NANDA: Nursing Diagnosis, ADPIE, Evidence Based
Practice, Nursing Data Collection - Fundamental Exam 2
Nursing diagnosis definition - ANSW A clinical judgment concerning a human
response to health conditions/life processes/or vulnerability for that response, by an
individual, family, group, or community
4 types of NANDA diagnoses (PRHS) - ANSW Problem focused, risk, health
promotion, syndrome.
Components of problem focused diagnoses - ANSW Nursing diagnosis, relating
factors, as evidenced by
Example of problems:
Decreased cardiac output it, chronic functional constipation, impaired gas exchange.
Problem focus nursing diagnoses are typically based on - ANSW Signs and symptoms
present in the patient. Most common nursing Diagnoses.
risk nursing diagnosis - ANSW Applies when risk factors require intervention from the
nurse and healthcare team prior to a real problem developing.
Requires clinical reasoning and nursing judgment
Ex) Risk for imbalanced fluid volume, risk for ineffective childbearing process, risk for
impaired oral mucous membrane integrity.
Health promotion Diagnosis - ANSW To improve the overall well-being of an
individual/family or community
Examples: readiness for enhanced family processes, readiness for enhanced hope,
sedentary lifestyle
syndrome diagnosis refers to - ANSW A cluster of nursing diagnoses that occur and a
pattern or can we all be addressed through the same or similar nursing interventions
Examples: decreased cardiac output, decreased cardiac tissue perfusion, ineffective
cerebral tissue perfusion, ineffective peripheral tissue perfusion.
written problem focus Diagnosis - ANSW Problem focused
Diagnosis______R/T:_____ AEB:____
Risk Diagnosis written - ANSW Risk for_____aeb_____(risk factors)
,13 domains of nursing diagnosis - ANSW 1. health promotion
2. nutrition
3. elimination slash exchange
4. activity/ rest
5. perception/cognition
6. self perception
7. role relationship
8. sexuality
9. coping/stress tolerance
10. life principles
11. safety and protection
12. comfort
13. growth and development
Classes of Health promotion - ANSW Health awareness, health management
classes of nutrition - ANSW Indigestion, digestion, absorption, metabolism, hydration
Classes of Elimination and exchange - ANSW Urinary function, Gastrointestinal
function, Integumentary function, respiratory function
Classes of activity/rest - ANSW Sleep/rest, activity/exercise, energy balance,
cardiovascular and pulmonary responses, self-care.
Classes of perception/cognition - ANSW Attention, orientation, sensation/perception,
cognition, communication
Classes of self perception - ANSW Self-esteem, self-concept, body image
Classes of role relationship - ANSW Caregiving rules, family relationships, role
performance
Classes of sexuality - ANSW Sexual identity, sexual function, reproduction
Classes of coping/stress techniques - ANSW Post trauma responses, coping
responses, neurobehavioral stress
Classes of life principles - ANSW Values, beliefs, value and belief of action
congruence.
Classes of safety/protection - ANSW Infection, physical injury, violence, environmental
hazards, defensive processes, thermoregulation
Classes of comfort - ANSW Physical comfort, environmental, and social comfort
, Classes of growth and development - ANSW Growth, development-Risk for delayed
development
Where/When do you start to collect data? - ANSW As soon as you meet your pt you
should start your assessment.
Define Assessing - ANSW The systematic and continuous collection, validation,
analysis, and communication of pt data
Types of Nursing Assessment - ANSW 1. Initial comprehensive
2. Focused
3. Emergency
4. Time-lapsed
Initial comprehensive Assessment - ANSW Preformed shortly after admittance to the
hospital by nurse to collect data on all aspects of pt health
Focused Assessment - ANSW Performed to gather data about a specific problem
already identified, or to look at new problems
Emergency Assessment - ANSW Performed when a crisis is present
Time-lapsed Assessment - ANSW performed to compare to pt current status to
baseline data obtained earlier
Medical Assessment - ANSW Target data pointing to that pathological conditions
(more the cure)
Nursing Assessment - ANSW Focus on the patient's response to health problems (we
help pt along the way)
Objective data - ANSW observable and measurable data that can be seen, heard or
felt by someone other than the person experiencing them. Ex: high temp, vomiting
Establishing Assessment priorities - ANSW health orientation
developmental stage
need for nursing
Sources of data - ANSW pt, family, pt record, other healthcare professionals
Four phases of a Nursing Interview - ANSW 1. preparatory phase
2. introduction
3. working phase
4. Termination
preparatory phase - ANSW ex: report form previous shift
Practice, Nursing Data Collection - Fundamental Exam 2
Nursing diagnosis definition - ANSW A clinical judgment concerning a human
response to health conditions/life processes/or vulnerability for that response, by an
individual, family, group, or community
4 types of NANDA diagnoses (PRHS) - ANSW Problem focused, risk, health
promotion, syndrome.
Components of problem focused diagnoses - ANSW Nursing diagnosis, relating
factors, as evidenced by
Example of problems:
Decreased cardiac output it, chronic functional constipation, impaired gas exchange.
Problem focus nursing diagnoses are typically based on - ANSW Signs and symptoms
present in the patient. Most common nursing Diagnoses.
risk nursing diagnosis - ANSW Applies when risk factors require intervention from the
nurse and healthcare team prior to a real problem developing.
Requires clinical reasoning and nursing judgment
Ex) Risk for imbalanced fluid volume, risk for ineffective childbearing process, risk for
impaired oral mucous membrane integrity.
Health promotion Diagnosis - ANSW To improve the overall well-being of an
individual/family or community
Examples: readiness for enhanced family processes, readiness for enhanced hope,
sedentary lifestyle
syndrome diagnosis refers to - ANSW A cluster of nursing diagnoses that occur and a
pattern or can we all be addressed through the same or similar nursing interventions
Examples: decreased cardiac output, decreased cardiac tissue perfusion, ineffective
cerebral tissue perfusion, ineffective peripheral tissue perfusion.
written problem focus Diagnosis - ANSW Problem focused
Diagnosis______R/T:_____ AEB:____
Risk Diagnosis written - ANSW Risk for_____aeb_____(risk factors)
,13 domains of nursing diagnosis - ANSW 1. health promotion
2. nutrition
3. elimination slash exchange
4. activity/ rest
5. perception/cognition
6. self perception
7. role relationship
8. sexuality
9. coping/stress tolerance
10. life principles
11. safety and protection
12. comfort
13. growth and development
Classes of Health promotion - ANSW Health awareness, health management
classes of nutrition - ANSW Indigestion, digestion, absorption, metabolism, hydration
Classes of Elimination and exchange - ANSW Urinary function, Gastrointestinal
function, Integumentary function, respiratory function
Classes of activity/rest - ANSW Sleep/rest, activity/exercise, energy balance,
cardiovascular and pulmonary responses, self-care.
Classes of perception/cognition - ANSW Attention, orientation, sensation/perception,
cognition, communication
Classes of self perception - ANSW Self-esteem, self-concept, body image
Classes of role relationship - ANSW Caregiving rules, family relationships, role
performance
Classes of sexuality - ANSW Sexual identity, sexual function, reproduction
Classes of coping/stress techniques - ANSW Post trauma responses, coping
responses, neurobehavioral stress
Classes of life principles - ANSW Values, beliefs, value and belief of action
congruence.
Classes of safety/protection - ANSW Infection, physical injury, violence, environmental
hazards, defensive processes, thermoregulation
Classes of comfort - ANSW Physical comfort, environmental, and social comfort
, Classes of growth and development - ANSW Growth, development-Risk for delayed
development
Where/When do you start to collect data? - ANSW As soon as you meet your pt you
should start your assessment.
Define Assessing - ANSW The systematic and continuous collection, validation,
analysis, and communication of pt data
Types of Nursing Assessment - ANSW 1. Initial comprehensive
2. Focused
3. Emergency
4. Time-lapsed
Initial comprehensive Assessment - ANSW Preformed shortly after admittance to the
hospital by nurse to collect data on all aspects of pt health
Focused Assessment - ANSW Performed to gather data about a specific problem
already identified, or to look at new problems
Emergency Assessment - ANSW Performed when a crisis is present
Time-lapsed Assessment - ANSW performed to compare to pt current status to
baseline data obtained earlier
Medical Assessment - ANSW Target data pointing to that pathological conditions
(more the cure)
Nursing Assessment - ANSW Focus on the patient's response to health problems (we
help pt along the way)
Objective data - ANSW observable and measurable data that can be seen, heard or
felt by someone other than the person experiencing them. Ex: high temp, vomiting
Establishing Assessment priorities - ANSW health orientation
developmental stage
need for nursing
Sources of data - ANSW pt, family, pt record, other healthcare professionals
Four phases of a Nursing Interview - ANSW 1. preparatory phase
2. introduction
3. working phase
4. Termination
preparatory phase - ANSW ex: report form previous shift
