Nursing Process: Diagnosis
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14 terms
Terms | Definitions |
|---|---|
Before making diagnosis, you have to do what? | 1 validate data2 determine the meaning of data 3 cluster related data 4 identify client needs |
What is true about Nursing Diagnosis? | Nsg dx are specific for NURSES! Provide basis for nursing interventions for which the nurse is accountable. |
Nursing Diagnosis identify what? for what? | Dx identify actual and potential health problems (as well as strengths). Provide a basis for selecting nursing interventions |
NANDA is what? | North America Nursing Diagnosis Association |
What are the Med Dx Vs Nur Dx? | 1 Identifies Dz. to treat Vs Identifies pt response 2 Write orders to direct primary treatments of Dz. Vs Write nursing interventions that we can do to resolve & treat independently 3 Does not change Vs Changes day to day |
What are the 3 parts of Nur Dx? | PED1 Problem (Pattern of related cues that are signs and symptoms) 2 Etiology (cause or contributing factors) 3 Defining Characteristic (As evidence by: "supports/proves the nursing diagnosis Subjective or objective") |
What are the 5 Types of Nursing Diagnoses ? | 1 Actual Nursing Dx 2 "Risk for" Nursing Dx 3 Possible Nursing Dx 4 Wellness Nursing Dx 5 Syndrome Nursing Dx |
What is Actual Nursing Dx? | Human responses that do exist |
What is "Risk for" Nursing Dx? | Human responses that may developPlanning aimed at prevention |
What is Possible Nursing Dx ? | Suspected problems need more data |
What is Wellness Nursing Dx? | Readiness of enhanced learning,Human responses to levels of wellness |
What is Syndrome Nursing Dx? | Rape Trauma ,Cluster of actual or potential dx |
Give Examples of Diagnoses? | 1 Deficient Fluid Volume R/T active fluid volume loss AEB diarrhea and vomiting for past 3 days, decreased urine output and concentrated dark amber urine, fever, and weakness. 2 Diarrhea R/T intestinal irritation and infectious process AEB 12 watery stools a day for the last 3 days and lower abdominal pain. |
What are Things to know about Documenting the Dx? | 1 Before documenting in the medical record, check with your clinical instructor2 Where do I document my patient's dx? 3 What about care maps? 4 Many patients will have very similar or the same med dx but different nsg dx 5 Remember, "if it's not documented, it's not done!" |
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