Download
1 / 21
311 likes | 1.51k Vues
Nursing process. Nursing diagnosis. 2- Diagnosis. The second step in the nursing process involves: Analysis; breaking the whole down into parts that can be examined Synthesis; putting data together in a new way of the data that have been collected. .
E N D
Nursing process Nursing diagnosis
2- Diagnosis The second step in the nursing process involves: • Analysis; breaking the whole down into parts that can be examined • Synthesis; putting data together in a new way of the data that have been collected. Mrs.Mahdia Samaha Kony
North American Nursing Diagnosis Association (NANDA) • According to (NANDA)the nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. • Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. (Carroll-Johnson, 1990, p. 50).
Purposes of nursing diagnosis - Nursing diagnosis is unique in that it focuses on a client’s response to a health problem, rather than on the problem itself, and it provides the structure through which nursing care can be delivered. • Nursing diagnosis also provides a means for effective communication. - Holistic client, family, and community-focused care are facilitated with the use of nursing diagnosis. - Nursing diagnosis has an important impact on the health care delivery system Mrs.Mahdia Samaha Kony
Components of a nursing diagnosis:- A nursing diagnosis has three components: • the problem and its definition • the etiology • the defining characteristics. Mrs.Mahdia Samaha Kony
Classifications of diagnosis The Two-Part Statement The components of a nursing diagnosis typically consist of two parts. • The first component is a problem statement or diagnostic label. The diagnostic label is the name of the nursing diagnosis as listed in the NANDA. Some examples include stress urinary incontinence, Anxiety. • The second component is the etiology;is the related cause or contributor to the problem. The diagnostic label and etiology are linked by the term related to (RT).
Examples of nursing diagnoses are Disturbed Body Image RT loss of left lower extremity and Activity Intolerance RT decreased oxygen-carrying capacity of cells. Mrs.Mahdia Samaha Kony
Descriptive words • Are terms may be added to clarify specific nursing diagnoses. • These descriptive words are called qualifiers and include; Acute, Chronic, Decreased, Deficient, Depleted, Disturbed, Dysfunctional, Enhanced, Excessive, Impaired, Increased, Ineffective, Intermittent, Potential for, and Risk. • These terms specify a degree of qualification for the identified nursing diagnosis and are placed (used) before the problem statement.
The Three-Part Statement • As in the two-part statement, the first two components are the diagnostic label and the etiology. • The third component consists of defining characteristics (collected data that are also known as signs and symptoms, subjective and objective data, or clinical manifestations). • Example; In the three-part nursing diagnosis format, the third part is joined to the first two components with the connecting phrase “as evidenced by” (AEB).
Differentiating Nursing Diagnosis versus Medical Diagnosis Mrs.Mahdia Samaha Kony
Myocardial infarction (heart attack) is a medical diagnosis. Examples of nursing diagnoses for a person with myocardial infarction include Fear, Altered Health Maintenance, Knowledge Deficit, Pain, and Altered Tissue Perfusion. Mrs.Mahdia Samaha Kony
Nursing Diagnosis versus Collaborative Problems collaborative health problems; problems that require physician – prescribed and nurse – prescribed action. Collaborative problems refer to actual or potential physiologic complications that can result from disease, trauma, treatment, or diagnostic studies for which nurses intervene in collaboration with personnel of other disciplines.
Example1; stress urinary incontinence Diagnostic statement Stress Urinary Incontinence related to degenerative changes in pelvic muscles and structural supports associated with advanced age, obesity, gravid uterus Select nursing responses Teach Kegel exercises to increase muscle tone; explore patient’s willingness and motivation to pursue weight reduction and exercise program; evaluate need for bladder-training program. Mrs.Mahdia Samaha Kony
Example 2 42-year-old woman; 1 hour after delivery; spinal anesthesia; 1500 mL fluid infused in past 4 hours without patient voiding; unable to void. Diagnostic statement Potential complication: Urinary Retention related to fluid overload and effects of anesthesia. Select nursing responses Monitor for signs of increasing urine retention; offer bedpan, and encourage voiding with running water, warm water dripped over perineum, and so forth; if no result, administer physician-prescribed medication; if no result, perform physician-prescribed catheterization. Mrs.Mahdia Samaha Kony
Example 3 “Whenever I have to urinate it burns terribly. I also feel like I have to go all the time—real bad.” Small, frequent voidings, cloudy urine; T—100.8°F Diagnostic statement Cystitis Select nursing responses Report signs and symptoms to physician; obtain urine culture; report results to physician; administer appropriate physician-prescribed antibiotic. Mrs.Mahdia Samaha Kony
Types of Nursing Diagnoses 1- Actual Nursing Diagnoses; Is a client problem that is present at the time of the nursing assessment. An actual nursing diagnosis is based on the presence of associated signs and symptoms. Example – Acute pain related to surgical trauma and inflammation, as evidenced by grimacing and verbal reports of pain. 2- Risk nursing diagnosis; Is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurse intervene. Risk nursing diagnoses are two – part statements because they do not include defining characteristics (diagnostic label, risk factors). Example - Risk for infection related to surgery and immunosuppression.
Types of Nursing Diagnoses 3- Wellness nursing diagnosis; Is a statement that describe the human response to levels of wellness in an individual, family, or community that have a potential for enhancement to a higher state (NANDA, 2005). Wellness nursing diagnosis are one part statement includes diagnostic label. Example; Readiness for Enhanced Self-Esteem. 4- Possible Nursing Diagnoses; Is made when not enough evidence supports the presence of the problem but the nurse thinks that is highly probable and wants to collect more information. Possible Nursing Diagnoses are two part statement includes diagnostic label, related factors (unknown). Example- Possible self – esteem disturbance related to unknown etiology
Types of Nursing Diagnoses 5- A syndrome diagnosis; Is a diagnosis that is associated with a cluster of other diagnosis. Risk for disuse syndrome, for example, may be experienced by long term bedridden clients. For each diagnosis, the nurse should discuss with the client the significance of the problem, determine the client’s perception of the reason for the problem, and ask whether the client desires help to resolve or to diminish the problem.
