This is a comprehensive and detailed summary on Chapter 4: Nursing Process: Diagnosis - Physical Examination & Health Assessment.
*Essential Study Material!!
Chapter 4: Nursing Process: Diagnosis
I. Diagnosis can not be delegated
II. Diagnostic process: thinking aspect of nursing diagnosis
III. Diagnostic format: concrete product
IV. DIAGNOSIS: THE SECOND STEP OF THE NURSING PROCESS
A. Nursing diagnosis: identifying patterns in the data and drawing conclusions aboit the
client’s health status
B. Overlapping
1. Begin diagnostic reasoning during assessment
2. Nursing diagnosis is the basis for planning client centered goals and
interventions, so accuracy is essential
C. The formal list of nursing diagnostic labels describe health problems that can be
addressed by independent nursing actions and, in that sense, forms the body of
knowledge that is unique to nursing
D. What are Health Problems?
1. Health Problem: any condition that requires intervention to promote wellness
or to prevent or treat disease or illness
2. Human responses: reactions to disease, injury or other stressors
3. Nursing diagnosis: a clinical judgment about individual, family, or community
experiences/responses to actual or potential health problems/life processes.
4. Medical diagnosis: describes a disease, illness, or injury. Identifies a patology so
that appropriate medical treatment can be given
5. Except for APN, nurses can not legally diagnose or treat medical problems
6. Collaborative problems: certain physiologic complications that nurses monitor
to detect onset or changes in status
a) A collaborative problem is always a potential problem
E. Types of Nursing Diagnosis
1. Actual
a) Determine etiology
b) Intervene to treat and/or relieve symptoms
2. Risk (potential)
a) Intervene to remove risk factors
3. Possible nursing diagnosis
a) Continue to assess for more defining characteristics
4. Wellness diagnosis
a) Institute interventions to promote health
V. WHAT IS DIAGNOSTIC REASONING?
A. Diagnostic reasoning: thinking process that enables you to make sense of data
1. Analyze and Interpret Data
a) Identify significant data (cues)
(1) Cues are usually an unhealthy response, a deviation from norms,
change in behavior or health patterns
b) Cluster cues
(1) A cluster is a group of cues that relate to each other
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