NURSING DIAGNOSING
NURSING DIAGNOSING
NURSING DIAGNOSIS
Analyze Data
Identify Health problems, risks, and strength
Formulate Diagnostic statement
Nursing Diagnosing
- Is the 2nd phase of the nursing process
- In this phase, the nurse use critical-thinking skills to interpret assessment data and identify client strengths and problems.
Definitions
Diagnosing - refers to the reasoning process
Diagnosis - is a statement or conclusions regarding the nature of a phenomenon.
Diagnostic labels - the standardized NANDA names for diagnoses
The client's problem statement, consisting of the diagnostic label plus etiology.
NANDA - North American Nursing Diagnosis Association
Types of Nursing Diagnoses
Actual diagnosis
- is a client problem that is present at the time of the nursing assessment
Ex: Ineffective Breathing Pattern Anxiety
It is based on the presence of associated signs and symptoms
Risk Nursing diagnosis
- is a clinical judgement that the problem does not exist, but the presence of risk factors indicates that the problem is likely to develop unless nurses intervene.
Ex: Risk for infection
Wellness diagnosis
- describe human responses to levels of wellness in an individual, family or community that have a readiness for enhancement.
Ex: Readiness for Enhanced, Spiritual Well-being & Readiness for Enhanced Family Coping
Possible Nursing diagnosis
- is one in which evidence about a health problem is incomplete or unclear.
Ex: Possible Social Isolation
Syndrome diagnosis
- is a diagnosis that is associated with cluster of. other diagnoses.
Ex: Risk for Disuse Syndrome
Components of a NANDA Nursing Diagnoses:
Problem (Diagnostic Label) and Definition
- describe the client's health problem or response for which nursing therapy is given.
- it describes the client's health status clearly and concisely in a few words.
Ex. Deficient knowledge (medications)
Qualifiers
Are words that have been added to some NANDA label to give additional meaning to the diagnostic statement:
Deficient (inadequate amount, quality or degree, incomplete, not sufficient
Impaired (made worse, weakened, damaged, reduced, deteriorated)
Decreased ( lesser in size, amount or degree)
Ineffective (not producing the desire effect)
Compromised (to make vulnerable to threat)
Etiology (Related factors and risks factors)
- identifies one or more probable causes of the health problem, gives direction to acquire nursing therapy, and enables the nurse to individualized clients card.
Defining Characteristics
- are cluster of signs and symptoms that indicates the presence of a particular diagnostic label.
- For actual nursing diagnosis, these are the client's signs and symptoms
Diagnosis and definition | Etiology/related factors | Defining characteristics |
Activity intolerance | Bedrest or Immobility | Verbal report of fatigue and weakness |
Constipation | Prolonged laxative use | Hard stool, difficulty of defecation |
Difference between Nursing Diagnosis and Medical Diagnosis
Nursing Diagnosis | Medical Diagnosis |
Activity intolerance related to decreased cardiac output | Myocardial infarction |
Describe human responses to disease process or health problem; Consist of one, two, three part statement usually including problem and etiology | Describe disease and pathology; do not consider other human response: usually consist not more than three word. |
Oriented to the individual; nurses responsible for diagnosing | Oriented to pathology: Physician responsible for diagnosing |
Nurse orders most interventions to prevent | Physician orders primary interventions to prevent and treat |
Prevent | Implement medical orders for treatment and monitor status or condition |
Nursing actions: Independent | Nursing actions: Dependent |
Can change frequently | Remains the same while patient is present |
Classification system is develop and being used but is not universally accepted | Well-developed classification system accepted by the medical profession |
Formulating Diagnostic Statement
Basic two-part Statements
a. Problem (P): statement of the client's response (NANDA label)
b. Etiology (E): factors contributing to or probable causes of the response.
- These are joint by the words related to rather than due to.
Ex.
Problem | Related to | Etiology |
Constipation | related to | Prolonged use of laxative |
Ineffective breastfeeding | related to | Breast engorgement |
Basic Three-part Statements
a. Problem (P): statement of the client's response (NANDA label)
b. Etiology (E): factors contributing to or probable causes of the response.
c. Signs and Symptoms (S): Defining Characteristics manifested by the client
Ex.
Problem | Related to | Etiology | As manifested by | Signs and Symptoms |
Situational low self-esteem | related to | rejection by husband | as manifested by | Hypersensitivity to criticism |
One-Part Statement
- wellness diagnoses and syndrome diagnoses, consist of a NANDA label only.
- NANDA has specified that any new wellness diagnosis will be developed as one-part statement.
Ex. Readiness for enhanced parenting
Classification of Nursing Diagnosis
High - priority
- life threatening and requires immediate attention.
Medium - priority
- resulting to unhealthy consequences.
Low - priority
- can be resolve with minimal interventions.
GUIDELINES FOR WRITING A NURSING DIAGNOSTIC STATEMENT
1. State in terms of a problem, not need.
Correct statement: Deficient fluid volume (problem) related to fever
Incorrect statement: Fluid replacement (need) related to fever
2. Word the statement so that it is legally advisable
Correct statement: Impaired skin integrity related to immobility (legally acceptable)
Incorrect Statement: Impaired skin integrity related to improper positioning (implies legal liability)
3. Use nonjudgmental statements
Correct statement: Spiritual distress related to inability to attend church services secondary to immobility (nonjudgmental)
Incorrect Statement: Spiritual distress related to strict rules necessitating church attendance (judgmental)
4. Make sure that both elements of the statement do not say the same thing.
Correct statement: Risk for impaired skin integrity related to immobility
Incorrect Statement: Impaired skin integrity related to ulceration of sacral area (response and probable cause are the same)
5. Be sure that cause and effect are correctly stated
Correct statement: Pain: severe headache related to fear of addiction to narcotics
Incorrect Statement: Pain related to severe headache
6. Word the diagnosis specifically. and precisely to provide direction for planning nursing intervention.
Correct statement: Impaired oral mucous membrane related to decreased salivation secondary to radiation of neck (specific)
Incorrect Statement: Impaired oral mucous membrane related to noxious agent (vague)
7. Using nursing terminology rather than medical terminology to describe the client's response.
Correct statement: Risk for ineffective airway clearance related to accumulation of secretions in lungs (nursing terminology
Incorrect Statement: Risk for pneumonia (medical terminology)
8. Use nursing terminology rather than medical terminology to describe the probable cause of the client's response.
Correct statement: Risk for ineffective airway clearance related to accumulation of secretions in lungs (nursing terminology)
Incorrect Statement: Risk for ineffective airway clearance related to emphysema (medical terminology)
In planning, ABCD.
A - Audience
B - Behavior
C - Condition (time-frame)
D - Degree (adjective of the behavior)