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