Medical Diagnosis Correct Answer-Is a concept that defines a disease
process or injury
Nursing Diagnosis Correct Answer-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? Correct Answer-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? Correct Answer--Rules
-Must use from the NANDA list
-Cannot add/remove "risk for" for any diagnosis- must use as written
Components of Nursing Diagnosis Correct Answer--NANDA
-PATHO
, -As evidenced by statement - evidence you see supporting your
diagnosis
Variations (Actual vs. Risk) Correct Answer--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 Correct Answer--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 Correct Answer-1. Assessment
2. Planning
3. Interventions
4. Evaluation
Assessment Correct Answer-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 Correct Answer-Short-term and long-term goals