There is no real use for simply providing a list of terms – to do so
defeats the purpose of a standardized language. Unless the definition,
defining characteristics, related and / or risk factors are known, the
label itself is meaningless. Therefore, we do not believe it is in the
interest of patient safety to produce simple lists of terms that could
be misunderstood or used inappropriately in a clinical context.
It is essential to have the definition of the diagnosis - and more importantly - the diagnostic indicators
(assessment data / patient history data) required to make the diagnosis. For example, the signs / symptoms that you collect through your assessment
("defining characteristics") and the cause of the diagnosis
("related factors") or those things that place a patient at significant risk for a diagnosis
As you assess the patient, you will rely on both your clinical knowledge and "book knowledge" to see patterns in the data; diagnostic indicators that cluster together which may relate to a diagnosis. Questions to ask to identify and validate the correct diagnosis include:
- Are the majority of the defining characteristics/risk factors present in the patient?
- Are there etiological factors ("related factors") for the diagnosis evident in your patient?
- Have you validated the diagnosis with the patient / family or with another nurse peer (when possible)?
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