NURSING DIAGNOSIS INTRODUCTIONDiagnosis is the second phase of nursing process. It isoften referred to as analysis as well as problemidentification or nursing diagnosis. It provide the basisfor the selection of nursing intervention to achieve theoutcome for which the nurse is accountable.
DEFINITIONDiagnosing refers to the reasoning process.Diagnosis A statement or conclusion regarding thenature of phenomenon.Nursing diagnosis definition by NANDA (1990):- A nursing diagnosis is a clinical judgement aboutindividual, family or community response to actual andpotential health problems/ life process. Nursing diagnosisprovides the basis for selection of nursing intervention toachieve the outcome for which the nurse is accountable.
PURPOSE Identify how an individual, group or Community responds to actual or potential health and life processes. Identify factors that contribute to or cause health problems (etiologies). Identify resources or strengths the individual, group or community can draw on to prevent or resolve problems.
Development of Nursing diagnosisBegan in 1973 by faculty members of Saint Louis University, Kristine Gebbie & Mary Ann Lavin.In 1977 International recognition came with the first Canadian Conference in Toronto & the International Nursing Conference in 1987, Canada.1982 The Conference group accepted the Name North American Nursing Diagnosis Association (NANDA), (Nurses in Canada & US.)
PURPOSE OF NANDAo To define, refine and promote a taxonomy of Nursing diagnostic terminology of general use to Professional Nurses.(Taxonomy is a classification system or set of categories arranged on the basis of single principle or set of principles).o Members of Nanda Staff Nurses, Clinical Specialists, faculty, Directors of Nursing, Deans, Theorists & Researchers.
In 2000 NANDA approved new TaxonomyII, which has 13 Domains, 106 classes and 155Diagnosis.Taxonomy II DomainsDomain 1 : Health Promotion. 2 : Nutrition 3 : Elimination 4 : Activity / Rest 5 : Perception / Cognition 6 : Self – perception 7 : Role relationships 8 : Sexuality 9 : Coping / Stress tolerance 10 : Life principles 11 : Safety / Protection 12 : Comfort 13 : Growth / Development.
NURSING DIAGNOSIS VERSES MEDICAL DIAGNOSISMedical diagnosis Nursing diagnosis Identify disease. Focuses on unhealthy responses to health and illness. Describe problems for Describe problems treated by which the physician directs nurses within the scope of the primary treatment independent Nursing practice. May change from day to day as the patients’ response change Remains the same as long as the disease is present. Example of Nursing diagnosis for a person with myocardial infarction Example of Medical Fear diagnosis Altered health maintenance Myocardial infarction (heart Pain attack) Knowledge deficit Altered tissue perfusion.
TYPES OF NURSING DIAGNOSIS Actual Nursing Diagnosis Risk Nursing Possible Nursing Diagnosis Diagnosis Syndrome Wellness Nursing Nursing Diagnosis Diagnosis
Actual Nursing Diagnosis: It is judgement about the clientresponse to a health problem that ispresent at a time of nursingassessment. Eg: Ineffective breathing pattern &anxiety
Risk Nursing Diagnosis It is a clinical judgement that a client ismore vulnerable to develop the problemthan others in the same or similarsituation.Eg: Risk for impaired skin integrityrelated to surgery.
Possible Nursing Diagnosis It describe a suspected problem forwhich current and available data areinsufficient to validate the problem.Eg: Possible social isolation related tounknown etiology.
Syndrome Nursing DiagnosisIt is a cluster of nursing diagnosis thatfrequently go together and present aclinical picture.Eg: Rape Trauma Syndrome
Wellness Nursing Diagnosis It is clinical judgement about anindividual, group or community intransition from a specific level ofwellness to a higher level of wellness.Eg: Family coping: potential for growthrelated to unexpected birth of twins.
COMPONENT OF NURSING DIAGNOSIS Problem Statement Defining Etiology Characterstics
Problem Statement (Diagnostic Label): It describe the client health problem orresponse for which nursing therapy is givenclearly and concisely in a few words.Eg: Knowledge deficit(medications) Some Qualifier are also added to giveadditional meaning to the statement such asImpaired, Decreased, Ineffective, Acute, Chronic.
Etiology (Related Factors & Risk Factors): This component identifies one or more probablecauses of health problem. It help the nurse to giveindividualized patient care.Eg: Anxiety related to hospitalization.
Defining Characterstics: These are the clusters of signs and symptoms thatindicate the presence of a particular diagnosticlebel.Eg: Fluid volume deficit related to decreased oralintake manifested by dry skin and mucusmembranes.
Nursing Diagnostic process Assess the client health status Validate data with other resourcesReasses Is additional data needed?s No Yes Interpret and analyses of data
Data clustering, group sign & symptoms, classify & organize Look for defining characterstics Identify client needsFormulate nursing diagnosis & collaborative problems
FORMULATION OF NURSING DIAGNOSTIC STATEMENT The basic format for a diagnosticstatement is “ problem related toetiology” however nurses must be ableto write one , two, three and four partdiagnostic statement, as well as somevariation of each.
BASIC TWO PART STATEMENT The basic two part statement is used for actual, high risk, and possible nursing diagnosis. It includes the following: 1. PROBLEM (P) : statement of client response 2. ETIOLOGY(E) : Factors contributing to or probable causes of responses.
The two part joined by the words related to, or associated with rather than due to.e.g.1. Noncompliance ( diabetic diet) related to denial of having disease. 2. Pain related to surgery
BASIC THREE PART STATEMENT The basic three part statement is called the PES 1.PROBLEM (P): Statement of client response. 2.ETIOLOGY (E): Factors contributing to or probable causes of responses. 3.SIGN AND SYMPTOMS(S) : defining characteristics manifested by the client.
4.Using “secondary to” divided the etiology intotwo parts thereby making the statement moredescriptive and useful.e.g. High risk for impaired skin integrity related todecreased peripheral circulation secondary todiabetes.
5.Adding a second part to the general response orNANDA label to make it more precisee.g.PROBLEM DESCRIPTER RELATED TO ETIOLOGYImpaired physical inability to work related to knee joint stiffnessmobility and pain secondary to muscle atrophy
FOUR PART STATEMENTThese statement are the combination of basic statement and variation 4 and 5 discuss abovee.g.1. High risk for impaired skin integrity2. Pressure sore related to3. Immobility4. Secondary to presence of traction and casts.