Diagnosis Book Ch

a nursing diagnosis

may change from day to day as the patient's responses change

Most nursing diagnoses are written either as two-part statements listing ____________ or as three-part statements that also include the _________________

the patient's problem and its cause; problem's defining characteristics (Table 15-3 on page 374).

PE

"problem" and "etiology"

PED

"problem," "etiology," and "defining characteristics."

Related factor

Cause or contributing factors (etiologic factors)

At-risk populations

Groups of people who share a characteristic that causes each member to be susceptible to a particular human response. These are characteristics that are not modifiable by the professional nurse.

A problem-focused nursing diagnosis for a patient who has experienced vomiting, diarrhea, and excessive diaphoresis for 3 days is

Deficient fluid volume related to abnormal fluid loss. If the diarrhea persists and weakness interferes with the patient's normal perineal hygiene, the patient might be at risk for skin breakdown. This is written as the risk diagnosis, Risk for impaired skin integrity.

Risk factor

Determinant (increase risk)

Associated conditions

Medical diagnoses, injury procedures, medical devices, or pharmaceutical agents. These conditions are not independently modifiable by the professional nurse.

Remember these guidelines to ensure that your diagnostic statements are correctly written.

Phrase the nursing diagnosis (DX) as a patient problem or alteration in health state rather than as a patient need. Check to make sure that the patient problem precedes the etiology and that the two are linked by the phrase "related to" (R/T). Consider when at-risk populations or associated conditions should be identified. Defining characteristics, when included in the nursing diagnosis, should follow the etiology and be linked by the phrase "as manifested by" or "as evidenced by" (AEB). Write in legally advisable terms. Use nonjudgmental language. Be sure the problem statement indicates what is unhealthy about the patient or what the patient wants to change (enhance). Avoid using defining characteristics, medical diagnoses, or something that cannot be changed in the problem statement. Reread the diagnosis to make sure that the problem statement suggests patient outcomes and that the etiology will direct the selection of nursing measures.

Nursing diagnosis

Problem, strength, or risk identified for a patient, family, group, or community

Defining characteristic

Sign or symptom (objective or subjective cues)

Nursing diagnosis

a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. It also provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable

NANDA-I also recognizes syndromes. A syndrome is

a clinical judgment concerning a specific cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions. Chronic pain syndrome is an example (2018, pp. 35-36).

problem-focused nursing diagnosis

a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, group, or community. This type of nursing diagnosis has four components: label, definition, defining characteristics, and related factor.

health promotion nursing diagnosis

a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential. These responses are expressed by a readiness to enhance specific health behaviors, and can be used in any health state. Health promotion responses may exist in an individual, family, group, or community.

risk nursing diagnosis

a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes.

collaborative problems

certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using physician-prescribed and nurse interventions to minimize the complications of the event

Nursing diagnoses are written to

describe patient problems or issues that nurses can treat independently, such as activity, pain and comfort, and tissue integrity and perfusion problems

Medical diagnoses

describe problems for which the physician or advanced practice nurse directs the primary treatment

NANDA-I describes three types of nursing diagnoses

problem focused, risk, and health promotion.

A medical diagnosis

remains the same for as long as the disease is present

The etiology identifies ___________. Because the etiology identifies the factors that maintain the unhealthy patient state and prevent the desired change, the etiology directs nursing intervention. Unless the etiology is correctly identified, nursing actions might be inefficient and ineffective. For example, a diabetic patient who is frequently admitted to the hospital with hyperglycemia and who has a poor history of dietary and pharmacologic management is diagnosed to be noncompliant. Mistakenly assuming that the noncompliance is related to a knowledge deficit, the nurse channels all nursing activities and energies into teaching the patient how to manage the diabetes. However, this would be useless if the noncompliance were actually a result of the patient's decreased will to live, an etiology that would necessitate a different group of nursing interventions.

the physiologic, psychological, sociologic, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor.

the purpose of the problem statement is ________________. Because this section of the nursing diagnosis identifies what is unhealthy about the patient and what the patient would like to change in his or her health status, it _____________. NANDA-I recommends the use of quantifiers or descriptors to limit or specify the meaning of a problem statement. For example, the descriptor "anticipatory" placed before the concept "grieving" clarifies the nursing diagnosis for a pregnant couple informed prenatally that their child will most likely be stillborn and who are already grieving the death of their child. Some common descriptors are listed in Table 15-4.

to describe the health state or health problem of the patient as clearly and concisely as possible; suggests patient outcomes