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NURSING DIAGNOSIS LECTURE

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Identifies or determines a specific disease, condition, or pathological state. ... that identifies the client's responses to a health state, problem or condition. ... – PowerPoint PPT presentation

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Title: NURSING DIAGNOSIS LECTURE


1
NURSING DIAGNOSIS (LECTURE 4)
2
NURSING DIAGNOSIS
  • Identified PRIORITIZED problems will become basis
    for clients plan of care
  • Identified strengths will be invaluable when
    choosing effective interventions

3
What is a Nursing Diagnosis?
  • It provides the basis for selection of nursing
    interventions to achieve outcomes for which the
    nurse is accountable
  • It is focused on client-centered (holistic)
    problems

4
PURPOSES
  • Contributes to the professional status of nursing
    as a discipline
  • Provides a means for effective communication
  • Facilitates holistic client, family
    community-focused care

5
NANDA DEFINITIONNorth American Nursing Diagnosis
Association
  • Clinical judgment about clients responses to
    actual or potential health problems or life
    processes
  • Identifies problems for which the nurse is
    accountable and is capable of diagnosing
    treating independently

6
ComparisonMedical vs. Nursing Diagnosis
  • Medical terminology used for a clinical judgment
    by the physician. Identifies or determines a
    specific disease, condition, or pathological
    state.
  • Nursing clinical judgment that identifies the
    clients responses to a health state, problem or
    condition.

7
Taxonomy ??
  • System of identification, naming classification
  • Drawn from human responses both physiological
    (Maslows) as well as behavioral aspects
  • Data clustered to human needs

8
MAKING SENSE..
  • COMPONENTS
  • LABEL
  • DEFINITION
  • SET OF DEFINING CHARACTERISTICS
  • GROUP OF RELATED FACTORS OR RISK FACTORS

9
FORMATS
  • Different formats may be used to structure
    (write) the diagnosis statement
  • 1 part wellness
  • 2 part at risk for
  • 3 part actual

10
(No Transcript)
11
  • Both 2 3 part statements have
  • label a problem statement
  • etiology a related cause or a contributor to the
    problem identified (related to r/t)
  • 3 part will also have list of defining
    characteristics (as manifested by amb as
    evidenced by aeb)

12
The difference isA 2 part statement
  • identifies that which the nurse may anticipate or
    needs to monitorproblem does not currently
    exists
  • Risk for ineffective airway clearance r/t history
    of smoking for 20 years.

13
Versus a 3 part statement..
  • identifies a priority need/problem that is
    actual.
  • Ineffective airway clearance r/t increased
    production of secretions amb (as manifested by)
    or aeb (as evidenced by) clients cough, presence
    of crackles in lung bases.

14
THE LABEL
  • Remember - you cluster the data prioritize
    clients needs (think holistic!)
  • Label - may include a qualifier
  • impaired, altered, decreased, acute, chronic,
    ineffective
  • (refer to NANDA list after you cluster
    prioritize your collected data)

15
What does the Diagnosis look like?
  • LABEL / DEFINITION (1)
  • Concise description of the prioritized problem.
  • Example IMPAIRED PHYSICIAL MOBILITY

16
Etiology (2)
  • The related cause or contributor to the
    identified problem..
  • Example IMPAIRED PHYSICAL MOBILITY R/T (related
    to) PRESCRIBED BEDREST

17
DEFINING CHARACTERISTICS (3)
  • Collected data (objective subjective) -known as
    signs symptoms or clinical manifestations that
    support the existence of the problem.
  • Example IMPAIRED PHYSICAL MOBILITY R/T
    PRESCRIBED BEDREST AMB DECREASED ROM TO LOWER
    EXTREMITIES

18
  • (1) IMPAIRED PHYSICAL MOBILITY
  • (2) R/T PRESCRIBED BEDREST
  • (3) AMB (OR AEB) DECREASED ROM TO LOWER
    EXTREMITIES

19
SO THE DIFFERENCE IS.
  • 2 PART (RISK FOR) Risk for impaired physical
    mobility r/t bedrest
  • versus
  • 3 PART (ACTUAL) Impaired physical mobility r/t
    bedrest amb decreased ROM to lower extremities

20
Lets review the types...
  • ACTUAL (3 PART) describes the human responses to
    health conditions or life processes that actually
    exist in the client, their family, or the
    community.
  • RISK FOR (2 PART) describes human responses that
    may develop in a vulnerable client, family, or
    community.

21
Things to think about..
  • Identify appropriate Nursing Diagnoses
  • Determine the related factor/factors
  • Identify actual defining characteristics for 3
    part statement
  • DISCUSS THE DIAGNOSES WITH THE CLIENT TO
    FORMULATE PLAN OF NURSING CARE

22
POTENTIAL ERRORS
  • Use of medical diagnosis
  • Leads to premature termination of data collection
  • Nurse cannot address independently

23
More Potential Errors
  • Lack of nurses holistic approach
  • Inadequate data collection
  • Inadequate assessment
  • Including a nurses personal judgement
  • Data clustering errors
  • inadequate data
  • poor critical thinking

24
INTERPRETATION ERRORS
  • CUES OR CLUSTERED DATA ARE INTERPRETED
    INCORRECTLY
  • ASSESSMENT DATA IS AMBIGUOUS
  • DATA LEADS YOU TO 2 OR MORE POSSIBLE DIAGNOSES

25
  • Dont forget to include the family !
  • Dont under or over diagnose !
  • COMING ATTRACTIONS ..To be presented in Medical
    Surgical Nursing COLLABORATIVE PROBLEMS! In
    contrast to independent nursing diagnoses - those
    problems which require interdependency with
    health care team (hemorrhage /shock)
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