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Definition
| identification of disease condition based on a specific evaluation of physical signs, Symptoms, The patient's medical history and the results of the diagnostic test |
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Definition
A Clinical judgment about individual, family or community responses to actual and potential health problems or life processes that the nurse is licensed and competent rot treat.
Provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.
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Definition
| An actual or potential physiological complication that nurses monitor to detect e onset off changes in patients status |
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| north american nursing diagnosis association organized in 1973. It formally identifies, develops, and classifies nursing diagnoses |
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| Set of signs or stymtoms that are grouped together in logical together |
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Definition
| Related signs and symptoms or clusters of data that supports the Nursing diagnosis |
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Definition
| Objective or subjective signs and symptoms, clusters, of signs, and symptoms or risk factors |
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Definition
| Any condition or event that accompanies or is linked w the patient's health care problem |
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| Judgement that is clinically validated by the presence of major defining characteristics |
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| Describes human responses to health conditions/health processes that may develop in a vulnerable individual, family, or community |
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| Health promotion nursing diagnosis |
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Definition
| A Clinical judgement of a persons, family, or community motivation, desire, and readiness to increase well-being and actualize human health potential |
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Definition
| The name of the nursing diagnosis as approved by NANDA Internatioal |
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Definition
Study of all factors that may be involved in the development of a disease
- Physiological
- psychological
- social
- spirtual
- environmental factors
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Term
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Definition
P(problem) NANDA-I label- example: impaired physical immobility
E (etiology or related factor)- example: incisional pain
S (symtoms or defining characteristics) - briefly lists defining characteristic(s) that show evidence of the health problem. - example: evidence by restricted turning and positioning |
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Term
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Definition
PRIMARY HEALTH PROBLEM: radical prostatectomy
PRIORITY ASSESMENTS: condition of wound, level of comfort, knowledge of care requirements when discharged,ability to manage home care, and emotional response to changes from surgury
Nursing Diagnosis: acute pain related to incisional trauma
- Winces when incision is palpated
- Acknowledges pain over incision
- Rates discomfort a 7 on a scale of 0 to 10
- Asks if pain medicine is available
Nursing Diagnosis: impaired physical mobility related to incisional pain
- Has not turned since some time last night
- Lies flat in bed w muscles tensed
- Reports discomfort of incision
Nursing diagnosis: deficient knowledge related to inexperience w surgery
- Requests information about postoperative care
- Has no knowledge about postoperative wound care
- Ask questions
- Has no previous experience w wound care
Nursing diagnosis: anxiety
- States, "I am worried about me and my wife"
- States, "doctor told me surgery could change our ability to have sex"
- States, "I have a friend who died from cancer"
- Has uncertainty
- Has poor eye contact
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Term
| Nursing Diagnostic Process |
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Definition
-Assessment of patient's health status
- Patient, family, health care resources constitute database
- Nurse clarifies inconsistent or unclear information Critical thinking guides and directs line of questioning and examination to reveal detailed and relevant database
-validate data w other sources
ARE ADDITIONAL DATA NEEDED?
yes: repeat above
no: continue
-interpret and analyze meaning of data
-data clustering
- Groups signs and stymtoms
- Classify and organize
- Look for defining characteristics and related factors
-identify patient needs
-formulate nursing diagnoses and collaborative problems |
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Definition
- Begin to interpret and analyze data
- Recognize patterns or cluster data
- Identify strengths, problems
- Actual, or potential problems are translated into nursing diagnosis which serve as the basis of care
- What is the value and significance of the data
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