Nursing Process. What Is Nursing Diagnosis (Dx)? Step 2: Nursing Diagnosis Step 3: Outcome Identification. Nursing Diagnosis.

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Evangeline Harmon
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1 Nurse Caring Concepts 1A Nursing Process Step 2: Nursing Diagnosis Step 3: Outcome Identification Week 6 September 22, 2003 What Is Nursing Diagnosis (Dx)? Has two related meanings: Nursing diagnosis is an action: the process of analyzing assessment data to arrive at a.nursing diagnosis! Nursing diagnosis is a label that describes the patient s response to an actual or potential health problem Medical Diagnosis Describes a disease or pathology Conditions MD treats MD cares for a pt with Congestive Heart Failure (CHF) - treats pathology with meds, oxygen, diet & fluid restriction Nursing Diagnosis Describes pt s response to a health problem Situations RNs can treat Nursing dx describe pt s response to CHF: such as: Anxiety; Activity Intolerance, Impaired Peripheral Tissue Perfusion, Powerlessness 1

Nursing diagnosis is a label that describes the patient s response to an actual or potential health problem Medical Diagnosis Describes a disease or pathology Conditions MD treats MD cares for a pt

2 Nursing Diagnosis: The Action RN reviews assessment data to identify patterns Subjective & objective cues are organized into groups that seem to fit together & indicate actual or potential client problems (nursing dx) RN makes an educated hunch about which nursing diagnoses might fit the cue cluster Review the selected nursing diagnoses to decide which is most accurate Nursing Diagnosis: The Label North American Nursing Diagnosis Association (NANDA): official organization responsible for developing system of naming & classifying nursing diagnoses Diagnostic label is often called a NANDA Each NANDA describes the essence of the problem in as few words as possible. Acute Pain NANDA Definitions Each NANDA-approved nursing diagnosis is accompanied by a definition that describes its characteristics: NANDA: Impaired Physical Mobility NANDA Definition: state in which a person experiences or is at risk of experiencing limitation of physical movement but is not immobile 2

Label North American Nursing Diagnosis Association (NANDA): official organization responsible for developing system of naming & classifying nursing diagnoses Diagnostic label is often called a NANDA

3 Types of Nursing Diagnoses Actual nursing diagnoses: patient has problem Risk diagnoses: patient is at risk for developing the problem (Either begins with Risk for or the definition will include is at risk for ) Wellness diagnoses: patient functioning effectively but desires higher level of wellness Others that you do not need to know: Possible diagnoses Syndrome diagnoses Collaborative problems: Parts of a Nursing Diagnosis: Defining Characteristics These are the signs & symptoms that validate that an actual nursing diagnosis is present. Major: at least one must be present to use the nursing diagnosis Minor: may not be present, but if it is, helps to validate selecting the nursing diagnosis Defining characteristics are not present in Risk dx because signs & symptoms don t exist if the problem hasn t happened Parts of a Nursing Diagnosis: Related Factors or Risk Factors Related Factors: factors that contributed to the development of patient s problem (nursing dx) Risk Factors: factors that increase the possibility of the patient developing a problem Is a relationship rather than direct cause & effect (is related to rather than caused by ) Only one of these factors (risk or related) needs to be present to justify use of the nursing dx 3

problems: Parts of a Nursing Diagnosis: Defining Characteristics These are the signs & symptoms that validate that an actual nursing diagnosis is present.

4 Nursing Diagnosis Action Revisited Make a hunch about which diagnosis might fit Read the diagnosis definition to see if it fits Check out the defining characteristics Major: one must be present Minor: if present may help confirm hunch Rule out any diagnosis for which your patient does not meeting the defining characteristics Formulating the Diagnostic Statement After identifying the best NANDA to describe your patient s problem... You need to formulate a diagnostic statement An actual diagnosis has a three-part statement A risk diagnosis has a two part statement A wellness diagnosis has a one part statement Actual Diagnostic Statement Three-Part Format Three parts: 1 NANDA label 2 Related factors (follows NANDA & linked by the words related to ) 3 Defining characteristics (follows related factors & linked by the words as manifested by ) 4

NANDA to describe your patient s problem.

5 Actual Diagnostic Statement Example 1 Impaired Physical Mobility 2 related to (r/t) decreased motor agility and muscle weakness 3 as manifested by (AMB) limited ROM Impaired Physical Mobility r/t muscle weakness AMB limited ROM Risk Diagnostic Statement Two-Part Format Two parts: 1 NANDA label 2 Risk factors (follows NANDA label and is linked by the words related to) Risk Diagnostic Statement Example 1 Risk for Impaired Physical Mobility 2 related to (r/t) full leg cast Risk for Impaired Physical Mobility r/t full leg cast 5

Format Two parts: 1 NANDA label 2 Risk factors (follows NANDA label and is linked by the words related to) Risk Diagnostic Statement

6 Clarifying the Related Factors Part of the Diagnostic Statement You will often need to add words to the related to portion of an actual or a risk diagnostic statement to clarify the origin of the problem These words always follow the related to and are linked with the words secondary to (2 ) NOTE: This is the only way a medical diagnosis can ever be inserted into a nursing dx statement Examples: Adding a Secondary Factor to the related to part of a Diagnostic Statement for Clarity Impaired Physical Mobility r/t muscle rigidity and tremors secondary to (2 ) Parkinson s Disease AMB limited ROM and compromised ability to move purposefully Risk for Impaired Skin Integrity r/t immobility 2 fractured hip Wellness Diagnostic Statement Used when pt doesn t have a health problem but can attain higher level of health Is a one part statement consisting only of the NANDA: Readiness for Enhanced Parenting Readiness for Enhanced Family Processes Readiness for Enhanced Spiritual Well- Being 6

$limited ROM and compromised ability to move purposefully Risk for Impaired Skin Integrity r/t immobility 2 fractured hip Wellness Diagnostic Statement Used when pt doesn t have a health problem but$

7 Step 3 of the Nursing Process: Outcome Identification NANDA label describes human responses that are problems. Usually, the healthy alternative is goal that patient wants to achieve To identify a goal, ask yourself: If the problem were solved (actual nsg dx) or prevented (risk nsg dx), how will patient look or behave? What will I see, hear, palpate or observe? Establish goals with patient if possible Types of Goals Goals can be: Long term goal: objective expected to be achieved over weeks or months Short-term goal: a stepping stone on the way to reaching long-term goal Long Term Goal Characteristics Is a broad statement that reflects: Resolution of a problem Progress towards resolution of a problem Prevention of a problem Should be attainable and realistic for the patient Is expected to be achieved during length of stay in facility 7

or behave? What will I see, hear, palpate or observe?

8 Short Term Goal Characteristics Must describe a measurable behavior that nurse can validate by seeing or hearing or that patient can measure subjectively and describe Only one action verb allowed per goal Short term goal should be: Attainable & realistic during your time with pt Specific in time - when is it to have occurred? Specific as to who or what is to achieve goal Specific in content - what is to occur? Example of Long & Short Term Goals Impaired Tissue Integrity r/t destruction of tissue 2 pressure and friction AMB stage II pressure ulcer on coccyx Long term goal: Patient s pressure ulcer will heal Short term goal: Patient will demonstrate 3 measures that she can do to prevent pressure ulcers during my shift Example of Long & Short Term Goals Fear r/t anticipated dependence 2 nursing home rehab admit AMB statement I am afraid that I will never go home Long term goal: Patient will report an increase in psychological comfort Short term goals: Patient will discuss fears with RN during today (9/22) Patient s pulse & respiratory rate will be WNL following discussion with RN 8

Specific as to who or what is to achieve goal Specific in content - what is to occur?

9 Nursing Process Terminology Tips Nursing Diagnosis is also called: NANDA Diagnostic label Defining Characteristics are also called: Cues Subjective & objective assessment data Signs & symptoms (S/Sx) Related factors & risk factors are also called: Etiology (Origin) Contributing factors Goals = outcomes = objectives Your first step in care planning! For clinical, identify two nursing diagnoses for your primary patient; actual or risk Write a diagnostic statement for each one (remember: risk is 2-part & actual is 3-part) For each diagnostic statement, identify a long term goal & a short term goal Write these on a copy of your Cuesta Care Plan form & turn in to your clinical instructor first thing in the morning on your clinical day Cuesta Nursing Care Plan Due 9/23 or 9/24 P R Nursing Diagnosis Outcome Criteria M O Diagnostic Statement # 1 Long term goal # 1 Short term goal # 1 Interventions T C Evaluation Diagnostic Statement # 2 Long term goal # 2 Short term goal # 2 9

For clinical, identify two nursing diagnoses for your primary patient; actual or risk Write a diagnostic statement for each one (remember: risk is 2-part & actual is 3-part) For each diagnostic

Diagnosis. Ra'eda Almashagba 1

Diagnosis. Ra'eda Almashagba 1 Diagnosis Chapter 17 Ra'eda Almashagba 1 Nursing Diagnosis: A statement that describes a client s actual or potential health problems that a nurse can identify and for which she can order nursing interventions