Glossary of Ch. 16 - Nursing Diagnosis
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- Identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history, and the results of diagnostic tests and procedures.
- Medical Diagnosis
- Clinical judgement about individual, family, or community responses to actual and potential health problems or life processess.
- Nursing Diagnosis
- NANDA International
- North American Nursing Diagnosis Association
- Purpose to develop, refine, and promote a taxonomy of nursing diagnostic terminology of general use for professional nurses
- Decision-making steps, including gathering the assessment database, validating data, analyzing and interpreting data, identifying client's needs, and formulatin nursing diagnoses.
- Diagnostic process
- Clinical criteria or assessment findings that support (validate) and actual nursing diagnosis.
- Defining Characteristics
- Describes human responses to health conditions/life processes that exist in an individual, family, or community.
- Actual Nursing Diagnosis
- Describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or commmunity.
- Risk Nursing Diagnosis
- Describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement
- Wellness Nursing Diagnosis
- name of the nursing diagnosis as approved by NANDA International.
- Diagnostic Label
- Causative or ther contributing factors that have influenced the client's actual or potential response to the health problem and can be changed by nursing interventions.
- Related Factors
- Cause of the nursing diagnosis
- Describes charactersitics of the human response identified
- Environmental, physiological, psychological, genetic, or chemical elements that increase the vulnerability of an individual, family or community to an unhealthful event.
- Risk Factors
- Nursing assessment data mush support the diagnostic label, and the related factors must suppor the etiology.
- Support of the Diagnostic Statement
- List the Components of a Nursing Diagnosis:
- 1.Diagnostic Label
5.Support of the Diagnostic Statement
- Allows a student nurse to plot out associated thoughts, link together lines of reasoning, and see the relationship of one problem or diagnosis with another.
- Mind Mapping
- Sources of Diagnotic Error
- Lack of knowledge or skill
- Diagnostic Errors Collecting Data
- Inaccurate interpretation of cues
Failure to consider conflicting cues
Using an insufficient number of cues
Using unreliable or invalid cues
Failure to consider cultural influences or developmental stage
- Diagnostic Errors Interpreting Data
- Insufficient cluster of cues
Premature or early closure
- Errors in Data Clustering
- Wrong diagnostic label selected
Evidence exists that another diagnosis is more likely
Condition is a collaborative problem
Failure to validate nursing diagnosis with client
Failure to seek guidance
- Errors in the Diagnostic Statement
- Actual or potential physiological complications that can result from disease,trauma, treatment, or diagnostic studies for which nurses intervene in collaboration with personnel of other health care disciplines.
- Collaborative problems
- A map for nursing care and demonstrates accountability for client care.
- Care Plan
- A classification system that is used to facilitate knowledge of common language for nurses to manage
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