Term
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Definition
| Clinical judgement about individual,family,or community responses to actual or potential health problems/life process that the nurse is licensed and competent to treat. |
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Term
| Significance of Nursing Diagnosis |
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Definition
| Distinguishes nurse's role from the physican and other health care providers. |
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Term
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Definition
| Human responses to health conditions or life processes that exist in an individual,family, or community. |
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Term
| Potential nursing diagnosis(Risk for) |
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Definition
Have risk factors that place them at risk for a health problem
Human responses to health conditions or life processes that may develop in a vunerable individual,family, or community. |
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Term
| Possible nursing diagnosis |
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Definition
| The nurse tentatively believes exists. one sigh/symptom without a cluster of data. |
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Term
| Guidelines for writing a nursing diagnosis. |
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Definition
PES Format (Actual nursing)3 parts
P(problem) Or diagnostic label
E(etiology or related factor)*
S(signs/symptoms OR defining characteriscs
*Incorrect to identify the etiology as a medical diagnosis only. |
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Term
| PES Format 3 part example |
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Definition
(problem/diagnostic label) r/t (etiology or related factor) A.M.B.**
(signs;symptoms:defining characteristics)
Acute pain r/t tissue trauma secondary to appendectomy A.M.B. pain rating 2 on scale of 0-10, pain X 2 days, facial grimacing.
**A.M.B. is the abbreviation for "as manifested by" |
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Term
| PES Format-Risk for Nursing Diagnosis (2 parts) |
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Definition
P(problem) Or diagnostic label
E(risk factor)
Example:
Risk for(problem)r/t(risk factors) |
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Term
| Identify the patient's response, not the medical diagnosis |
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Definition
Incorrect:
Acute pain r/t prostatectomy
Correct
acute pain r/t trauma of incision |
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Term
Identify a NANDA-I diagnostic statement rather than the symptom.
Identify nursing diagnoses from a cluster of defining characteristics and not just a single symptom. |
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Definition
Example:
Dyspnea alnone does not definitively lead you to a diagnosis.
Correct:
dyspnea,shortness of breath, pain on inspiration, and productive cough with thick secretions are defining characteristicsthat lead you to the diagnosis of
ineffective breathing pattern r/t increased airway secretions. |
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Term
| Identify a treatable etiology or risk factor rather than a clinical sighn or chronic problem that is not treatable through nursing intervention. |
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Definition
Incorrect:
ineffective breathing pattern r/t shallow respirations.
Correct:
Ineffective breating pattern r/t pain in chest. |
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Term
| Identify the problem caused by the treatment or diagnostic study rather than the study itself. |
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Definition
Incorrect:
anxiety r/t cardiac catherization
Correct:
anxiety r/t lack of knowledge about catherization |
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Term
| Identify patient response to the equipment rather than the equipment. |
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Definition
incorrect:
anxiety r/t cardiac monitor
correct:
deficient knowledge regarding the need for cardiac monitoring. |
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Term
| Identify the patient's problem rather than your problem with nursing care. |
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Definition
incorrect:
Potential intravenous complications r/t poor vascular access.
correct:
risk for infection. |
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