syndrome
Relocation stress syndrome
Impaired environmental interpretation syndrome
Made up of a cluster of actual or high risk nursing diagnosis that are predicted to be present because of a specific event or situation
Nursing Diagnosis Associated with Disuse Syndrome
Impaired physical immobility
High risk for:
altered respiratory function
venous thrombosis
Activity intolerance
body image disturbance
self-care deficits
impairment of skin integrity
Nursing Diagnosis Associated with Rape Trauma Syndrome
High risk for:
sleep/rest disturbances
altered sexuality patterns
Documentation of Nursing Diagnosis
Diagnostic statement is very disciplined - the label cannot be modified in any way.
Precise terminology is used to aid communication, research and reimbursement
Nursing Diagnosis is the problem and we are building the care plan to solve that problem.
Wellness Diagnosis
One part statement
Contains the label only
Example: Potential for enhanced...
High Risk Nursing Diagnosis
Statement of degree of risk
"high risk" or "risk"
Diagnostic labels - client problems
a situation a nurse can treat
Statement of the risk factors
those situations which increase the vulnerability of the client to the problem
Ex: High risk for activity intolerance r/t enforced bedrest
Actual Nursing Diagnosis
Diagnostic Label - problem
describes client's situation/condition is unhealthy
May be changed by nursing
Include any qualifiers that clarify the problem
identifies why the problem exists
may be:
treatment related
linked to the problem by term "related to" - R/T
legal issue
don't use "caused by" (medical diagnosis) because that is not in our scope of practice. Can use "secondary to" to further describe the etiology.
Defining characteristics
positive data that supports the problem
data may be subjective or objective
validated data
joined to the diagnostic statement by "as evidenced by" or "a.e.b."
PES Format
P = Problem
E = Etiology
S = Symptoms
Ex: Ineffective breathing pattern r/t accumulation of fluid in lungs s/t CHF a.e.b. c/o dyspnea, RR = 32, O2 Sat 88%, etc.
Syndrome Diagnosis
One part diagnostic statement
etiology or contributing factors for Dx is contained in the diagnostic label
could consider cluster of diagnoses individually, but syndrome diagnosis says it all
Collaborative Problem
Certain physiological complications that nurses monitor to detect onset or changes in client status
Nurses monitor them using MD prescribed interventions to minimize the complication or event.
Nursing Diagnosis vs. Collaborative Problem
Nursing Diagnosis
a statment of the client's high risk or actual health problem which nurses by virtue of their education and experience are licensed to treat
Collaborative Problem
certain physiological complications that nurses monitor to detect the onset or a change in status. Doctor's prescribe the definitive treatment. Nurse use prescribed treatment and interventions that are in the domain of nursing.
Validating an Actual Nursing Dx
Carpenito's criteria
determine that major defining characteristics are present
defining characteristics refer to clinical cues (objective and subjective) signs and symptoms
must be present 80-100% of time
Case Study
Mr. B. has been on enforced bedrest for 2 weeks. When the doctor finally decides he can ambulate, he finds that walking to the bathroom causes dyspnea and a rapid pulse.
VS: 98.6-100-26-150/70
Baseline: 98.8-80-18-130/68
P and R do not return to baseline by 3 min. (standard recovery)
Activity intolerance related to compromised oxygen transport secondary to prolonged bedrest of 2 weeks a.e.b. dyspnea and a rapid pulse when walking to the bathroom that do not return to baseline within 3 min. P100, RR26