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Nursing diagnosis
This document discusses the nursing diagnosis process. It begins by introducing nursing diagnosis as the second phase of the nursing process and a pivotal step. It then discusses NANDA's role in developing standardized nursing diagnoses and taxonomy. The document outlines the 13 domains of nursing diagnosis and characteristics such as being clear, evidence-based, and amenable to nursing intervention. It describes different types of diagnoses and provides examples. Finally, it discusses formulating diagnostic statements, including one, two and three part statements, and qualities of accurate diagnostic statements.
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Nursing diagnosis
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- 3. Introduction • 2nd phaseof nursing process • Pivotal step in nursing process • North American Nursing Diagnosis Association (NANDA) 1982 Critical thinking
- 4. North American NursingDiagnosis Association (NANDA) • The purpose of NANDA is to define refine and promote a taxonomy of nursing diagnostic terminology. • Taxonomy : A taxonomy is a classification system or set of categories arranged based on a single principles. • In 2000, taxonomy 1 revised to taxonomy 2 • Currently, approved,13 domains and 47 classes, 247 nursing diagnosis.
- 5. NANDA NURSING DIAGNOSIS Definitions •Diagnosis : diagnosis is a statement or conclusion regarding the nature of phenomenon. • Diagnostic label: the standardized NANDA names for the diagnoses are diagnostic label. • In 1990 ,NANDA adopted on official working definition of nursing diagnosis,
- 6. Nursing diagnosis “A clinicaljudgment about individual family, or community responses to actual or potential health problems / life process”. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcome for which the nurse’s accountable Professional nurses are responsible for making nursing diagnosis
- 7. 13 domains ………… •Health promotion • Nutrition • Elimination exchange • Activity /rest • Perception or cognition • Self perception • Role relationships • Sexuality • Coping or stress tolerance • Life principle • Safety /protection • Comfort • Growth and development
- 8. Characteristics of nursing diagnosis… •It states clear and concise health problem • It derived from existing evidences about the client • It is potentially amenable to nursing therapy • It is the basis for planning and carrying out nursing care
- 9. Types of nursingdiagnosis ……. Actual nursing diagnosis Risk nursing diagnosis Health promotion nursing diagnosis Possible nursing diagnosis Syndrome nursing diagnosis
- 10. Actual nursing diagnosis……. “Aclinical judgment about human experience/responses to health conditions /life processes that exist in an individual ,family or community.” Actual client problem present at the time of assessment. It is based on the presence of signs and symptoms Eg : Ineffective breathing pattern Disturbed sleep pattern
- 11. Risk nursing diagnosis….. •It is a clinical judgment that a problem doesn't exist but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. • No subjective or objective cues • Eg : A client with DM or compromised immune system is at high risk than others Risk for infection Risk for injury
- 12. Health promotion nursingdiagnosis… • Describes human responses to level of wellness in an individual, family or community that have a readiness for enhancement. • Clinical judgment about a person’s ,families or communities motivation and desire to increase well being • Eg : Readiness for enhanced family coping Readiness for enhanced self esteem
- 13. Possible nursing diagnosis………. •A possible nursing diagnosis is one in which evidence about a health problem is incomplete or unclear. • A possible diagnosis requires more data either to support or to refuse it • Eg : – Possible social isolation related to unknown etiology potential risk of constipation as a result of enforced bed rest
- 14. Syndrome nursing diagnosis……….. • Aclinical judgment describing a specific cluster of nursing diagnoses that occurs together and are best addressed together and through similar interventions. • Eg: – Rape trauma syndrome
- 15. Components of nursingdiagnosis …… Nursing diagnosi s Problem and its definition The etiology Defining characteristics
- 16. 1. Problem (diagnostic label)/definition Theproblem statement describes the client health problem or response for which nursing therapy is given • The diagnostic label should be specific • Each diagnostic label approved by NANDA carries a definition that clarifies its meaning • Qualifiers ; Are words that have been added to some NANDA labels to give additional meaning to the diagnostic statement Deficient Impaired Ineffective Decreased Acute Chronic Imbalanced Interrupted
- 17. 2. Etiology (relatedfactors or risk factor)…. • Identifies one or more probable causes of the health problem, gives directions to the required nursing therapy. • Enables the nurses to individualized client care PROBLEM ETIOLOGY Constipation Long term laxative use, inactivity and insufficient fluid intake Anxiety Threat to physiologic integrity Possible cancer diagnosis
- 18. 3. Defining characteristics......... Thecluster of signs and symptoms that indicate the presence of a particular diagnostic label . Actual diagnosis: client signs and symptoms Risk diagnosis : no subjective signs are present
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- 21. Steps of diagnosticprocess….. 1. Analyzing data 2. Identifying health problems risks and strengths 3. Formulate diagnostic statement
- 22. 1. Analyzing data……… Comparedata against the standard Cluster cues Identifies gaps and inconsistencies
- 23. 2. Identifying healthproblems… • The nurse and client can together identify strengths and problems • Primarily decision making process • Medical diagnosis • Nursing diagnosis • Collaborative problem Determine problems • Resources • Ability to cope up Determine strengths
- 24. Nursing diagnosis One part statement Two part statement Three part statement Formulatingdiagnostic statement……
- 25. Basic two parts……….. 1.Problem :statement of the client responses 2. Etiology :factors contributing to or probable causes of the responses “related to” phrase implies a relation ship Eg : Constipation related to insufficient fluid intake Acute pain related to presence of surgical incision Insomnia related to hospitalization
- 26. Basic three parts………….. Alsocalled PES format; 1. Problem 2. Etiology 3. Signs and symptoms (defining characteristics manifested by the client) Actual nursing diagnoses can be documented by using the three part statement Not used for risk diagnosis
- 27. Basic three parts………….. •Eg : – Acute pain r/t surgical incision as evidenced by verbalization – Ineffective airway clearance r/t accumulation of pulmonary secretions as evidenced by crackles on auscultation – Hyperthermia r/t underlying infectious process as evidenced by temperature 100 F
- 28. Basic one part………… Thediagnostic label are defined and tend to become more specific ,the interventions can be derived from the label itself …… etiology may not be needed. Syndrome and wellness diagnosis consist Nanda label only Eg : Rape trauma syndrome Spiritual well being
- 29. Variations of basicformats…….. • Writing unknown etiology – Noncompliance (medication regimen) related to unknown etiology • Using the phrase complex factors – Chronic low self esteem r/t complex factors • Using the word possible to describe either problem or etiology – Possible low self-esteem r/t loss of job and rejection by family – Altered thought processes possibly r/t unfamiliar surroundings • Using secondary to divide the etiology into two parts – Risk for impaired skin integrity r/t decreased peripheral circulation secondary to diabetes • Adding second part to the general response or NANDA label to make it more precise – Impaired skin integrity (left lateral ankle) r/t decreased peripheral circulation.
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- 31. What all arethe errors can be
- 32. Errors in diagnostic reasoning…..,………. •Verify • Build a very good knowledge base and acquire clinical experience • Have a working knowledge of what is normal • Consult resources • Base diagnosis on pattern that is , on behavior over time –rather than on an isolated incident • Improving critical thinking skills
- 33. Nursing diagnosis v/smedical diagnosis Nursing diagnosis Medical diagnosis Care focused Etiology focused Identifies risk and problems of the patient Identifies as nearly possible the specific clinical entity that is causing illness Focused on the signs and symptoms on the patient and his /her care givers The medical diagnosis specify the pathology Focused on the person and their physiological / psychologic all responses to illness Focuses on illness Eg : Ineffective denial related to difficulty coping with new diagnosis of “heart attack” Eg : Myocardial infarction
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