Transcript Nursing Diagnosis

Nursing Diagnosis
Definition of Nursing Diagnsis
• A nursing diagnosis is a statement of
the high risk or actual problems in the
client’s health status that the nurse is
licensed and competent to treat
Components of Analysis Phase
• 3 major components of analysis phase:
– Analysis and interpretation of data
• Validation of data
• Clustering of data
– Identification of problems/health care needs
– Formulation of nursing diagnosis statement
Nursing Diagnostic Statement
• Derived from actual or potential problems
• Derived from physiological, sociocultural,
developmental, and spiritual dimensions of
client
• Focus: Helping client to achieve a
maximal level of wellness and highest
level of independence
Categories of
nursing diagnoses
Nursing diagnoses?
What’s up with that?
• Nursing diagnoses are what you get when you finish
your assessment and look at your data.
• Nursing diagnoses describe patient needs or responses
to health conditions and treatments
• Nursing diagnoses reflect the patient’s level of health or
response to disease, emotional state, socio-cultural
phenomenon, or developmental stage
Medical vs. nursing diagnoses
• Medical diagnosis- Identifies disease or pathology
• Nursing diagnosis- Identifies patient’s response to said
disease or pathology
• Medical diagnosis goal- to cure the disease
• Nursing diagnosis goal- to direct the nursing plan of care
to meet the patient’s needs
This nurse is validating the cues collected
from this
client during the assessment phase.
Nursing diagnoses
• Help facilitate communication between members of the
nursing staff
• Help prioritize the needs of the patient
• Help to guide charting
In practice, you…
• Do your assessment and think “My patient is in pain!”
• Take your impressions and put fancy labels on them like
“impaired comfort” or “acute pain”
• Those are nursing diagnoses in a nutshell
You got to stick with NANDA!
• Unfortunately, you are not allowed to make up new and
creative nursing diagnoses for your patients
• No matter how much your patient merits a nursing
diagnosis of “persistent stupidity” or “constant whining”
you just can’t do it!
• Some authors like Carpenito have developed nursing
diagnoses similar to NANDA’s, but the OU SON
professors require only NANDA diagnoses for your care
plans and papers
Writing nursing diagnoses
• The first part is the NANDA nursing diagnosis statement
• If your patient doesn’t meet the criteria for the diagnosis
yet, you put “Risk for…” in front of the diagnosis
– Risk for nausea
– Risk for deficient fluid volume
• After the diagnosis, you put why you chose the diagnosis
for the patient with a “related to” (R/T) statement…
– Risk for nausea R/T side effects from chemotherapy medications
– Risk for deficient fluid volume R/T poor fluid intake and high
temperature
– Sleep deprivation R/T busy ICU environment
Writing “related to” statements
• Don’t put medical diagnoses or diagnostic tests like
•
pneumonia, hip fracture, or angioplasty in the “related
to” statement.
Do put factors that you can take care of with nursing
interventions…
BAD
Impaired gas exchange R/T
increased blood CO2 levels
BETTER!!
Impaired gas exchange R/T
shallow breathing postop
Diarrhea R/T C. difficile infection Diarrhea R/T food intolerance
Acute pain R/T hip fracture
Acute pain R/T swelling and
tissue damage
More examples…
Bad
Risk for aspiration
R/T stroke
Good
Risk for aspiration
R/T impaired
swallowing
Why??
Nurses can work with
patients to improve
swallowing ability
Acute pain R/T hip Acute pain R/T
Nurses can give medications
fracture
tissue damage and to help relieve pain from
swelling in right hip tissue damage, and provide
ice to reduce swelling
Risk for falls R/T
Multiple Sclerosis
Risk for falls R/T
poor balance and
leg weakness
Nurses can help patients with
transfers to compensate for
poor balance and weakness
Care Plan Formats
After the R/T statement…
• After you say why you chose the diagnosis for the
patient with the “related to” statement, include an “as
evidenced by” statement that includes specific signs and
symptoms of the particular patient
• This step is not needed when there is only “Risk for …”
diagnoses, as the patient is only at risk for the condition
and has not actually developed it yet
• You can use “AEB” for “as evidenced by” so that you
don’t need to write it out
AEB statements
• Don’t include prejudicial statements such as:
– Risk for impaired skin integrity R/T poor hygiene
habits, AEB foul stench from perineal area
• Instead, you could use:
– Risk for impaired skin integrity R/T inability to
reach perineal area to clean, AEB patient
verbalized need for nursing assistance with
perineal care
Diagnostic testing…
• Don’t use diagnostic tests specifically in nursing
diagnoses like:
– Anxiety R/T cardiac catheterization, AEB patient
statements of uneasiness and nervously pacing floor
• Instead, focus on patient responses to the tests:
– Anxiety R/T awaiting of cardiac catheterization
results, AEB patient statements of uneasiness
and nervously pacing floor
Phrasing diagnoses
• Don’t use blaming phrases or ones that could imply
negligence or malpractice, like:
– Excess fluid volume R/T IV infused too quickly
– Acute pain R/T improper placement of epidural
catheter
• Don’t overload diagnoses…
– Constipation and abdominal pain should be 2 different
nursing diagnoses
– Noncompliance and knowledge deficit should be 2
different diagnoses