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nursing 203

A nursing diagnosis a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.
A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.
A classification system for nursing diagnosis involves knowledge of nursing practice, theoretical framework, and the characteristics of taxonomies.
A medical diagnosis describes a disease or pathology of specific organs or body systems.
collaborate health problems. are both physician and nurse prescribed actions
Collaborative health problems refer to actual or potential physiologic complications that can result from disease, trauma, or treatment.
Descriptors or modifiers are words used to give additional meaning to a nursing diagnosis. Examples include anticipatory, compromised, decreased, deficient, delayed, disproportionate, disabled, disorganized, disturbed, dysfunctional, effective, excessive, etc.
Defining characteristics are the observable “cues or inferences that cluster as manifestations of an actual illness or wellness health state, or nursing diagnosis.” Each piece of information is considered a clinical cue.
Related factors describe the conditions, circumstances, or etiology that contribute to the problem. Terms that can be used include: associated with, related to, or contributing to.
The term risk factor is used to describe clinical cues in risk nursing diagnoses and are not used for actual nursing diagnoses.
Risk nursing diagnosis describes human responses to health conditions/life process that may develop in a vulnerable family, individual, or community
A wellness nursing diagnosis is a diagnostic statement that describes human responses to levels of wellness in an individual, family, or community, that have a readiness for enhancement. It is a one part statement including the diagnostic label.
Actual nursing diagnosis Three-part statement includes diagnostic label, related factors, and defining characteristics
Risk nursing diagnosis Two-part statement includes diagnostic label and risk factors
Possible nursing diagnosis Two-part statement includes diagnostic label and related factors (unknown)
Wellness diagnosis One-part statement includes diagnostic label
Outcome identification is the formulation of goals and measurable outcomes that provide the basis for evaluating nursing diagnoses.
The Nursing-Sensitive Outcomes Classification system (NOC) is organized according to categories, classes, labels, outcome indicators, and measurement activities for outcomes.
A patient outcome is an educated guess, made as a broad statement, about what the patient’s state will be after the nursing intervention is completed.
Planning is the fourth phase of the nursing process, refers to the development of nursing strategies designed to ameliorate patient problems.
Nursing interventions are any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient outcomes.
The evaluation of a nursing intervention written statement that determines the patient’s status in relation to the outcome criteria at a particular time.
Assessment commonly refers to the evaluation or appraisal of a patient’s health state. It is the systematic collection of subjective and objective data.
Created by: 691650210