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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
2.Related Factors
4.Risk Factors
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
Inaccurate data
Missing Data
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
Incorrect clustering
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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