NANDA: Nursing Diagnosis, ADPIE, Evidence Based
Practice, Nursing Data Collection - Fundamental Exam 2
UPDATED ACTUAL Questions and CORRECT Answers
Nursing diagnosis definition A clinical judgment concerning a human response to health conditions/life
processes/or vulnerability for that response, by an individual, family, group, or
community
4 types of NANDA diagnoses (PRHS) Problem focused, risk, health promotion, syndrome.
Components of problem focused diagnoses Nursing diagnosis, relating factors, as evidenced by
Example of problems:
Decreased cardiac output it, chronic functional constipation, impaired gas
exchange.
Problem focus nursing diagnoses are typically based on Signs and symptoms present in the patient. Most common nursing Diagnoses.
risk nursing diagnosis Applies when risk factors require intervention from the nurse and healthcare team
prior to a real problem developing.
Requires clinical reasoning and nursing judgment
Ex) Risk for imbalanced fluid volume, risk for ineffective childbearing process, risk
for impaired oral mucous membrane integrity.
Health promotion Diagnosis To improve the overall well-being of an individual/family or community
Examples: readiness for enhanced family processes, readiness for enhanced
hope, sedentary lifestyle
syndrome diagnosis refers to A cluster of nursing diagnoses that occur and a pattern or can we all be
addressed through the same or similar nursing interventions
Examples: decreased cardiac output, decreased cardiac tissue perfusion,
ineffective cerebral tissue perfusion, ineffective peripheral tissue perfusion.
written problem focus Diagnosis Problem focused Diagnosis______R/T:_____ AEB:____
Risk Diagnosis written Risk for_____aeb (risk factors)
, 13 domains of nursing diagnosis 1. health promotion
2. nutrition
3. elimination slash exchange
4. activity/ rest
5. perception/cognition
6. self perception
7. role relationship
8. sexuality
9. coping/stress tolerance
10. life principles
11. safety and protection
12. comfort
13. growth and development
Classes of Health promotion Health awareness, health management
classes of nutrition Indigestion, digestion, absorption, metabolism, hydration
Classes of Elimination and exchange Urinary function, Gastrointestinal function, Integumentary function, respiratory
function
Classes of activity/rest Sleep/rest, activity/exercise, energy balance, cardiovascular and pulmonary
responses, self-care.
Classes of perception/cognition Attention, orientation, sensation/perception, cognition, communication
Classes of self perception Self-esteem, self-concept, body image
Classes of role relationship Caregiving rules, family relationships, role performance
Classes of sexuality Sexual identity, sexual function, reproduction
Classes of coping/stress techniques Post trauma responses, coping responses, neurobehavioral stress
Classes of life principles Values, beliefs, value and belief of action congruence.
Classes of safety/protection Infection, physical injury, violence, environmental hazards, defensive processes,
thermoregulation
Classes of comfort Physical comfort, environmental, and social comfort
Classes of growth and development Growth, development-Risk for delayed development
Where/When do you start to collect data? As soon as you meet your pt you should start your assessment.
Define Assessing The systematic and continuous collection, validation, analysis, and communication
of pt data
Practice, Nursing Data Collection - Fundamental Exam 2
UPDATED ACTUAL Questions and CORRECT Answers
Nursing diagnosis definition A clinical judgment concerning a human response to health conditions/life
processes/or vulnerability for that response, by an individual, family, group, or
community
4 types of NANDA diagnoses (PRHS) Problem focused, risk, health promotion, syndrome.
Components of problem focused diagnoses Nursing diagnosis, relating factors, as evidenced by
Example of problems:
Decreased cardiac output it, chronic functional constipation, impaired gas
exchange.
Problem focus nursing diagnoses are typically based on Signs and symptoms present in the patient. Most common nursing Diagnoses.
risk nursing diagnosis Applies when risk factors require intervention from the nurse and healthcare team
prior to a real problem developing.
Requires clinical reasoning and nursing judgment
Ex) Risk for imbalanced fluid volume, risk for ineffective childbearing process, risk
for impaired oral mucous membrane integrity.
Health promotion Diagnosis To improve the overall well-being of an individual/family or community
Examples: readiness for enhanced family processes, readiness for enhanced
hope, sedentary lifestyle
syndrome diagnosis refers to A cluster of nursing diagnoses that occur and a pattern or can we all be
addressed through the same or similar nursing interventions
Examples: decreased cardiac output, decreased cardiac tissue perfusion,
ineffective cerebral tissue perfusion, ineffective peripheral tissue perfusion.
written problem focus Diagnosis Problem focused Diagnosis______R/T:_____ AEB:____
Risk Diagnosis written Risk for_____aeb (risk factors)
, 13 domains of nursing diagnosis 1. health promotion
2. nutrition
3. elimination slash exchange
4. activity/ rest
5. perception/cognition
6. self perception
7. role relationship
8. sexuality
9. coping/stress tolerance
10. life principles
11. safety and protection
12. comfort
13. growth and development
Classes of Health promotion Health awareness, health management
classes of nutrition Indigestion, digestion, absorption, metabolism, hydration
Classes of Elimination and exchange Urinary function, Gastrointestinal function, Integumentary function, respiratory
function
Classes of activity/rest Sleep/rest, activity/exercise, energy balance, cardiovascular and pulmonary
responses, self-care.
Classes of perception/cognition Attention, orientation, sensation/perception, cognition, communication
Classes of self perception Self-esteem, self-concept, body image
Classes of role relationship Caregiving rules, family relationships, role performance
Classes of sexuality Sexual identity, sexual function, reproduction
Classes of coping/stress techniques Post trauma responses, coping responses, neurobehavioral stress
Classes of life principles Values, beliefs, value and belief of action congruence.
Classes of safety/protection Infection, physical injury, violence, environmental hazards, defensive processes,
thermoregulation
Classes of comfort Physical comfort, environmental, and social comfort
Classes of growth and development Growth, development-Risk for delayed development
Where/When do you start to collect data? As soon as you meet your pt you should start your assessment.
Define Assessing The systematic and continuous collection, validation, analysis, and communication
of pt data
