Chapter 7 Nursing Diagnoses - Vocabulary Flashcards

Vocabulary flashcards covering key concepts of nursing diagnoses from the provided notes.

Nursing diagnosis

A clinical judgment about a patient’s actual or potential health response to health conditions or needs, derived from assessment data and guiding nursing interventions; not a medical diagnosis.

Diagnosis phase

The stage in the nursing process where patterns are identified, diagnoses are validated, and the diagnostic statement is formulated.

Clinical judgment

The nurse’s interpretation of assessment data to determine a patient’s status and needs.

Assessment data

Collected information about a patient’s health status used to form diagnoses and plan care.

Diagnostic statement

The formal nursing diagnosis expressed after data synthesis, including the diagnostic label, associated factors, and indicators (for actual diagnoses).

ICNP

International Classification for Nursing Practice, a classification system for nursing diagnoses.

HHCC

Home Health Care Classification of Nursing Diagnoses, a taxonomy used in home health nursing.

North American Nursing Diagnosis-International Taxonomy II

A taxonomy (NANDA-International Taxonomy II) of nursing diagnoses used in North America.

Medical diagnosis

Describes a disease or pathology of specific organs or body systems and guides medical treatment.

Nursing diagnosis vs medical diagnosis

Nursing diagnosis describes the patient’s response to health problems; medical diagnosis describes a disease or pathology.

Collaborative health problems

Actual or potential physiologic complications requiring coordinated nursing and medical care across disciplines.

Associated factors

Conditions, circumstances, or etiologies that contribute to the nursing problem (related to/with).

Risk factors

Clinical cues or variables that place the patient at risk for a problem.

Indicators

Observable cues or data (signs/symptoms) that signal the diagnosis.

Cue clustering

Grouping related cues to identify patterns that support a diagnosis.

Validation (of nursing diagnosis)

Confirming a nursing diagnosis, often with patient input, to legitimize its significance.

3-part nursing diagnosis

A full format: Diagnostic Label, Associated Factors (etiology), and Indicators (signs/symptoms) for an actual diagnosis.

2-part nursing diagnosis

A format typically used for risk diagnoses: Diagnostic Label and Associated factors (etiology).

1-part nursing diagnosis

A simplified format for improved or positive diagnoses: Diagnostic Label only.

Diagnostic label

The concise description of the core problem expressed in as few words as possible.

Associated factors (etiology)

Factors that contribute to the problem and help explain its cause.

Indicators (signs and symptoms)

Observable data that demonstrate the presence of a diagnosis.

Pneumonia vs impaired airway clearance

Medical diagnosis example is pneumonia; nursing diagnosis is impaired airway clearance associated with thick secretions.

Oxygenation

A patient need described in nursing diagnoses (e.g., oxygenation) related to respiratory health.

Bronchoscopy vs oxygen therapy

Bronchoscopy is a procedure; oxygen therapy is a treatment cited in nursing diagnosis examples, not a diagnosis.

Validation purpose

To legitimize the nursing diagnosis by confirming its relevance with the patient.

Nursing practice significance

Nursing diagnoses communicate care needs, support quality care, and focus on patients’ health needs.