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Nursing Diagnosis

MC Nursing Diagnosis Ch 17

Medical Diagnosis 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.
Nursing Diagnosis A clinical judgement about individual, family, or community responses to actual and potential health problems or life processes.
Collaborative Problem An actual or potential physiological complication that nurses monitor to detect the onset of changes in a client's status. (Nurses manage collaborative problems such as homorrhage, infection, and cardiac arrhythmia using both physician-prescribed and nurs
Client-Centered Problems Early theorists defined nursing intervention in terms of client-centered problems.
Defining Characteristics The clinical criteria or assessment findings that support actual nursing diagnosis.
Clinical Criteria Objective or subjective signs and symptoms, clusters of signs and symptoms, or risk factors that lead to a diagnostic conclusion.
Actual Nursing Diagnosis An actual nursing diagnosis describes human responses to health conditions of life processes that exist in an individual, family, or community. (Ex: Acute Pain.)
Risk Nursing Diagnosis Describes human responses to health conditions/life processes that will possibly develop in a vulnerable individual, family, or community. (Ex: Risk for infection.)
Health Promotion Nursing Diagnosis Clinical judgment of a person's, family's, or community's, motivation and desire to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors, such as nutrition and exercise. (Ex: Readine
Wellness Nursing Diagnosis Human responses to levels of wellness in an individal, family, or community that have a readiness for enhancement. (Readiness for ehnaced coping related to successful cancer treatment.)
Diagnostic Label The name of the nursing diagnosis as approved by NANDA.
Related Factors Condition or etiology identified from the clint's assessment data. It is associated w/ the client's actual problem.
Etiology Part of nursing diagnosis always w/in the domain of nursing practice and a condition that responds to nursing interventions.
Definition Definition describes the characteristics of the human response identified.
Risk Factors Environmental, physiological, psychological, genetic, or chemical elements that increase the vulnerability of an individual, family or community to an unhealthful event.
Support of the Diagnostic Statement Nursing assement data needs to support the diagnostic label, and the related factors need to support the etiology.
Culture and N.Diagnoses Cultural differnces, impaired communication, client value system all could impact diagnostic conclusions.
Error Sources in Nursing Diagnostic Process Errors occur during data collection, clustering, interpretation, and statement of diagnosis.
Practice Ti[ps to Avoid Data Collection Errors Be knowledgeable & experienced in assessment techniques. Approach assessment in steps. Review your clinical assessments. Determine veracity of data by having co-worker validate findings. Be organized and have approp. forms/equipment.
Error in Data Clustering Don't make nursing diagnosis fit the signs and symptoms obtained.
Errors in Diagnostic Statement Word correctly. Use NANDA terminology. Problem and etiology need to be w/in scope of nursing.
Created by: flaherties