RLE M5

• A form of decision-making that the nurse uses to arrive at judgements and conclusions about patients' responses to actual or potential health problems

  Diagnosing
• To make judgment and specifically name actual and potential health problems or risk factors present, based on evidence from assessment data

  Diagnose
• Having the knowledge and skills to identify problems and risks and to perform actions safely and efficiently in various situations

  Competency
• Being competent and having the authority to perform an action or give a professional option

  Qualified
• Actions a nurse is legally qualified to perform

  Nursing Domain
• • It refers to a problem statement that a nurse makes regarding a patient's condition
  • a clinical judgment about the patient’s response to actual or potential health conditions or needs
  • provides the basis for prescriptions (interventions) for definitive therapy for which the nurse is accountable
  • expressed concisely and includes theetiology of the condition when known

  Nursing Diagnosis
• Activities and actions a physician is legally qualified to perform depending on state regulations, APN are legally qualified to perform some things in this domain

  Medical domain
• Being responsible and answerable for something

  Accountable
• Most specifci actions or treatments required to prevent, resolve, or manage a health problem

  Definitive Interventions
• The result of prescribed interventions. Usually referred to as desired result to interventions, includes a specific time frame when this is expected to be achieved

  outcome
• Objective (observable) data, known to suggest a health problem

  Signs
• Subjective (reported) data known to suggest a health problem

  Symptoms
• Signs and symptoms that prompt you to suspect the presence of a health problem or desire to improve health

  Cues
• Most specific, most correct diagnosis that clearly identifies both the problem and the cause

  Definitive Diagnosis
• A cluster of signs and symptoms, and related factors usually seen with a specific nursing diagnosis

  Defining characteristic
• To decide that a certain problem is NOT present

  Rule Out
• Something known to be associated with the problem

  Related Factor
• Something known to a cause, or contribute to a diagnosis

  Etiology
• This process uses the critical thinking skills of analysis and synthesis

  Diagnostic Process
•  The separation into components, that is, the breaking down of the whole into its parts

  Analysis
• the putting together of parts into the whole (inductive reasoning).

  Synthesis
• • Analyzing data
  • Identifying health problems, risks, and strengths
  • Formulating diagnostic statements

  Steps of diagnostic process
• a client problem that is present at the timeof the nursing assessment.  It is based on the presence of associated signs and symptoms

  Actual diagnosis
•  relates to clients’ preparedness to implement behaviors to improve their health condition. These diagnosis labels begin with the phrase Readiness for Enhanced

  health promotion
• a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene

  risk nursing diagnosis
•  assigned by a nurse’s clinical judgment to describe a cluster of nursing diagnoses that have similar interventions

  syndrome diagnosis
• a statement of nursing judgment and refers to a condition that nurses, by their education, experience, and expertise, are licensed to treat

  nursing diagnosis
• made by a physician and refers to a condition that only a physician can treat

  medical diagnosis
• refer to disease processes—specific pathophysiologic responses that are fairly uniform from one client to another.

  Medical diagnoses 
• describe the human response, a client’s physical, sociocultural, psychological, and spiritual responses to an illness or a health problem.

  nursing diagnoses