CH.17 P&P: Nursing Diagnosis

CH.17 P&P: Nursing Diagnosis

1. Nurse Diagnosis

   • Clinical judgement- 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
   • Changes on basis of Pt needs
   • Focuses on response
   • Types (3)
     • Problem focused
       • Supported by defining characteristics
         • Cues
       • Includes related factor
         • Etiology/cause for Diagnosis
       • Undesirable human response
     • Risk
       • Vulnerability for developing undesirable human response
       • No defining characteristic / related factors b/c have not yet occurred
     • Health promotion
       • Pt motivation to wellness
       • Includes Only defining characteristics
   • Diagnostic Process
     • Data clustering
       • Gathered Cues, signs, symptoms
         • Cues reveal risk factors-recognizing pattern
     • Data interpretation
       • Eliminate irrelevant risk factors/characteristics, confirm relevant
       • Compare to norms
     • Diagnostic statement
       • 1. Label (approved by NANDA-I)
         • Essence of Pt response to health condition in few words
       • 2. related factor
         • Etiology contributing to diagnosis
       • 3. Defining characteristics
         • Not always used
       • PES (easy way to remember)
         • Problem
         • Etiology
         • Symptoms
     • Cultural relevance
       • Patient centered care
     • Concept mapping to link, focus on Pt
     • Document
       • Highest priority first
     • For common errors, see PGS 234-236

2. Collaborative Problem

   • Shared decision making
   • Actual/potential physiologic complication
     • Nurse monitor onset of changes in Pt health status

3. NANDA-I

   • North American nursing Diagnosis association international
   • List of Nursing diagnoses and practice guidelines
   • Common language for nurses to understand Pt needs
   • Distinguishes nurse role