Chapter 12: Diagnosing Vocabulary

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UNIT III: Person-Centered Care and the Nursing Process Chapter 12: Diagnosing
Alexandra Bozan
Fichas por Alexandra Bozan, actualizado hace más de 1 año
Alexandra Bozan
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The purposes of diagnosing are 1) to identify how a person/group/ community responds to actual/potential health/life process 2) identify factors that contribute to/cause health problems (etiologies) 3) identify resources/strengths that the person/group/community can draw on to prevent/resolve problems
PPMP The shift from diagnose and treat to Predict, Prevent, Manage and Promote (PPMP) . Predict the most common/dangerous complications and take immediate action to prevent them, manage them, in case they cannot be prevented.
Nursing diagnoses focus on unhealthy responses to health & illness. treated w/in the nursing scope. written to describe patient problems or issues that nurses can treat independently (i.e. activity, pain/comfort, tissue integrity, perfusion problems)
Medical diagnosis Identify diseases. describe problems the physician directs the primary treatment
collaborative problems certain physiologic complications that nurses monitor to detect onset or changes in status
to write a collaborative problem... focus on the potential complications. use "PC" followed by colon, list the complications that might occur, link potential problem and the collaborative problem with "related to": PC: Paralytic ileus related to anesthesia
standard norm. generally accepted rule, measure, pattern, or model to which data can be compared to
data cluster a grouping of patient data or cues that point to the existence of a health problem
5 types of nursing diagnosis WARPS W - wellness A - actual R - risk P - possible S - syndrome
Components of actual diagnoses 1. label 2. definition 3. defining characteristics 4. related factor
Risk nursing diagnoses clinical judgments that a person, family, or community is more vulnerable to develop the problem than others in the same or similar situation
Possible nursing diagnoses statement describing a suspected problem for which additional data are needed
Wellness diagnosis clinical judgments about a person, group or community in transition from a specific level of wellness to a higher level of wellness. more applicable in nursing settings w/healthy patients.
to write a wellness diagnosis it is a one part statement that contains the label "Readiness for Enhanced" followed by the desired higher-level wellness. Related factors are not included. Readiness for Enhanced Health Maintenance
Parts of Nursing Diagnosis Problem, Etiology, Defining Characteristics
Nursing Diagnosis: Problem describes the health state or health problem. identifies what is unhealthy and what the patient would like to change, as well as suggests patient outcomes "Bathing/Hygiene Self Care Deficit"
Nursing Diagnosis: Etiology identifies the physiologic, psychological, sociologic, spiritual and environmental factors believed to be related to the problem "related to Fear of falling in the tub and obesity"
Nursing Diagnosis: Defining Characteristics Subjective/objective data that signal the existence of the actual/possible health problem "as manifested by/as evidenced by Strong body and urine odor"
Nursing diagnoses benefits 1. Improved communication among nurses and other health professionals 2. Help in defining the domain of nursing for health care administrators, legislators and other health care providers 3. Important when seeking funding for nursing reimbursement for nursing services 4. Define curriculum content and direct specialization/advancement in nursing & nursing research
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