32 notecards = 8 pages (4 cards per page)
The identification of a disease condition based on a specific evaluation of physical signs, symptoms, the patient's medical history and the results of diagnostic tests and procedures.
(2nd step of the nursing process) A clinical judgement about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. Ex: acute pain, nausea
Actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's status.
North American Nursing Diagnosis Association International- Known for its identification of over 80 nursing diagnoses.
ANA's paper Scope of Nursing Practice
Defined nursing as the diagnosis and treatment of human responses to health and illness, helped strengthened the definition of nursing diagnosis. Most state Nurse practice acts include nursing diagnosis as part of the domain of nursing practice.
The purpose of using a standard formal nursing diagnostic statement.
-Provides a precise definition of a patient's problem that gives nurses and other members of the health care team a common language for understanding the patient's needs.
The diagnostic process is a clinical judgement that involves reviewing assessment information, and identifying the patient's specific health care problems.
Nursing diagnostic process
-One purpose of nursing diagnosis is that it provides a precise definition of a patient's problem that gives nurses and other members of the health care team a common language for understanding the patient's needs.
-The nursing diagnosis process includes:
1. data clustering, 2. identifying patient needs or problems, and3. formulating the nursing diagnosis or collaborative problem.
The clinical criteria that are observable and verifiable.
An objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a diagnostic conclusion.
2. Interpretation-Identifying health problems
Analyze clusters of data
3. Formulating a nursing diagnosis
To individualize a nursing diagnosis, you identify the associated related factor.
-Provides the basis for selection of nursing interventions to achieve outcomes for which you, as a nurse, are accountable.
Types of Nursing diagnosis
1. Actual nursing diagnosis- currently exists
1. Actual nursing diagnosis
Describes human responses to health conditions or life processes that exist in an individual, family, or community. Defining characteristics support the diagnostic judgement.
2. Risk nursing diagnosis
(potential) Describes human responses to health conditions, or life processes that may develop in a vulnerable individual, family, or community.
Environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem.
3. Health promotion nursing diagnosis
A clinical judgement of a person's, family's, or community's motivation, desire, and readiness to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors such as nutrition and exercise.
Components of a Nursing diagnosis
When communicating a nursing diagnosis, it is important to use the language adopted within an agency.
The name of the nursing diagnosis as approved by NANDA-I. It describes the essence of a patient's response to health conditions in as few words as possible.
Identified from the patient's assessment data and is the reason the patient is displaying the nursing diagnosis. Associated with a patient's actual or potential response to the health problem and can change by using specific nursing interventions.
(aka related factor) of a nursing diagnosis is always with in the domain of nursing practice and a condition that responds to nursing interventions.
The purpose of concept mapping a nursing diagnosis
Concept mapping a nursing diagnosis is a way to graphically represent the connections among concepts (nursing diagnosis) and ideas that are related to a central subject (patient's problems).
Sources of diagnostic errors
Errors may occur in the nursing diagnostic process during data collection, interpretation, clustering, and labeling of the diagnosis.
-Errors in Data Collection
*Lack of knowledge or skill
-Errors in Interpretation and Analysis of Data
* Inaccurate interpretation of cues
-Errors in Data Clustering
* Insufficient cluster of cues
Errors in the Diagnostic Statement/ Labeling
* Wrong diagnostic label selected
Guidelines to reduce errors when formulating the diagnostic statement
1. Identify the patient's response, not the medical diagnosis.
How would you document a patient's nursing diagnosis
Enter the nursing diagnosis either on a written plan of care or in the electronic health information record of the agency. List chronologically, placing the highest-priority nursing diagnosis first.