Nursing Process: Diagnosis

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Created by:

Molika  on September 17, 2010

Subjects:

health promotion

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Nursing Process: Diagnosis

Before making diagnosis, you have to do what?
1 validate data
2 determine the meaning of data
3 cluster related data
4 identify client needs
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Before making diagnosis, you have to do what? 1 validate data
2 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? PED
1 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 develop
Planning 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 instructor
2 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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