MODULE 3 NURSING DIAGNOSIS

ACTUAL DIAGNOSIS

ACTUAL DIAGNOSIS

• Problem of the client is present at the time of the nursing assessment

• Based on the presence of associated signs and symptoms

HEALTH PROMOTION DIAGNOSIS

• Relates to clients’ preparedness to implement behaviors to improve their health condition

SYNDROME DIAGNOSIS

• Associated with a cluster of other diagnoses

POSSIBLE DIAGNOSIS

• Statements describing  a suspected problems for which additional data are needed to confirm or rule out of the suspected problem

RISK DIAGNOSIS

• Clinical judgement that a problem does not exist, however the presence of risk factors indicates that a problem is likely to develop unless nurse intervenes

• There are no current signs or symptoms at present

PROBLEM/RISK

• Describes the client’s health problem or response for which nursing therapy is given

• Describes the health status clearly and concisely in a few words

• The purpose of diagnostic label is to direct the formation of client goals and desired outcomes

• May also suggest some nursing interventions

ETIOLOGY

• Related factors and risk factors Identifies

• One or more portable cause of the health problem

• Gives direction to the required nursing therapy

• Enables the nurse to individualize the client’s care

• Differentiating possible case is essential because each may require different nursing interventions

DEFINING CHARACTERISTICS

• The cluster of signs and symptoms that indicate the presence of a particular diagnostic label

• actual nursing diagnoses, the defining characteristics are the client’s subjective and objective data

• risk diagnoses, no sign and symptoms exist thus the factors that cause the client to be more vulnerable to the problem for the etiology

NURSING DIAGNOSIS

• Describes human responses to disease processes or health problems

• Consist of one, -two or three part statements including problem and etiology

• Oriented to the client

• Nurse is responsible for diagnosing and ordering most interventions to prevent and treat the health problem

• Most are independent nursing actions, and the nursing diagnosis may change frequently

Two parts statement

1. problem

2. etiology

• usually joined by the words related to, rather than, or due to

Three parts statement

1. problem

2. etiology

3. signs/symptoms

One part statement

consist of NANDA label only ; health promotion diagnoses and syndrome

MEDICAL DIAGNOSIS

• Describes disease and pathology

• Do not consider human responses usually consists of a few words and are oriented to pathology

• The primary care provider is responsible for diagnosing and ordering primary interventions

• Nurses implement medical orders for treatment and monitor the status of the client’s condition

• Diagnosis remains the same while diseases is present and there is a well developed classification system accepted by medical profession

COLLABORATIVE PROBLEMS

• Involves human response mainly physiological complications of disease, tests, or treatments.

• They consist of two part statements of situation/pathophysiology and the potential complication.

• Collaborative problems are oriented to pathophysiology and nurses are responsible for diagnosing

• Nurses collaborate to other healthcare workers and physicians to prevent and treat.

ANALYZING DATA

• Nurse must compare data against standards or norms, generally accepted measures, rules, models, or patterns

• Cluster the cues (generate tentative hypotheses) to determine the relationship of facts, determining whether patterns are present or represent isolated incidents and whether the data are significant

• Identify gaps and inconsistencies ; all inconsistencies must be clarified before valid patterns can be established

IDENTIFYING HEALTH PROBLEMS

• Client and nurse then identify problem that support tentative actual, risk, and possible diagnoses

• Nurse must identify whether the client’s problem is a nursing diagnosis, medical or collaborative

RISKS AND STRENGTHS

The nurse and client must establish the client’s strengths, resources and abilities to cope.

FORMULATING DIAGNOSTIC STATEMENTS

Last step in diagnostic process

GUIDELINES FOR WRITING NURSING DIAGNOSIS

1. Write the statement in terms of a problem

2. Word the statement so that it is legally advisable

3. Use a nonjudgmental statement

4. Ensure both elements of the statement do not say the same thing

5. Ensure cause and effect are stated correctly

6. State the diagnosis specifically and precisely

7. Use nursing terminology rather than medical terminology to describe the client’s response.

Human response pattern includes

1. exchanging (mutual giving and receiving)

2. communicating (sending messages)

3. relating (establishing bonds)

4. valuing (assigning relative worth)

5. choosing (selection of alternatives)

6. moving (activity)

7. perceiving (reception of information)

8. knowing (meaning associated with information)

9. feeling (subjective awareness of information)