Nursing diagnosis for nurses
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  • 1. Prepared by :- Taghreed hamza hawsawi RN- BSN Nursing Educator
  • 2.  Introduction  Definition  Steps of formulating nursing diagnosis  Category of nursing diagnosis  Type of nursing diagnosis  summary  Reference
  • 3. diagnosis :- 1. determination of the nature of a cause of a disease. 2. a concise technical description of the cause, nature, or manifestations of a condition, situation, or problem.
  • 4. physical diagnosisdifferential diagnosis medical diagnosisclinical diagnosis diagnosis based on information obtained by inspection, palpation, percussion, and auscultation the determination of which one of several diseases may be producing the symptoms diagnosis based on information from sources such as findings from a physical examination, interview with the patient or family or both, medical history of the patient and family, and clinical findings as reported by laboratory tests and radiologic studies diagnosis based on signs, symptoms, and laboratory findings during life
  • 5.  a statement of a health problem or of a potential problem in the client's health status that a nurse is licensed and competent to treat.  The process of assessing potential or actual health problems, including those pertaining to an individual patient, a family or community, that fall within the scope of nursing practice; a judgment or conclusion reached as a result of such assessment or derived from assessment data.
  • 6. 1. A database is established by collecting information from all available sources:- a. including interviews with the client and the client's family b. a review of any existing records of the client's health c. observation of the client's response to any alterations in health status, a physical assessment, and a consultation with others concerned in the client's care.The database is continually updated.
  • 7. 2.The second step includes analysis of the client's responses to the problems, healthy or unhealthy, and classification of those responses as psychologic, physiologic, spiritual, or sociologic. 3.The third step is the organization of the data so that a tentative diagnostic statement can be made that summarizes the pattern of problems discovered.
  • 8. 4.confirmation of the sufficiency and accuracy of the database by evaluation of the appropriateness of the diagnosis to nursing intervention and by the assurance that, given the same information, most other qualified practitioners would arrive at the same nursing diagnosis.
  • 9.  Part 1 the term that concisely describes  Part 3 the problem, the probable cause of the problem  Part 3 the defining characteristics of the problem.
  • 10. 1- ACTUAL: This diagnosis has 3 parts and follows the PES format. It will actually paint a picture of the existing health problem. The evidence in this diagnostic statement must be specific. Example: Impaired gas exchange r/t status of secretions associated with difficulty coughing up secretions from fatigue . 1. Large amounts thick green-yellow sputum 2. Frequent coughing with expectoration of sputum 3. Crackles throughout both lung fields 4. O2 sat of 90% without oxygen
  • 11. RISK: This diagnosis indicates from the data, a strong likelihood that it will occur if actions are not taken. The Risk diagnosis only has 2 parts. It can be used with any NANDA diagnosis. Example: Risk for falls r/t to unsteady gait
  • 12. POTENTIAL COMPLICATION: This is also known as a collaborative diagnosis. This is a problem the nurse cannot treat independently. Nursing care will focus on monitoring and preventing the problem. A collaborative diagnosis can be written as a one or two part statement. Example: P.C of surgery: Hemorrhage or P.C. of chronic obstructive pulmonary disease: respiratory failure
  • 13.  Merely a nursing diagnosis label that you make up that “sounds like” it explains what you are seeing in your patient.  Another way of explaining the medical diagnosis, or of renaming a medical condition.  Something that “goes with a particular medical diagnosis”.  A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.” (Herdman, 2012, p. 515).  The medical diagnosis provides one important piece of data, but it does not provide anywhere near the depth of information necessary for making an accurate nursing care