Nursing Process Nursing Diagnosis
Nursing Process Nursing Diagnosis
Nursing Process Nursing Diagnosis
A clinical judgment about individual, family, or community responses to actual or potential health/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable
Analyze collected data Identify the clients strengths Identify the clients normal functional level and indicators of actual or potential dysfunction Formulate a diagnostic statement in relations to this synthesis
Gives nurses a common language Promotes identification of appropriate expected outcomes Provides acuity information Can create a standard for nursing practice Provide a quality improvement base
Nursing Diagnosis Made by the nurse Describes clients response Responses vary between individuals Changes as client responses change Nurse orders interventions
Medical Diagnosis Made by a physician Refers to the disease process Somewhat uniform between clients Remains same during disease process Physician orders interventions
Steps
Identify patterns
Review data and look for cues Cluster cues (signs and symptoms) Synthesizing the cue clusters Three questions to ask self
What are my concerns about this client Can I or am I doing something obout it Can the overall risk be decreased by nursing interventions
Look at all data as a whole Test for a fit Refer to the NANDA DX and defining characteristics
NANDA
Actual (3 parts)
Risk (2 parts)
A clinical judgment that the client is more vulnerable to develop this problem than others in the same or similar situation
Potential for enhancement of current well state
Wellness (2 parts)
Diagnostic Label
P Qualifier E
Etiology
Defining characteristics
Diagnostic Label
Problem
Name of the nursing diagnosis as listed in the taxonomy Describes the problem using as few words as possible Used to give additional meaning to the NDX
Qualifier
DO NOT use the medical diagnosis Must be a problem the nurse and/or client can change to do something about Relating the problem to an unchangeable situation
Dont confuse the etiology with the problem Focus on the human responses to the problem Avoid the use of one piece of assessment data as a NDX (EDEMA)
Be specific Dont combine NDX Dont relate one NDX to another. There is a different related to factor if this is a valid NDX Nursing interventions should not be included in the NDX Keep your language non-judgmental Dont make assumptions or statements you cant prove with assessment data Be sure your statement is legally advisable
Etiology
This is the related to, R/T portion of the diagnosis. What caused the client to have the problem listed? Problems to avoid in writing this part
DO NOT use the medical diagnosis Must be a problem the nurse and/or client can change to do something about
Defining Characteristics
These are the major and minor clinical cues that validate the presents of an actual nursing diagnosis Must have at least the major defining characteristics as listed in the taxonomy and minor characteristics will help support the NDX
Standard II: Diagnosis: The nurse analyzes the assessment data in determining diagnosis.
Diagnoses are derived from assessment data Diagnoses are validated with the patient, family, and HCP when possible and appropriate Diagnoses are documented in a manner that facilitates the determination of expected outcomes and plan of care