Fundamentals of Nursing Diagnosing

Actual nursing diagnosis Represents a problem that has been validated by the presence of major defining characteristics. Collaborative problems Certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using physician-prescribed and nurse interventions to minimize the complications of the event. Cue Significant data or data that influences analysis ("raises a red flag") Data cluster Grouping of patient data or cues that points to the existence of a patient health problem. Nursing diagnoses should always be derived from clusters of significant data instead of a single cue Diagnosing 1. Identify how an individual, group or community responds to actual or potential health and life processes 2. Identify factors that contribute to or cause health problems (etiologies) 3. Identify resources or strengths the individual, group or community can draw on to prevent or resolve problems. Diagnostic error Labeling selected patient health patterns as unhealthy while failing to detect an actual unhealthy behavior. Health problem A condition that necessitates intervention to prevent or resolve disease or illness, or promote coping and wellness. Medical diagnosis Identify diseases; describe problems for which the physician directs the primary treatment; remains the same for as long as the disease is present Nursing diagnosis Focus on unhealthy responses to health and illness; describe problems treated by nurses within the scope of independent nursing practice; may change from day to day as the patient's responses change. Possible nursing diagnosis Statements describing a suspected problem for which additional data is needed. Risk nursing diagnosis Clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation. Standard Norm Syndrome nursing diagnoses Comprise a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation. (Ex, Rape-Trauma Syndrome or Post-Trauma Syndrome.) Wellness diagnoses Clinical judgments about an individual, family, or community in transition from a specific level of wellness to a higher level of wellness. Two cues must be present: a desire for a higher level of wellness, and an effective present status or function Describe the four steps involved in data interpretation and analysis 1. Recognizing significant data 2. Recognizing patterns or clusters 3. Identifying strengths and problems 4. Identifying potential complications 5 types of nursing diagnoses 1. Actual 2. Risk 3. Possible 4. Wellness 5. Syndrome Describe the benefits of nursing diagnoses Individualized care; allows patients to be informed and willing participants in their care; defines the role of nursing List the concerns that are clearly nursing responsibilities 1. Recognize signs and symptoms of common health problems and those that may indicate the need for expert diagnosis. 2. Predict problems in those at risk and take steps to manage risks and prevent complications 3. Identify human responses and promote optimum function, independence, and quality of life 4. Initiating actions and referrals in a timely way to ensure appropriate, qualified treatment Describe the limitations of nursing diagnoses Classification of standardized nursing diagnoses limits nursing 3 components of an ACTUAL nursing diagnoses 1. Label/definition (Nursing Dx) 2. Related factor/s (R/T) 3. Defining characteristics (AEB) Parts of nursing diagnosis statements 1. Problem - describe the health state of the patient as clearly as possible (Dx) 2. Etiology - describes the physiologic, psychological, sociologic, spiritual, and environmental factors believed to be related to the problem as either the cause or a contributing factor (R/T) 3. Defining Characteristics - the subjective and objective data that signal the existence of the actual or potential health problem (AEB) 2 components of POTENTIAL nursing diagnoses 1. Label/define potential problems (Risk for) 2. Related factor/s (R/T)