29 Questions
What is the primary purpose of the nursing process?
To identify a client's health care status and potential health problems
What is the first phase of the nursing process?
Assessment
What characteristic of the nursing process involves working with others?
Interpersonal and collaborative
What is the result of the assessment phase of the nursing process?
Data is collected and organized
What is the primary difference between a nursing diagnosis and a medical diagnosis?
A nursing diagnosis is focused on the client's response to a health problem
Why is critical thinking important in the nursing process?
To make sound judgments in every phase of the nursing process
What is the primary characteristic of an actual nursing diagnosis?
The presence of associated signs and symptoms
What type of nursing diagnosis is concerned with a client's preparedness to implement healthy behaviors?
Health promotion diagnosis
What is the purpose of the etiology component in a NANDA nursing diagnosis?
To provide direction for nursing therapy
What is the defining characteristic of a risk nursing diagnosis?
The presence of risk factors that may lead to a problem
What is the format of a NANDA nursing diagnosis?
PES format
What is the purpose of the problem component in a NANDA nursing diagnosis?
To describe the client's health problem or response
What does a complete physical examination include?
Patient's height, weight, vital signs, and head-to-toe examination of all body systems
What is the purpose of palpation in physical examination?
To use the sense of touch to gather information
What is auscultation?
Listening to sounds made by the body
What is the purpose of validating data in the assessment phase?
To double-check or verify data to confirm that it is accurate and complete
What is the definition of nursing diagnosis according to NANDA?
A clinical judgment about individual, family, or community responses to actual and potential health problems/life processes
What is the final step in the assessment phase?
Documenting data collected about the client's health status
What is the primary difference between an actual nursing diagnosis and a risk nursing diagnosis?
The presence of signs and symptoms
What are the three components of an actual nursing diagnosis?
Problem, related to, and as evidenced by
What is the purpose of the 'related to' component in a nursing diagnosis?
To identify the factors contributing to the problem
What is the correct format for a two-part nursing diagnosis statement?
Problem related to etiology
What is the term for the signs and symptoms present in a client with an actual nursing diagnosis?
Defining characteristics
What is included in a client's database?
All information about the client, including nursing health history and laboratory test results
What type of data is described as sensations, feelings, values, beliefs, attitudes, and perception of personal health status?
Subjective data
What type of data is detectable by an observer or can be measured or tested against an accepted standard?
Objective data
Who is the primary source of data?
The client
What is one method of data collection that uses the senses?
Observation
What is a planned communication or conversation with a purpose?
Interview
Study Notes
Types of Nursing Diagnosis
- An actual diagnosis is a client problem that is present at the time of nursing assessment, based on associated signs and symptoms (e.g., ineffective breathing pattern and anxiety).
- A risk nursing diagnosis is a clinical judgment that a problem doesn't exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene (e.g., all people admitted to a hospital have a higher risk for infection).
- A health promotion diagnosis relates to clients' preparedness to implement behaviors to improve their health condition, with labels beginning with "Readiness for Enhanced" (e.g., Readiness for Enhanced Nutrition).
Components of a NANDA Nursing Diagnosis
- Problem (diagnostic label) and definition: describes the client's health problem or response for which nursing therapy is given (e.g., Deficient Knowledge (Medications) or Deficient Knowledge (Diet)).
- Etiology (related factors and risk factors): identifies one or more probable causes of the health problem, giving direction to required nursing therapy and enabling individualized care.
- Defining characteristics (signs and symptoms): a cluster of signs and symptoms indicating the presence of a particular diagnostic label.
Nursing Process
- Definition: a systematic, rational method of planning and providing nursing care to identify a client's health care status, actual or potential health problems, and establish plans to meet identified needs.
- Phases: 5 phases of nursing process are assessment, diagnosis, nursing planning, implementation, and evaluation.
- Characteristics: cyclic and dynamic, client-centered, adaptive, problem-solving, decision-making, interpersonal, and collaborative.
Assessment
- Collection, systematic organization, and documentation of data.
- Physical examination includes height, weight, vital signs, and a head-to-toe examination of all body systems.
- Techniques of physical examination: inspection, palpation, percussion, and auscultation.
- Diagnostic and laboratory data: organizing, validating, and documenting data.
- Written or computerized format that organizes assessment systematically.
Nursing Diagnosis
- Definition: a clinical judgment about individual, family, or community responses to actual and potential health problems/life processes.
- Actual nursing diagnosis contains 3 parts: diagnostic label, related factors, and signs and symptoms (defining characteristics).
- Example: Noncompliance related to knowledge deficit of the need for weekly blood pressure measurements, as evidenced by "I don't keep my BP appointments if I am busy."
- Basic two-part statements: problem (P) and etiology (E).
Data
- Database: all information about a client, including nursing health history, physical assessment, primary care provider's history, and laboratory and diagnostic tests.
- Types of data: subjective (symptoms or covert data) and objective (signs or overt data).
- Source of data: primary (client) and secondary (family members, other health professionals, records, and reports).
- Methods of data collection: observation, interview, examination, diagnostic procedure, and lab investigation.
Test your understanding of the nursing process, its characteristics, steps, and components of a NANDA nursing diagnosis. Learn how to apply the nursing process in medical surgical nursing.
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