32 4 Wellness clinical judgments about an individual family or community in

32 4 wellness clinical judgments about an individual

This preview shows page 32 - 42 out of 52 pages.

32
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4. Wellness: - clinical judgments about an individual, family, or community in transition from it a specific level of wellness to higher level of wellness. 5. Syndrome: - comprises a cluster of actual or risk nursing diagnosis that is predicted to present b/c of a certain situation or event. 33
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Parts of Nursing Diagnosis 1. Problem Statement :-describes a physiological or psychological response to a health problem. When writing use: altered, disturbed, decreased, excessive, dysfunctional…etc 2. Etiology Statement :-describes contributing factors that influence development of the response. Identifies the physiologic, psychological, sociologic, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor. Etiology identifies the factor that maintain the un healthy patient state and prevent the desired change, thus directs the nursing intervention. Unless the etiology is correctly identified, nursing actions may be inefficient and ineffective. 34
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3. Defining Characteristics :-the subjective and objective data that signal the existence of the actual health problem. Writing Nursing Diagnosis 1. The actual nursing diagnosis has data that support and the presence of the problem. It has three parts: Problem (NANDA) + related to etiology + as evidenced by defining characteristics. E.g. Ineffective airway clearance related to weak cough and incision pain, as evidenced by poor or no cough effort. 35
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2. The high-risk nursing diagnosis- indicates the clients at risk for this response, although it is not yet present. o It has only two parts:-Problem (NANDA) and related to etiology. o It has no defining characteristics. o E.g. .high- risk for impaired skin integrity related to advanced age, immobility, confinement to bed 3. Possible/probable-has possible problem and factor. E.g. .possible sexual patterns related to partner’s diagnosis of herpes 36
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4. Diagnostic statements for wellness nursing diagnoses are one- part , containing the diagnostic label . e.g -Readiness for enhanced family process. -Readiness for enhanced nutrition 5. Syndrome nursing diagnoses usually are one- part diagnostic statements with the contributing factors contained in the diagnostic lable. 37
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NANDA has five syndrome diagnoses : - Rape trauma syndrome. - Disuse syndrome. - Post -trauma syndrome. - Relocation stress syndrome. - Impaired environmental Interpretation syndrome. 38
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Guidelines for Writing Nursing Diagnosis 1. Phrase the nursing diagnosis a patient’s problem or alteration in health state rather than as a patient need 2. Use “related to” rather than “caused by” or “due to” 3. Write the diagnosis in legally advisable terms 4. Use non-judgemental language 5. Do not reverse the cause with the problem 6. Single nursing diagnosis should contain only one specific problem 7. Avoid medical diagnosis 39
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8. The problem and etiology should be expressed in terms of that can be change 9. Check the diagnosis to make sure the problem statements patient goals and that the etiology will direct the selection of nursing measures 10. Defining characteristics should follow the etiology and be lining by the phrase “as evidenced by” or “as manifested by” 40
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Nursing Diagnosis Example Actual diagnosis Deficient Fluid Volume related to
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