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Describe the term nursing diagnosis, distinguishing it from a collaborative problem and a medical diagnosis.
Diagnosing—the second step in the nursing process—begins after the nurse has collected and recorded the patient data. The purpose of diagnosing is to (1) identify how an individual,group, or community responds to actual or potential health and life processes; (2) identify factors that contribute to or cause health problems (etiologies); and (3) identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems.When a health problem is identified, the nurse must decide which healthcare professional can best address the problem.Actual or potential health problems that can be prevented or resolved by independent nursing intervention are termed nursing diagnoses. The nurse formulates, validates, and lists nursing diagnoses for each patient. Nursing diagnoses provide the basis for selecting nursing interventions that will achieve valued patient outcomes for which the nurse is responsible. Medical diagnoses identify diseases, whereas nursing diagnoses focus on unhealthy responses to health and illness.Medical diagnoses describe problems for which the physician directs the primary treatment, whereas nursing diagnoses describe problems treated by nurses within the scope of independent nursing practice. A medical diagnosis remains the same for as long as the disease is present, whereas a nursing diagnosis may change from day to day as the patient’s responses change. These distinctions reflect key differences in medical and nursing practices. Myocardial infarction (heart attack) is a medical diagnosis.Examples of nursing diagnoses for a person with myocardial infarction include Fear, Altered Health Maintenance, Deficient Knowledge, Pain, and Altered Tissue Perfusion. Nursing diagnoses are also different from collaborative problems.Together, nursing diagnoses and collaborative problems constitute the range of responses that nurses treat, and as such, they define the unique nature of nursing. Collaborative problems are “certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using physician-prescribed and nurse interventions to minimize the complications of the event” Unlike medical diagnoses, collaborative problems are the primary responsibility of nurses. Unlike nursing diagnoses,with collaborative problems, the prescription for treatment comes from nursing, medicine, and other disciplines. When the nurse writes patient outcomes that require delegated medical orders for goal achievement, the situation is not nursing diagnosis, but a collaborative problem. Because collaborative problems involve potential complications, they must be identified early so that preventive nursing care canbe instituted early.To write a diagnostic statement for a collaborative problem,focus on the potential complications of the problem. Use “PC”(for potential complication), followed by a colon, and list the complications that might occur. For clarity, link the potential complications and the collaborative problem by using “related to.” Example: PC: Paralytic ileus related to anesthesia.
Identify five types of nursing diagnoses
- 1. Actual: represent a problem that has been validated by the presence of major defining characteristics.
- 2. Risk: clinical judgments that an individual,family, or community is more vulnerable to develop the problem than others in the same or similar situation.
- 3. Wellness: are clinical judgments about an individual,group, or community in transition from a specific level of wellness to a higher level of wellness. Two cues must be present for a valid wellness diagnosis:
- • A desire for a higher level of wellness
- • An effective present status or function
- 4. Possible: are statements describing a suspected problem for which additional data are needed. Additional data are used to confirm or rule out the suspected problem.
- 5. Syndrome: comprise a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation; for example, Rape-Trauma Syndrome or Post-Trauma Syndrome.
Which activities does the nurse perform during the diagnosing stg?
- - IDs factors contributing to the pts health problem.
- - Prioritizes the pt's health problems with input from the pt.
- - Validates the identified health problems with the pt.
A wellness diagnosis consists of how many parts? Risk? Actual? And Possible?
Wellness: 1 Risk: 2 Actual: 3 Possible: 2
When caring for a pt, the nurse identifies and analyzes data to identify nursing diagnoses and collaborative problems. Which of the following is an important role of the nurse when caring for a pt with collaborative problems?
Reporting trends that suggest development of complications (The nurse should report trends that suggest development of complications to bring to notice the need for collaborative intervention for a pt. Collaborative problems are physiologic complications that require both nurse- and physician- prescribed interventions. Identifying factors that place the pt at risk, resolving health issues through independent nursing measures, and managing an emerging problem with the help of the RN are nursing roles performed during a nursing diagnosis.)
A nurse who is caring for a pt admitted to the nursing unit with acute abdominal pain formulates the care plan for the pt. Which of the following nursing diagnoses is the highest priority?
A. impaired comfort
B. disturbed sleep pattern
C. activity intolerance
D. disturbed body image
A. impaired comfort (because acute pain in the abdomen disturbs all the systems of the body, and relieving pain should be the nurse's first priority. According to Maslow, physiologic needs are the highest priority.)
(this multiple choice question has been scrambled)
allows for direct reimbursement for nurses
lack of adequate cues
At one time, nurses were only urged to use NANDA accepted terms to state nursing diagnoses. Today, accepted terms vary. Nurses should use the terms recommended by their school, employer, or specialty org.
to limit or specify the meaning of a problem statement
involves a result of disease, trauma, treatment, or diagnostic studies.
Validate the diagnosis after. In addition, pts who are able to participate in decision making should be encourage to validate the diagnosis.
A misdiagnosis can happen when...
- - premature diagnoses based on an incomplete database
- - erroneous diagnoses resulting from an inaccurate or a faulty data analysis
- - routine diagnoses resulting from the nurse's failure to tailor data collection and analysis to the unique needs of the pt
- - errors of omission