FUNDA LEC

• Nursing Diagnosis


  is a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability to that response, by an individual, family, group, or community.
• Medical Diagnosis


  is made by the physician or advanced health care practitioner that deals more with the disease, medical condition, or pathological state only a practitioner can treat
• Collaborative Problems


  are potential problems that nurses manage using both independent and physician-prescribed interventions. These are problems or conditions that require both medical and nursing interventions, with the nursing aspect focused on monitoring the client’s condition and preventing the development of the potential complication.
• Problem-focused diagnosis


  also known as actual diagnosis, a client problem present at the time of the nursing assessment
• Anxiety


  related to stress as evidenced by increased tension, apprehension, and expression of concern regarding upcoming surgery
• Acute pain


  related to decreased myocardial flow as evidenced by grimacing, expression of pain, guarding behavior.
• Health promotion diagnosis


  (also known as wellness diagnosis) is a clinical judgment about motivation and desire to increase well-being
• Syndrome Diagnosis


  is a clinical judgment concerning a cluster of problem or risk nursing diagnoses that are predicted to present because of a certain situation or event written as a one-part statement requiring only the diagnostic label.
• Possible Nursing Diagnosis


  are statements describing a suspected problem for which additional data are needed to confirm or rule out the suspected problem.
• Risk Diagnosis


  is based on the patient’s current health status, past health history, and other risk factors that may increase the patient’s likelihood of experiencing a health problem
• 3 Component of Nursing Diagnosis

  -The problem and its definition

  -The Etiology

  -The defining characteristics or risk factors
• The etiology


  or related factors, component of a nursing diagnosis label identifies one or more probable causes of the health problem, are the conditions involved in the development of the problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client’s care.
• Risk factors


  are used instead of etiological factors for risk nursing diagnosis.
• PES Format


  Stands for Problem (diagnostic label), Etiology (related factors), and Signs/Symptoms (defining characteristics).
• Using "secondary to"


  to divide the etiology into two parts to make the diagnostic statement more descriptive and useful often a pathophysiologic or disease process or a medical diagnosis.
• Using "complex factors"


  when there are too many etiologic factors or when they are too complex to state in a brief phrase.
• Using "unknown etiology"


  when the defining characteristics are present but the nurse does not know the cause or contributing factors. For example, Ineffective Coping related to unknown etiology.
• Assesement


  is the systematic and continuous collection organization validation and documentation of data.
• Client records


  contain information collected by many members of the healthcare team, such as demographics, past medical history, diagnostic test results and consultations
• Interview


  is to gather and provide information, identify problems of concerns, and provide teaching and support.
• Opening


  purpose is to establish rapport by creating goodwill and trust; this is often achieved through a self – introduction, nonverbal gestures (a handshake), and small talk about the weather, local sports team, or recent current event; the purpose of the interview is also explained to the client at this time
• Body


  during this phase, the client responds to open and closed-ended questions asked by the nurse.
• Closing


  either the client or the nurse may terminate the interview, it is important from the nurse to try to maintain the rapport and trust that was developed thus far during the interview process.
• Closed questions used in directive interview


  1. Re____ short factual answers; e.g. “Do you have pain?”

  2. Answers usually reveal limited amounts of information

  3. Useful with clients who are highly stressed and/or have difficulty communicating
• Open-ended questions used in nondirective interview


  4. Encourage clients to express and clarify their thoughts and feelings; e.g. “How have you been sleeping lately?’

  5. Specify the broad area to be discussed and invite longer answers

  6. Useful at the start of an interview or to change the subject
• Subjective Data


  • May be called “covert data”

  • Not measurable or observable

  • Obtained from client (primary source), significant others, or health professionals (secondary sources).

  • For example, the client states, “I have a headache
• Objective Data


  • May be called “overt data”

  • Can be detected by someone other than the client

  • Includes measurable and observable client behavior

  • For example, a blood pressure reading of 190/110 mmHg.
• Physical Assessment


  Systematic collection of information about the body systems through the use of observation, inspection, auscultation, palpation and percussion
• Consultation


  The nurse collects data from multiple sources: primary (client) and secondary (family members, support persons, healthcare professionals and records)
• Review of literature


  • A professional nurse engages in continued education to maintain knowledge of current information related to health care

  • Reviewing professional journals and textbooks can help provide additional data to support or help analyze the client database
• Verbal communication


  – uses the spoken or written word
• Non-verbal Communication


  uses other forms, such as gestures or facial expressions, and touch.
• Electronic Communication


  many health care agencies are moving toward electronic medical records where nurses document their assessments and nursing care.
• Personal space


  is the distance people prefer in interactions with others.
• Proxemics


  is the study of distance between people in their interactions
• Territoriality


  Is a concept of the space and things that an individual considers as belonging to the self
• Documentation


  Is anything written or printed that is relied on as record or proof for authorized person.
• Database


  consists of all information known about the client when the client first enters the health care agency. It includes the nursing assessment, the physician’s history, social & family data
• Problem list


  derived from the database. Usually kept at the front of the chart & serves as an index to the numbered entries in the progress notes. Problems are listed in the order in which they are identified & the list is continually updated as new problems are identified & others resolved
• Plan of Care


  care plans are generated by the person who lists the problems. Physician’s write physician’s orders or medical care plans; nurses write nursing orders or nursing care plans