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statistics for nursing a practical approach
Fundamentals Of Nursing: Standards And Practices 2nd Edition Sue C. DeLaune, Patricia Kelly Ladner - Solutions
Nursing diagnosis is the second step in the nursing process and is the clinical judgment about individual, family, or community (aggregates) responses to actual or risk problems, wellness states, or syndromes.
7. Prioritize the nursing diagnoses.
6. Identify whether the nursing diagnoses on your list are actual, possible, risk, or wellness-oriented nursing diagnosis statements.
5. Write two-part nursing diagnosis statements by combining steps 3 and 4.
4. Attempt to identify etiological (related to) factors for the list you started in step 3.
3. Write the first part of the NANDA diagnosis for each cluster.
2. Look at the NANDA list of diagnoses and see which diagnoses “fit” best with your data clusters.
1. From the data cues in this case study, group data into clusters.
Continue communicating with other nurses about nursing diagnosis
Participate in conferences, workshops, and other educational activities that advance and promote nursing diagnosis.
Be willing to add to the existing body of knowledge by describing unusual nursing phenomena.
Adopt a positive attitude toward the principles and taxonomy of nursing diagnosis.
Support colleagues when they use nursing diagnosis language.
Discuss the purpose and value of nursing diagnosis with administrators and medical staff.
Acknowledge and embrace the fluid nature of the language of nursing diagnosis.
Agree on a common language.
Am I making any value judgments about the client?
Have I stated the diagnosis with a client response or a client need?
Am I implying negligence or blaming anyone in my diagnosis?
Am I using the medical diagnosis in my nursing diagnosis?
Am I saying the same thing twice?
What elements need to be referred to another discipline(e.g., medicine, social services, dietary)?
What elements of this situation/condition/problem are able to be enhanced or resolved by therapeutic nursing interventions?
What specific cues from the client made me form this conclusion?
What data fit together or have something in common?
Should I talk to the client and family again?
Is there any information on my database that seems incomplete or uncertain?
Are any data missing?
Do I have enough data to formulate a nursing diagnosis?
Is the information forming natural groupings?
Is the information falling into a logical arrangement?
Can this information be put together?
Is there a pattern?
What is this information telling me?
Birthmark right upper hip
Nonproductive cough.
Red scaly patches on skin.
Vital signs: HR 92; BP 130/80; R 17; T 98.9°F.
One bowel movement every other day.
Dimpling of buttocks.
Fleshy loose upper arms.
Double chin.
Protruding abdomen over belt and waist of pants.
Client is 5 feet 10 inches and weighs 204 pounds.
8. Phrases from steps 6 and 7 are combined to form a two-part nursing diagnosis.
7. Related to (RT) factors are identified.
6. The first part of the nursing diagnosis statement is written.
5. The NANDA list is consulted.
4. Data are grouped into clusters.
3. Data cues are interpreted and assigned a meaning through the use of critical thinking.
2. Data cues are validated and examined.
1. Data cues are collected from the assessment phase.
Wellness diagnoses identify the individual or aggregate condition or state that may be enhanced by healthpromoting activities. These consist of a one-part statement(no “related to” phrase) that uses the label“Potential for Enhanced”
Risk diagnoses are identified by the nurse in situations in which problems might occur but are not currently in existence. Examples of risk diagnoses may include Risk for Poisoning RT increased mobility of infant and failure to have house childproofed and Risk for Deficient Fluid Volume RT
Actual diagnoses are those problems identified by the nurse that are already in existence. Actual diagnoses may include Excess Fluid Volume related to (RT) intravenous infusion therapy overload and Anxiety RT unknown results of breast biopsy.
What changes have occurred within the family situation that have altered the dynamics between the client and caregiver?
Does the care performed by the caregiver for the client yield satisfactory results in terms of alleviation of symptoms?
Has the caregiver expressed concern or anxiety about performing certain functions for the client?
Is the client experiencing difficulty with the response being received from the caregiver about the type and level of care needed?
Documented so that they can be used in further development of expected outcomes and plan of care
Validated with client, significant others, and health care providers
Based on data collected during assessment of client
Nursing diagnosis is the terminology used for a clinical judgment by the professional nurse that identifies the client’s or aggregate’s actual, risk, wellness, or syndrome responses to a health state, problem, or condition.
Medical diagnosis is the terminology used for a clinical judgment by the physician that identifies or determines a specific disease, condition, or pathologic state.
“Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable”
“Nursing diagnosis is defined in the Roy Adaptation Model as a judgment process resulting in a statement conveying the person’s adaptation status” (Roy &Andrews, 1991, p. 37).
“A nursing diagnosis is a statement that describes the human response (health state or actual/potential altered interaction pattern) of an individual or group which the nurse can legally identify and for which the nurse can order the definitive interventions to maintain the health state or to
“Use of the term diagnosis is gaining acceptance as the logical end product of nursing assessment”(Gebbie & Lavin, 1974, p. 250).
“A creative approach to nursing involves a nursing diagnosis and the design and means for carrying out a plan for the care of an individual person. There are five areas of patients’ needs on which the nursing diagnosis is based . . . treatment and medication, personal hygiene, environmental,
11. Explain how a nursing diagnosis enhances accountability and empowerment in the nursing profession.
10. Describe how a nursing diagnosis enables the delivery of holistic or comprehensive nursing care.
9. Describe strategies to overcome the barriers to using nursing diagnosis.
8. Explore barriers that can affect the use of a nursing diagnosis.
7. Discuss the limitations of a nursing diagnosis.
6. Identify errors that can occur in the development of a nursing diagnosis.
5. Describe the process of developing a nursing diagnosis.
4. Explore characteristics of the nursing diagnosis taxonomy.
3. List the components of a nursing diagnosis.
2. Explain the purposes of nursing diagnoses.
1. Describe nursing diagnosis as a nursing function.
The purposes of the physical examination are to gather baseline data, confirm data obtained in the interview and health history, and evaluate progress toward established goals. The examination includes the techniques of inspection, palpation, percussion, and auscultation.
The elements of the health history are demographic information; reason for seeking health care; perception of health status; previous illnesses, hospitalizations, and surgeries; client/family medical history;immunizations/exposure to communicable disease;allergies; current medications;
A comprehensive health history is useful in determining the client’s functional health patterns, responses to changes in health status, and alterations in lifestyle.
The three stages of assessment interview are the introduction, working, and closure phases.
Data are collected through the interview, health history, symptom analysis, physical examination, and laboratory and diagnostic tests.
Assessment models such as Gordon’s Functional Health Patterns, NANDA’s Human Response Patterns, Orem’s Theory of Self-Care Model, Roy’s Adaptation Model, the body systems model, and Maslow’s hierarchy of needs model ensure comprehensive data collection and organization.
Although a variety of sources should be used in data collection, the client is the primary source of information.
The two types of data collected during the assessment process are subjective (data from the client’s point of view) and objective (observable and measurable data that are obtained through both the physical examination and laboratory and diagnostic tests).
Assessment can be comprehensive, focused, or ongoing, depending on the health care setting and needs of the client.
The nurse uses the process of assessment to establish a database about the client, to form an interpersonal relationship with the client, and to provide the client with an opportunity to discuss health care concerns.
Assessment includes collection, verification, organization, interpretation, and documentation of data.
What further data should be collected at this time?
Organize the data presented using a functional health pattern model.
Distinguish between the subjective and objective data presented about Mr. Bell.
Which of the three types of assessments discussed in this chapter is most appropriate at the time of his admission?
Therapy use (American Nurses Association, 2000)
Mental status
Medical needs
Activities of daily living (ADLs)
Unable to work for 3 days. Client is afraid will not be able to return to work.
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