100% CORRECT.
Medical Diagnosis - ANS.... -Is a concept that defines a disease process or injury
Nursing Diagnosis - ANS.... -Describe human responses to potential or actual
health problems and life processes; is a clinical judgment about actual or potential
individual, family, or community experiences/responses to health problems/life
processes; provides the basis for selection of nursing interventions to achieve
outcomes for which the nurse has accountability
Why do we have nursing diagnosis? - ANS.... -It is used to determine the
appropriate plan of care for the patient. The nursing diagnosis drives
interventions and patient outcomes, enabling the nurse to develop the patient
care plan. Nursing diagnoses also provide a standard nomenclature for use in the
Electronic Health Record, enabling clear communication among care team
members and the collection of data for continuous improvement in patient care -
drives the nursing care plan for the patient
How to write a nursing diagnosis? - ANS.... --Rules
-Must use from the NANDA list
-Cannot add/remove "risk for" for any diagnosis- must use as written
Components of Nursing Diagnosis - ANS.... --NANDA
-PATHO
-As evidenced by statement - evidence you see supporting your diagnosis
, Variations (Actual vs. Risk) - ANS.... --Risk for nursing Dx. has a r/t (related to)
statement followed by risk factors
-Actual risk nursing Dx has a r/t (related to) statement followed by evidence
statement
-To differentiate between evidence and risk factors you may use "risk factors"
Care Plan Building - ANS.... --Nursing diagnoses are the foundation of care plans
-Review your nursing diagnosis book for details to assist you in building a solid
plan
Care Plans Include - ANS.... -1. Assessment
2. Planning
3. Interventions
4. Evaluation
Assessment - ANS.... -Subjective/Objective information - complete head to toe
and collect all assessment and chart data needed. How do you know these things?
Did you get the information with your 5 senses (objective)? Or did the patient tell
you about is (subjective)?
Planning - ANS.... -Short-term and long-term goals
Think of these as during shift or less and those things which go beyond your 12
hour day
Interventions - ANS.... -What will you DO to achieve these goals?