Nursing Diagnosis

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Perry Potter Ch 17
Susie Curtis
Mind Map by Susie Curtis, updated more than 1 year ago
Susie Curtis
Created by Susie Curtis over 6 years ago
21
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Resource summary

Nursing Diagnosis
  1. Terms
    1. Medical diagnosis- identification of disease condition based on specific evaluation of physical signs, symptoms, medical history, and result of diagnostic tests and procedures.
      1. Nursing diagnosis – clinical judgement concerning a human response to health conditions/life processes, or vulnerability for that response by an individual, family, or community that a nurse is licensed and competent to treat.
        1. Collaborative Problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s health status.
    2. History of Nursing Diagnosis
      1. 1967 Yura and Walsh 4 part process
        1. Diagnosis was added, you cannot plan and intervene correctly for patients if you do not know the problems with which you are dealing.
          1. ANA defines nursing as the diagnosis and treatment of human responses to health and illness strengthening the definition of nursing diagnosis.
            1. NCLEX exam defines nursing process as scientific, clinical reasoning approach to patient care that includes assessment, analysis, planning, implementation, and evaluation. Note analysis instead of diagnosis. Types of Nursing Diagnoses
      2. Types of Diagnosis
        1. Problem-focused nursing diagnosis – clinical judgement concerning undesirable response t health condition/life
          1. Risk nursing diagnosis clinical judgement concerning vulnerability of individual, family, group, or community for developing undesirable human response to health conditions/life processes.
            1. Related factor etiological or causative factor for the diagnosis
        2. Critical thinking and the diagnostic process
          1. Data clustering Organize patient’s data into meaningful usable data clusters. Set of cues, signs or symptoms gathered during assessment.
            1. Data interpretation Comparison of characteristics or risk factors in database. Move from generalized to more specific Compare patient’s data with normal, healthy patterns.
              1. A nursing diagnosis focuses on a patient’s actual or potential response to a health condition rather than on the physiological event, complication, or disease
          2. Formulating a Nursing Diagnostic Statement
            1. "related to" phrase is not cause-effect.
              1. Two part = diagnosis meaning and relevance.
                1. Three part includes related to factor
                  1. Three part, PES, problem, etiology, symptom
            2. Cultural relevance
              1. Important to consider patient’s culture and own cultural competence to identify health care problems.
              2. Concept mapping
                1. help critically think about patients diagnoses and how they related to one another.
                  1. Organizes and links info to see holistic complexity of patient care
                    1. Central focus is on patient rather than disease or alteration in health.
                2. Sources of Diagnostic errors
                  1. Errors in Data collection
                    1. Errors in Analysis of Data
                      1. Errors in Data Clustering
                        1. Errors in Diagnostic statement
                  2. Documentation and informatics
                    1. Once diagnosis entered, outcome and intervention options are available (computer based)
                      1. List chronologically as you identify them
                        1. Care plan- highest priority diagnosis first
                          1. Review in order of priority not chronologically
                    2. Application to care planning
                      1. Care plan is a map for nursing care
                        1. Demonstrates accountability for nursing diagnosis, patient's health care problems.
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