Chapter 17-Nursing Process Analysis (Nursing Diagnosis)

A clinical judgment based on information.

Medical Diagnosis
Identification of a disease condition based on specific evaluation of signs and symptoms.

Nursing Diagnosis
Clinical judgment about the patient in response to an actual or potential health problem.

Collaborative Problem
Actual or potential physiological complication that nurses monitor to detect a change in patient status.

-Patient, family and health care resources
-Nurse clarifies inconsistent or unclear info
-Critical thinking
-Validate data with other sources
What does the assessment of patient’s health status include?

-Data clustering
-Look for defining characteristics and related factors
-Identify patient needs
-Formulate nursing diagnoses
If no additional data are needed, what do you do?

Data cluster
Set of signs or symptoms gathered during assessment that you group together in a logical way.

Defining characteristics
Clinical criteria that are observable and verifiable

Clinical criterion
Objective or subjective sign/symptom or risk factor that when analyzed with other criteria leads to diagnostic conclusion.

Nursing Diagnostic Statements
Provides precise definition of patient’s problem helps understand patient’s needs. Allows nurses to communicate. Distinguishes nurse’s role from physician. Helps nurses focus on scope of nursing practice.

Diagnostic Reasoning Process
The ___________ ___________ _____________ involves using the assessment data you gather about a patient to logically explain a clinical judgment or a nursing diagnosis.

Related factor
A condition, historical factor, or etiology that gives a context or the defining characteristics and shows a type of relationship with nursing diagnosis.

Problem Identification
Phase in assessment as the general health care problem and the formulation of the nursing diagnosis as the specific health problem.

The ___________ of certain defining characteristics suggests that you reject a diagnosis under consideration.

Related factor
Allows you to individualize a nursing diagnosis for a specific patient.

Actual Nursing Diagnosis
Describes human responses to health conditions or life processes.

Risk Nursing Diagnosis
Describes human responses to health conditions/life processes that may develop

Health Promotion Nursing Diagnosis
A clinical judgment of motivation, desire, and readiness to enhance well-being and actualize human health potential. People who want to better to prevent disease.

Diagnostic label
The name of the nursing diagnosis as approved by NANDA International. (problem) Describes the essence of a client’s response to health conditions in as few words as possible. (impaired, ineffective, deficient, compromised)

AKA the cause or related to factor

Defining Characteristics

Consider the patient’s ___________ diversity when selecting a nursing diagnosis.

Cultural awareness
__________ _____________ and sensitivity improve your accuracy in making nursing diagnoses.

Identified from assesment data. Causative/contributive factors that can be changed by nursing interventions. Pathophysiological, treatment-related, situational, maturational.

Risk factors
Environmental, Physiological, psychological, genetic, or chemical elements that increase the vulnerability of an individual, family or community. Serve as cues to indicate a risk ND. Ex: risk for falls.

Assessment data must ________ diagnostic label.

Related to
__________ ____ factors must support etiology.

Signs/symptoms of etiology
“As evidenced by (AEB)” or “As manifested by (AMB)

Data collection, data clustering, interpretation/analysis of data, labeling diagnosis, documentation and informatics
What are the sources of diagnostic errors?

-Identify patient’s response
-Identify NANDA-I diagnostic statement, not symptom
-Identify treatable cause or risk factor
-Identify problem
-Identify patient response to equipment
Diagnostic statement guidelines

-Identify patient’s problems rather than yours or nursing intervention or goalf care
-Make professional judgments
-Avoid legally inadvisable statements
-Identify problem and its cause
-Identify only one patient problem in diagnostic statement
Diagnostic statement guidelines

Nursing Diagnosis: Application to care planning
Communicate client’s health care problems to team. Helps ensure you select relevant and appropriate nursing interventions.

You are preparing to write a collaborative problem diagnosis. Which of the following elements is typically left out of a collaborative problem? Etiology Feedback A collaborative problem is always a potential problem (e.g., a complication of a disease, test, or …

Nursing Diagnosis A clinical judgment about individual, family, or community responses to a health problem Medical Diagnosis Disease, illness, injury, or condition validated by s/s and medical diagnostic studies WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY TOPIC SPECIFICALLY …

Actual nursing diagnosis Judgement that is clinically validated by the presences of major defining characteristics. Clinical criterion Objective or subjective signs and symptoms, clusters of signs and symptoms or risk factors. WE WILL WRITE A CUSTOM ESSAY SAMPLE ON ANY …

The 4 types of nursing diagnoses Actual, Risk, Health promotion, Wellness Actual nursing diagnosis describes human response to health conditions or life processes that exist in an individual, family or community. Defining characteristics that cluster! WE WILL WRITE A CUSTOM …

Nursing diagnostic process assessment of patients health status——->validate data with other sources————>are additional data needed?————>no—————>interpret and analyze meaning of data————–>data clustering (group signs and symptoms, classify and organize)————->look for defining characteristics and related factors———->identify patients needs———->formulate nursing dignoses and collaborative …

Nursing Process = Care Planning: • Approach to Problem Solving • Elements of Critical Thinking >Characteristics of a Process • Purpose, Organization, Creativity >Five Step Process: • Assessment, Diagnosis, Planning, Implementation, Evaluation (ADPIE) Nursing Assessment Systematic and continuous collection and …

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