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Nursing Diagnosis, Planning, & Implementation
Fundamentals
57
Nursing
Undergraduate 3
09/24/2012

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Cards

Term
Medical Diagnosis
Definition
The identification of a disease condition based on a specific evaluation of physical signs, symptoms, the patient's medical history and the results of diagnostic tests and procedures.
Term
The Nursing Diagnosis
Definition
Classifies problems within the domain of nursing
Term
Nursing Diagnosis
Definition
A clinical judgment about individual, family, or community responses to actual & potential health problems or life processes that the nurse is licensed and competent to treat.
Term
by having the patients involved, when possible, in the process.
Definition
What makes the nursing diagnosis/process unique?
Term
Collaborative Problem
Definition
an acutal or potential physiological complication that nurses monitor to detect the onset of changes in a patient's status.
Term
Nurses intervene in collaboration with personnel from other health care disciplines.
Definition
What do nurses do when a collaborative problem develops?
Term
North American Nursing Diagnosis Association International
Definition
What does NANDA I stand for?
Term
Nursing Diagnosis
Definition
DEFN: Nurses make diagnostic conclusions and therefore, the clinical decisions necessary for safe and effective nursing practice.
Term
Definition
Definition

Purposes of Nursing Diagnostic Statements:

Provides a precise__________ of a patien'ts problem that gives nurses and other members of the health care team common language

Term
other members of the health care team and the public
Definition

Purposes of Nursing Diagnostic statements:

allows nurses to communicate what they do among themselves, ___________,&____________.

Term
physician
Definition

purposes of nursing diagnostic statements:

Distinguishes the nurses role from that of the __________ or other health care providers

Term
Scope
Definition

Purposes of Nursing Diagnostic Statements:

Helps nurses focus on the _______ of  nursing practice

Term
Development
Definition

Purposes of Nursing Diagnostic Statements:

Fosters the __________ of nursing knowlede.

Term
essence
Definition

Purposes of Nursing Diagnostic Statements:

Promotes creation of practice guidelines that reflect the ________ of nursing

Term
Medical Diagnosis
Definition
identification of a disease conditon based on specific evaluation of signs and symptoms
Term
nursing diagnosis
Definition
clinical judgement about the patient in response to an acutal or potential health problem
Term
collaborative problem
Definition
actual or potential physiological complication that nurses monitor to detect a change in patient status
Term
False
Definition

True or False:

Nursing diagnoses were only developed with the last 10 years

Term
1950 (common language)
Definition
When were nursing Diagnoses first introduced?
Term
1982
Definition
When was NANDA founded?
Term

- Pt, family & healthcare resource

- Clarification of inconsistent and unclear information

-Critical thinking guides amd direces line of questioning and examiniation to reveal detailed and relevant data.

Definition
What are the steps needed for the assessment of the patient's health status as part of the Nursing diagnostic process?
Term
True
Definition

True or False

Always validate data.

Term

-Data clustering (classify and organize)

-Look for defining characteristics and related factors

-identify patient needs

-Formualte nursing diagnosis and collaborative problems

Definition
If the assessment data is collected, what are the next setps to take in the nursing diagnostic process?
Term
Assessment, Nursing Diagnosis, Planning, Implementation, Evaluation
Definition
what are the phases of the nursing process?
Term
Clinical judgement or a Nursing Diagnosis
Definition
The diagnostic reasoning process involves using assessment data you gather about a patient to logically explain a ___________ or a ____________
Term
Nursing diagnosis and definitions
Definition
What are defining characteristics?
Term
A set of signs and symptoms gathered during assessment, grouped together in a logical way
Definition
what is a data cluster?
Term
an objective or subjective sign, symptom, or risk factor
Definition
What do clinical criterion consist of?
Term
correct diagnostic label
Definition
When identifying health problems, it is critical to select the _________________ for the patient's need.
Term
general to specific
Definition
When you complete an asessement and you are considering the patient's information, you should move from _________ to ________
Term
The general health care problem and the formulation of the nursing diagnosis specific to the problem.
Definition
Explain what the problem identification phase in assessment is.
Term
What you think are causing their problems. They are a relationship with the nursing diagnosis
Definition
What are related factors and why are they improtant for a nursing diagnosis?
Term

-acutal nursing diagnosis

-risk nursing diagnosis

-health promotion nursing diagnosis.

Definition
What are the 3 types of Nursing Diagnoses?
Term
Acutal Nursing Diagnosis
Definition
which type of nursing diagnosis describes human responses to health conditions or life processes?
Term
Risk nursing diagnosis
Definition
which type of nursing diagnosis describes human responses to health conditions or life processes that may develop
Term
Health Promotion Nursing Diagnosis
Definition
Which type of nursing diagnosis is a clinical judgement of motiviation, desire, and readiness to enhance well being and actualize human health potential?
Term
Problem, Etiology, and Symptoms
Definition
Describe the PES format used to write a nursing diagnosis.
Term

What practices within your cultures are important to you?

Has this affected you and your family?

Definition
when considering a patient's cultural diversity when developing a nursing diagnosis, what types of questions could you ask the patient?
Term
Concept mapping promotes problem solving and critical thinking skill by organizing complex patient data.
Definition
How can concept mapping help nurses to develop nursing diagnoses?
Term
see page 232/233
Definition
Name and discuss the 12 diagnostic guidelines.
Term
your care plan will help communicate the patients health care problems to other professionals and will ensure that you select relevant and appropriate nursing interventions.
Definition
How does the development of a good nursing diagnosis relate to care planning?
Term

Collaborative Problem

Definition

is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patients status.

Term

-         as hemmorahage, infection, and paralysis using medical, nursing and allied health( ex: physical therapy).

p.224

Definition
Nurses manage collaborative problems such as:
Term
attitudes and standards
Definition

-         The application of critical thinking ______, and _________ helps you to be thorough, comprehensive and accurate when identifying nursing diagnoses that apply to your patients.

Term
diagnostic reasoning process
Definition

-         involves using the assessment data you gather about a patient to logically explain a clinical judgment  aka a nursing diagnosis.

Term
Diagnostic reasoning process
Definition

-         flows from the assessment process and includes decision making steps.

Steps: data clustering, identifying patient health problems, and formulating the diagnosis.

Term
data clusters
Definition

-         patterns of data that contain defining characteristics: the clinical criteria that are observable and verifiable.

Term
Clinical Criterion (used in data clustering)
Definition

-         is an objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a diagnostic conclusion.

Term
each NANDA I approved nursing diagnosis
Definition

-         has an identified set of defining characteristics that support identification of a nursing diagnosis.

Term
Interpretation
Definition

Step 2 in the diagnostic process:

While analyzing clusters of data, you begin to consider the patients health problems. Your interpretation of the information allows you to select among various diagnoses the ones that apply to your patient.

Term
TRUE
Definition

TRUE OR FALSE: Use defining characterisics to narrow down to your nursing diagnosis

Term
Related Factor
Definition

a condition, historical factor, or etiology that gives a context for the defining characterisitcs and shows a type of relationship with the nursing diagnosis.

Term

the nature of the patients health problem.

Definition

Placing a diagnosis in the context of the patients situation clarifies  what?

Term

so you appropriately individualize care for your patients

Definition

Critical thinking is necessary in identifiying nursing diagnoses and collaborative problems so you can do what.

Term
etiology
Definition

-         related factor of a nursing diagnosis is always within the domain of nursing practice and a condition that responds to nursing interventions.

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