Chapter 4

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Nursing process: diagnosis
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1

What is diagnosing?

Using critical thinking skills to identify patterns in the data and draw conclusions about the client's health status

2

Diagnosing includes:

strengths, problems, and factors contributing to the problems

3

In 1980s, most state nurse practice acts began to:

designate nursing diagnosis as an exclusive responsibility of registered professional nurse

4

Medical diagnosis:

describes a disease, illness or injury

5

Nursing diagnosis

a statement of client health status that nurses can identify, prevent, or treat independently

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A health problem is:

any condition that requires intervention in order to promote wellness or to prevent or resolve disease/illness

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How can you treat health problems?

Independently or collaboratively

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Collaborative problems are:

"certain physiologic complications that nurses monitor to detect onset or changes in status

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Types of Nursing diagnosis

Actual, risk, possible, syndrome, wellness

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All patients who have a certain disease or medical treatment are at risk for:

developing the same complications

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A collaborative problem is always a:

potential problem

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If you can prevent the complication with independent nursing interventions alone:

it is not a collaborative problem

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Actual Nursing diagnosis is when:

a problem is present

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Risk Nursing diagnosis:

problem may occur

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Possible Nursing Diagnosis:

Problem may be present

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Syndrome Nursing diagnosis:

several related problems are present

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Wellness Nursing diagnosis:

No problem is present

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The 3 levels or problem urgency are:

high priority, medium priority, and low priority

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High priority is:

life-treatening

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Medium priority is:

Not a direct threat to life, but may cause destructive physical or emotional changes

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Low priority:

requires minimal supportive nursing intervention

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Diagnostic reasoning is:

the thinking process that enables you to make sense of it.

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To analyze and interpret data, you need to follow three steps:

1. identify significant data, 2. cluster cues, 3. identify data gaps and inconsistencies

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Significant data are:

data that influence your conclusions about the client's health status; also known as cues

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Cluster cues are:

a groupe of cues that are related to each other in some way

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Data gap:

Missing data

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Inconsistencies:

Look for inconsistencies in the data

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Standardized language is:

one in which the terms are carefully defined and mean the same thing to all who use them

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Standardized nursing languages are:

a comparatively recent attempt to bring such clarity to communication about nursing knowledge and nursing thinking.

30

Taxonomy is:

a system for classifying ideas or objets based on characteristics they have in common

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A domain is:

an area of activity, study or interest

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A class is:

a subdivision of a domain.

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What are the components of a NANDA-I Nursing Diagnosis?

Diagnostic label, definition, defining characteristics, related factors, and risk factors

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Diagnostic label:

a word or phrase that represents a pattern of related cues and describes a problem or wellness response.

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Definition:

explains the meaning of the label and distinguishes it from similar nursing diagnoses

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Defining characteristics:

The cues that allow you to identify a problem or wellness diagnosis

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Related factor:

The cues, conditions or circumstances that cause, precede, influence, contribute to, or are in some way associated with the problem

38

Risk factors:

Events, circumstances, or conditions that increase the vulnerability of a person or group to a health problem