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Online Companion: Fundamentals of Nursing Standards and Practice 2E
What are the legal
implications for the nurse who makes a nursing diagnosis?
In order to practice nursing, the nurse needs to know what nurses do. Nursing
diagnosis assists nurses to define their scope of practice and to clarify the
legal boundary of nursing. In using nursing diagnosis, the nurse accepts the
accountability for performing actions within the identified scope of practice.
If a nursing diagnosis is inappropriate or the list of nursing diagnoses for
a client is incomplete, the nurse is liable for the error. If a nursing diagnosis
is established and documented but nursing interventions are not carried out,
the nurse may incur liability. The use of nursing diagnosis as a standard of
practice increases nurses' professional autonomy and accountability.
How does the use
of nursing diagnosis fit with the trend toward interdisciplinary care planning?
When the nurse participates in interdisciplinary care planning, a clear and
concise language to describe the nursing perspective on a client's needs promotes
effective communication. The nurses' time is used efficiently when a common
language is used to identify client problems. There are limitations to the use
of medical diagnosis terminology when describing clients' needs in a comprehensive
approach. For instance, the medical diagnosis of cerebrovascular accident tells
the health team very little about the problems the client is experiencing. In
contrast, the nursing diagnosis Impaired physical mobility related to inability
to move left arm and leg gives a clearer picture of the client's problem. The
NANDA-Approved Nursing Diagnoses may offer a resource to improve the interdisciplinary
process in health care.
What is the difference
between assessment data and cues?
During the assessment phase, the gathers a lot of data from observing, inspecting,
examining and listening to the client. The nurse uses critical thinking skills
to select from all the data certain pieces of data that are of importance to
the client's condition. This is a skill that takes time and clinical experience
to develop.The student of nursing takes extra time to review the data, compare
subjective and objective data and to search for patterns in the data. Care is
taken to be sure that data from all sources: interview, health history, symptoms,
physical exam lab and diagnostic data are examined and included in the decision
to identify a cue.
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