Fundamentals of Nursing

Study Notes

Nursing Diagnosis: The pivotal second phase of the nursing process.
Nurse interprets assessment data, identifies strengths and health problems, and formulates diagnostic statements.
NANDA Definition: Diagnosis is a clinical judgment about individual, family, and community response to actual or potential health problems/life processes.

Actual Diagnosis: A client problem present at the time of assessment.
- Examples: Anxiety, Ineffective breathing pattern
Risk Diagnosis: A clinical judgment that a problem may develop due to risk factors.
- Examples: Risk for infection
Wellness Diagnosis: Describes human responses to wellness levels in individuals, families, and communities, showing readiness for enhancement.
- Examples: Readiness for enhanced family coping
Possible Diagnosis: A diagnosis where evidence for a health problem is incomplete or unclear.

Problem: Describes the client's health problem or reaction prompting nursing intervention.
- Examples: Anxiety, Fluid Volume Deficit, Ineffective breathing pattern, Knowledge deficit, Risk for infection
Etiology: Identifies probable causes of the health problem.
- Example: Constipation related to inactivity and insufficient fluid intake
Defining Characteristics: A cluster of signs and symptoms indicating a specific problem.
- Example: Anxiety related to breathlessness and medications' side effects, manifested by patient verbalization and facial expressions

Chest Pain: Related to increased oxygen demand and decreased oxygen supply, as manifested by patient verbalizations, facial expression (e.g., furrowed eyebrows).
- Problem: Chest pain
- Etiology: Increased oxygen demand and decreased oxygen supply
- Defining characteristics: Patient verbalizations, facial expressions
Risk for Infection: Related to the presence of open surgical wounds in the chest and left leg.
- Problem: Risk for infection
- Etiology: Presence of open surgical wounds in chest and leg