10312021
Description
Mind Map by Susie Curtis, updated more than 1 year ago
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Created by Susie Curtis
over 7 years ago
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Nursing
Diagnosis
- Terms
- Medical diagnosis- identification of disease condition based on specific evaluation of
physical signs, symptoms, medical history, and result of diagnostic tests and procedures.
- Nursing diagnosis – clinical judgement concerning a human response to health conditions/life processes, or vulnerability
for that response by an individual, family, or community that a nurse is licensed and competent to treat.
- Collaborative Problem is an actual or potential physiological complication that nurses monitor to
detect the onset of changes in a patient’s health status.
- Collaborative Problem is an actual or potential physiological complication that nurses monitor to
detect the onset of changes in a patient’s health status.
- Nursing diagnosis – clinical judgement concerning a human response to health conditions/life processes, or vulnerability
for that response by an individual, family, or community that a nurse is licensed and competent to treat.
- Medical diagnosis- identification of disease condition based on specific evaluation of
physical signs, symptoms, medical history, and result of diagnostic tests and procedures.
- History of
Nursing
Diagnosis
- 1967 Yura and Walsh 4 part process
- Diagnosis was added, you cannot plan and intervene correctly for patients if
you do not know the problems with which you are dealing.
- ANA defines nursing as the diagnosis and treatment of human responses to
health and illness strengthening the definition of nursing diagnosis.
- NCLEX exam defines nursing process as scientific, clinical reasoning approach to patient care that includes
assessment, analysis, planning, implementation, and evaluation. Note analysis instead of diagnosis. Types of
Nursing Diagnoses
- NCLEX exam defines nursing process as scientific, clinical reasoning approach to patient care that includes
assessment, analysis, planning, implementation, and evaluation. Note analysis instead of diagnosis. Types of
Nursing Diagnoses
- ANA defines nursing as the diagnosis and treatment of human responses to
health and illness strengthening the definition of nursing diagnosis.
- Diagnosis was added, you cannot plan and intervene correctly for patients if
you do not know the problems with which you are dealing.
- 1967 Yura and Walsh 4 part process
- Types of Diagnosis
- Problem-focused nursing diagnosis – clinical judgement
concerning undesirable response t health condition/life
- Risk nursing diagnosis clinical judgement concerning vulnerability of
individual, family, group, or community for developing undesirable
human response to health conditions/life processes.
- Related factor etiological or causative factor for the
diagnosis
- Related factor etiological or causative factor for the
diagnosis
- Risk nursing diagnosis clinical judgement concerning vulnerability of
individual, family, group, or community for developing undesirable
human response to health conditions/life processes.
- Problem-focused nursing diagnosis – clinical judgement
concerning undesirable response t health condition/life
- Critical thinking and the
diagnostic process
- Data clustering Organize patient’s data into
meaningful usable data clusters. Set of cues, signs or
symptoms gathered during assessment.
- Data interpretation Comparison of characteristics or risk factors
in database. Move from generalized to more specific Compare
patient’s data with normal, healthy patterns.
- A nursing diagnosis focuses on a patient’s actual or potential response to a
health condition rather than on the physiological event, complication, or
disease
- A nursing diagnosis focuses on a patient’s actual or potential response to a
health condition rather than on the physiological event, complication, or
disease
- Data interpretation Comparison of characteristics or risk factors
in database. Move from generalized to more specific Compare
patient’s data with normal, healthy patterns.
- Data clustering Organize patient’s data into
meaningful usable data clusters. Set of cues, signs or
symptoms gathered during assessment.
- Formulating a
Nursing Diagnostic
Statement
- "related to" phrase is not cause-effect.
- Two part = diagnosis meaning and relevance.
- Three part includes related to factor
- Three part, PES, problem, etiology, symptom
- Three part, PES, problem, etiology, symptom
- Three part includes related to factor
- Two part = diagnosis meaning and relevance.
- "related to" phrase is not cause-effect.
- Cultural relevance
- Important to consider patient’s culture and own cultural
competence to identify health care problems.
- Important to consider patient’s culture and own cultural
competence to identify health care problems.
- Concept
mapping
- help critically think about patients diagnoses and how they related to one another.
- Organizes and links info to see holistic complexity of patient care
- Central focus is on patient rather than disease or alteration
in health.
- Central focus is on patient rather than disease or alteration
in health.
- Organizes and links info to see holistic complexity of patient care
- help critically think about patients diagnoses and how they related to one another.
- Sources of Diagnostic
errors
- Errors in Data collection
- Errors in Analysis of Data
- Errors in Data Clustering
- Errors in Diagnostic statement
- Errors in Diagnostic statement
- Errors in Data Clustering
- Errors in Analysis of Data
- Errors in Data collection
- Documentation and
informatics
- Once diagnosis entered, outcome and
intervention options are available
(computer based)
- List chronologically as you identify them
- Care plan- highest priority diagnosis first
- Review in order of priority not chronologically
- Review in order of priority not chronologically
- Care plan- highest priority diagnosis first
- List chronologically as you identify them
- Once diagnosis entered, outcome and
intervention options are available
(computer based)
- Application to care
planning
- Care plan is a map for nursing care
- Demonstrates accountability for nursing
diagnosis, patient's health care problems.
- Demonstrates accountability for nursing
diagnosis, patient's health care problems.
- Care plan is a map for nursing care
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