Nursing Process: Nursing Diagnosis (copy)
Terms
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- Nursing Diagnosis
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A statement of the client's current or high risk health problems which nurse's can change in the direction of health
Identifies cause and signs and symptoms
By virtue of our nursing education we are capable and licensed to treat these problems - Wellness Diagnosis
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One part statement
Contains the label only
Example: Potential for enhanced... - Actual Nursing Diagnosis
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Diagnostic Label - problem
describes client's situation/condition is unhealthy
May be changed by nursing
Include any qualifiers that clarify the problem - High-Risk Nursing Diagnosis
- NANDA defines a risk nursing diagnosis as “a clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation.â€
- Syndrome Nursing Diagnosis
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Diagnostic label
NANDA has approved five syndrome diagnosis:
Disuse syndrome
Rape trauma syndrome
Post - trauma syndrome
Relocation stress syndrome
Impaired environmental interpretation syndrome
Made up of a cluster of actual or high risk nursing diagnosis that are predicted to be present because of a specific event or situation - Nursing Diagnosis: Analysis
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Principles
problem identification begins with gathering and clustering data
the recognition of abnormal data is essential
before you can recognize abnormal data, you must know what is normal
authority and ability to diagnose a health problem depends on your nursing knowledge - Steps of diagnostic reasoning
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After the assessment is done, bring related data together (clustering)
Identify positive and negative data
If one piece of data suggests a problem, do a focus assessment - Components of Diagnostic Statements
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Wellness diagnosis - statement of effective functioning
NANDA - "a clinical judgement about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness."
2 cues must be present
Desire for a higher level of wellness
Effective present status or function - High Risk Nursing Diagnosis
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Statement of degree of risk
"high risk" or "risk"
Diagnostic labels - client problems
a situation a nurse can treat
Statement of the risk factors
those situations which increase the vulnerability of the client to the problem
Ex: High risk for activity intolerance r/t enforced bedrest - Nursing Diagnosis Associated with Disuse Syndrome
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Impaired physical immobility
High risk for:
altered respiratory function
venous thrombosis
constipation
infection
injury
Activity intolerance
body image disturbance
self-care deficits
impairment of skin integrity
powerlessness - Nursing Diagnosis Associated with Rape Trauma Syndrome
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Anxiety
Fear
Grieving
Pain
High risk for:
sleep/rest disturbances
altered sexuality patterns - Documentation of Nursing Diagnosis
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Diagnostic statement is very disciplined - the label cannot be modified in any way.
Precise terminology is used to aid communication, research and reimbursement
Nursing Diagnosis is the problem and we are building the care plan to solve that problem. - Etiology/cause
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identifies why the problem exists
may be:
pathological
maturational
treatment related
situational
unknown
linked to the problem by term "related to" - R/T
legal issue
don't use "caused by" (medical diagnosis) because that is not in our scope of practice. Can use "secondary to" to further describe the etiology. - Defining characteristics
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positive data that supports the problem
data may be subjective or objective
validated data
joined to the diagnostic statement by "as evidenced by" or "a.e.b." - PES Format
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P = Problem
E = Etiology
S = Symptoms
Ex: Ineffective breathing pattern r/t accumulation of fluid in lungs s/t CHF a.e.b. c/o dyspnea, RR = 32, O2 Sat 88%, etc. - Syndrome Diagnosis
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One part diagnostic statement
etiology or contributing factors for Dx is contained in the diagnostic label
could consider cluster of diagnoses individually, but syndrome diagnosis says it all - Collaborative Problem
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Certain physiological complications that nurses monitor to detect onset or changes in client status
Nurses monitor them using MD prescribed interventions to minimize the complication or event. - Nursing Diagnosis vs. Collaborative Problem
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Nursing Diagnosis
a statment of the client's high risk or actual health problem which nurses by virtue of their education and experience are licensed to treat
Collaborative Problem
certain physiological complications that nurses monitor to detect the onset or a change in status. Doctor's prescribe the definitive treatment. Nurse use prescribed treatment and interventions that are in the domain of nursing. - Validating an Actual Nursing Dx
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Carpenito's criteria
determine that major defining characteristics are present
defining characteristics refer to clinical cues (objective and subjective) signs and symptoms
must be present 80-100% of time -
Case Study
Mr. B. has been on enforced bedrest for 2 weeks. When the doctor finally decides he can ambulate, he finds that walking to the bathroom causes dyspnea and a rapid pulse.
VS: 98.6-100-26-150/70
Baseline: 98.8-80-18-130/68
P - Activity intolerance related to compromised oxygen transport secondary to prolonged bedrest of 2 weeks a.e.b. dyspnea and a rapid pulse when walking to the bathroom that do not return to baseline within 3 min. P100, RR26