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Related Flashcards
Cards In This Set
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Nursing Diagnosis
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Includes helath states nurses are able and liscensed to treat through systematic data collection, deals with quality of life issues
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Medical Diagnosis
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Diseases, trama, pathophysiology focus, provides a means of communicationg treatment requirements
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Components of nursing diagnosis
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Diagnostic label, descriptors, definition, risk factors, related factors
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Cue Clustering
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Take individual cues and group them to derive meaning from data collected, look for pattern, several cues form a cluster
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Cues
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Data from assessment, look for relationships and patterns from subjective and objective data that deviate from standards or norm
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Cluster Interpretation
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Synthesizes cue clusters based on pattern suggested by clusters, for forming diagnosis
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Errors in cluster interpretation
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Incorrect clustering, incorrect interpretation, inadequate information in cluster, lack of knoledge/experience
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Nursing diagnosis Validation
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2 statges: cue clusters interpreted and compared with norms, specific nursing diagnosis is evealuated for research base
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Format for Writing Nursing Diagnosis
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3 parts:problem statement, related to factors/etiology, as manifested by(actual problems)
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Nursing Diagnosis is never...
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The patient's medical diagnosis
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Example of nursing diagnosis
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Acute pain related to surgical trauma as manifested by facial grimmace and verbal reports of pain
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Risk Nursing Diagnosis
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Diagnostgic lable/problem statement, risk factors
i.e. risk for aspiration r/t decreased level consciousness
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Wellness Nursing Diagnosis
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Diagnosticl label only/clinical judgements about person in transition
i.e. Readiness for enhanced parenting
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Implementation
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Provides planned care to reduce extent of problem and meet pt. needs, action/initiation phase, documentation, all five steps in action
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Skills required for Implementation
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Intellectual, interpersonal, technical skills
nurse can delegae parts of plan of care to other members
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