Chapter 15-Diagnosing

standard

acceptable, expected level of performance established by authority, custom, or consent

nursing diagnosis

actual or potential health problem that an independent nursing intervention can prevent or resolve (actual problem is present; possible problem may be present, but more data are needed to confirm or disconfirm the problem; and potential problem may occur); defining characteristics are present as risk factors

collaborative problem

actual or potential health problem that may occur from complications of disease, diagnostic studies, or the treatment regimen; the nurse works together with other members of the health care team toward its resolution

diagnosing

analysis of patient data to identify patient strengths and health problems that independent nursing intervention can prevent or resolve

health promotion nursing diagnosis

behavior of an individual motivated by a personal desire to increase well-being and health potential

risk nursing diagnosis

clinical judgments that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation

syndrome

cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation

health problem

condition related to health requiring intervention if disease or illness is to be prevented or resolved and coping and wellness are to be promoted

diagnostic error

failure to detect an actual unhealthy behavior or condition

data cluster

grouping of patient data or cues that points to the existence of a patient health problem

cue

significant information that is helpful in making decisions

medical diagnosis

statement about a specific disease process using terminology from a well-developed classification system accepted by the medical profession