Chapter 7 Nursing Diagnosis PDF

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Notes from Fundamentals of Nursing Yoost/Crawford...

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CHAPTER 7: NURSING DIAGNOSIS! ! KEY TERMS! clustering - Organizing patient assessment data into groupings with similar etiologies (underlying causes).! defining characteristics - Cues or clusters of related assessment data that are signs, symptoms, or indications of an actual or health promotion nursing diagnosis.! diagnosis label - A concise term or phrase that represents a pattern of related clustered data.! etiology - The underlying cause of a patient problem or concern.! health promotion nursing diagnoses - NANDA-I diagnostic labels that are clinical judgments concerning the motivation and desire of an individual, family, group, or community to increase well-being and to actualize human health potential.! nursing diagnosis - Identification of an actual or potential patient problem or response to a problem based on the clinical judgment of the nurse.! problem-focused nursing diagnoses. - NANDA-I diagnostic labels that are clinical judgments about undesirable human responses to health conditions or life processes that occur in an individual, family, group, or community.! risk factors - Environmental, physical, psychological, or situational concerns that increase a patient's vulnerability to a potential problem or concern.! risk nursing diagnoses - NANDA-I diagnostic labels that identify risk factors that are vulnerabilities of an individual, family, group, or community for developing negative human responses to health conditions or life processes.! taxonomy - A unified language classification system. ! American Nurses Association’s Nursing: Scope and Standards of Practice (2015) - Consideration of the ethical and legal consequences for failure to identify areas of concern requiring treatment! ! Medical Diagnoses vs Nursing Diagnoses:! Medical diagnoses identify and label medical (physical and psychological) illnesses. Nursing diagnoses consider a patient’s response to medical diagnoses and life situations, as well as make clinical judgements on the basis of a patient’s actual medical diagnoses and conditions. Nursing diagnoses are primarily used to facilitate clear communication of patient needs.! ! NANDA-I Nursing Diagnostic Statements:! A health promotion nursing diagnosis statement is a type of nursing diagnosis that indicates a person’s readiness to enhance specific health behaviors for well-being. A human response to health conditions that may develop in a vulnerable individual is a risk nursing diagnosis statement. A human response to health conditions that exist in an individual or community is a problem-focused nursing diagnosis statement. ! ! A potential response to the health problem that can change by using specific nursing interventions is a related factor. They are the underlying cause or etiology of a patients problem.! ! • Health-promotion nursing diagnosis statement - diagnostic label and defining characteristics! • The risk nursing diagnosis statement - a diagnostic label and related risk factors! • The problem-focused nursing diagnosis statement - the diagnostic label, the related factors, and the defining characteristics! ! Collecting, clustering, and interpreting data are common sources of error in the nursing diagnostic process, according to NANDA-I.! ! ! ! ! ! ! ! ! ! ! ! ! ! !...