nursing diagnosis.pptx

The term diagnosis is a statement or conclusion regarding the nature of phenomenon.
A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.

1. Nursing D iagnosis: Nursing diagnosis is the 2 nd step of nursing process where the patient’s nursing problems is identified. Nursing diagnosis is the process of reasoning or the clinical act of identifying problems. It forms a link between the assessment and planning steps of nursing process. The effectiveness of any intervention depends upon the accuracy of the nursing diagnosis. 1

2. Contd….. In order to make accurate nursing diagnosis, the nurse should have clear understanding of what data to collect and should have ability to make judgment based on the data. To use the concept of nursing diagnosing effectively in generating and completing a nursing care plan, the nurse must be familiar with the definitions of terms used, the types and the components of nursing diagnoses. 2

3. Definitions: The term diagnosis is a statement or conclusion regarding the nature of phenomenon. A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability. (Approved at the ninth NANDA Conference; amended in 2009 and 2013.) 3

4. A nursing diagnosis is a statement of the high risk or actual problems in the client’s health status the nurse is licensed competent to treat Note: It is not medical diagnosis Data Analysis + Problem Identification = Formulation Of Nursing Diagnosis 4

5. PURPOSE OF NURSING DIAGNOSES a. For client: 1. Individualization of care 2. Appropriate selection of interventions 3. Establishment of goal b. For Nursing: Facilitates communication, documentation Continuity of care among health care providers 5

6. CHARACTERISTICS OF NURSING DIAGNOSIS 1. It states a clear and concise health problem 2. It is derived from existing evidences about the client 3. It is potentially amenable to nursing therapy 4. It is the basis for planning and carrying out nursing care 6

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9. Actual diagnosis: An actual diagnosis is a client problem that is present at time of the nursing assessment . An actual nursing diagnosis is based on the presence of associated signs and symptoms. Examples are ineffective breathing pattern, imbalance nutrition, acute pain and anxiety. 9

10. EXAMPLES OF ACTUAL NURSING DIAGNOSIS Ineffective breathing pattern related to bacterial / viral inflammatory Process. Ineffective breathing pattern related to Tracheo -bronchial obstruction Anxiety related to changes in the environment and routines, threat to socio economic status. Anxiety related to change in health status and situational crisis Body image disturbance related to temporary presence of a visible drain/ tube. 10

11. Contd…. 2. A risk nursing diagnosis: It is a clinical judgment that a problem does not exist, but the presence of risks factors indicate that a problem is likely to develop unless nurse intervene. For example, all people admitted to a hospital have some possibility of acquiring an infection; however, a client with diabetes or a compromised immune system is at higher risk than others. Therefore, the nurse would appropriately use the label risk for infection to describe the client’s health status. 11

12. EXAMPLES OF RISK NURSING DIAGNOSIS Eg . Admission in hospital prone for acquiring infection- compromised immune system 1. Risk for infection related to compromised immune system. 2. Risk for injury related to altered mobility and disorientation. 3. Risk for aspiration related to decreased cough and gag reflex Risk for impaired skin integrity related to immobility. Risk for impaired skin integrity related to edema and neuropathy Risk for injury related to generalized weakness Risk for Impaired skin integrity (left ankle) related to decrease peripheral circulation in diabetes. Risk for Impaired skin integrity related to loss of pain perception 12

13. Contd…. 3. Wellness diagnosis: Wellness nursing diagnoses involves a judgment about an individual, family or community in transition from one level of wellness to a higher level of wellness. Example of wellness diagnosis would be readiness for enhanced spiritual well- being or readiness for enhanced family coping. 13

14. Contd…. 4. A possible nursing diagnosis: Possible nursing diagnoses  are statements describing a suspected problem for which additional data are needed to confirm or rule out the suspected problem. A possible nursing diagnosis also provides the nurse the ability to communicate to other nurses that a diagnosis may be present but additional data collection is indicated to rule out or confirm the diagnosis. Examples include  Possible Chronic Low Self-Esteem ,  Possible Social Isolation . 14

15. For example, an elderly widow who lives alone is admitted to the hospital. The nurse notices that she has no visitors and is pleased with attention and conversation from the nursing staff. Until more data are collected, the nurse may write a nursing diagnosis of possible social isolation related to unknown etiology ; possible nutritional deficit RT nausea, Possible low self esteem RT loss job 15

16. Contd…. 5. A syndrome diagnosis: It is a diagnosis that is associated with a cluster of other diagnoses. Currently, only two syndrome diagnoses on the NANDA list are: Disuse syndrome Rape trauma syndrome For example: 1. Rape trauma syndrome related to anxiety about potential health problems as manifested by anger , genitourinary discomfort, and sleep pattern disturbance. 16

17. Contd…. 2. Risk for disuse syndrome, for example, may be experienced by long-term bedridden patients. Clusters of diagnoses associated with this syndrome include Impaired Physical Mobility, Risk For Impaired Tissue Integrity, Risk for Activity Intolerance, Risk for constipation, Risk for Infection, Risk for Injury, Risk for Powerlessness, Impaired Gas exchange, and so on. 17

18. Contd….. The nursing diagnosis should: Be clear and brief Be based on data Be related to only one problem State the cause of problem if known For e.g.:- Problem (Difficulty in breathing) + Cause (related to ineffective coughing) = Nursing Diagnosis (Difficulty in breathing related to ineffective coughing) 18

19. Components of a NANDA Nursing Diagnosis A nursing diagnosis has three components: 1 ) The problem and its definition :P 2) The etiology/ related factors/ causes: E 3) The defining characteristics/ signs and symptoms: S 19

20. Problem (Diagnostic Label) and Definition: The problem statement, or diagnostic label, describes the client’s actual or potential health problem or response for which nursing therapy is given. It describes the client’s health status or problems clearly and concisely as possible. The purpose of the diagnostic label is to direct the information of the client goals and desired outcomes. 20

21. Contd…… NANDA recommends the use of quantifiers when writing the problems statement, which includes altered (changed), impaired (reduced/ diminished), deficient (lacking/incomplete), excessive (extreme), ineffective (unproductive). etc. 21

22. Etiology (Related factors and Risk Factors) The etiology component of a nursing diagnosis identifies one or more probable causes of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client’s care . In other words, the etiology identified physiologic (e.g. Incision pain), psychologic (fear of loss of control), sociologic (inability to speak English language), spiritual (conflict between the beliefs and prescribed medical practice) and environmental (excessive noise). 22

23. Contd….. It reflects the factors believed to be related to problem as either as cause or a contributing factors for the problem while stating the diagnosis the problem and etiology are connected by “related to (R/T) which shows the relationship, ‘nor’ ‘cause’ and ‘effect’. 23

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25. Defining Characteristics Defining characteristics are the cluster signs and symptoms that indicate the presence of a particular diagnostic label. For actual nursing diagnoses, the defining characteristics are the client’s sign and symptoms. For risk nursing diagnosis, no subjective and objective signs are present. Thus , the factors that causes the client to be more vulnerable to the problem from the etiology of a risk nursing diagnosis. The NANDA lists of defining characteristics are still being developed and refined . Characteristics are listed separately according to whether they are subjective or objective in nature. 25

26. The D iagnostic Process The diagnostic process uses the critical thinking skills of analysis and synthesis. Critical thinking is a cognitive process during which a person reviews data and considers explanations before forming an opinion. Analysis is the separation into components, that is, the breaking down of the whole into parts (deductive reasoning). Synthesis is the opposite, that is, the putting together of parts into the whole (inductive reasoning). 26

27. Contd….. The diagnostic process has three steps: Analyzing the data Identifying health problems, risks and strengths . Formulating diagnostic statements 27

28. Contd….. 1. Analyzing the data: In the diagnostic process, analyzing involves the following steps: C ompare data against standards (identify significant cues)- normal V/S, Lab. Values, growth and development patterns Cluster cues and I dentify gaps and inconsistencies. 28

29. Contd….. 2. Identifying health problems, risks and strength: After data are analyzed, the nurse and client can together identify strengths and problems. This is primarily a decision-making process. After grouping and clustering the data, the nurse and client together identify problems that support tentative, actual, risk and possible diagnoses . In addition the nurse must determine whether the client problem is a nursing diagnosis, medical diagnosis or collaborative problem. 29

30. Contd…. 3. Formulating Diagnostic Statement Most nursing diagnoses are written as two-part or three-part statements, but there is variation of these. Basic two-part statement The basic two-part statements include the following: Problem(P): statements of client’s response (NANDA label) Etiology (E): factors contributing to or probable causes of responses 30

31. Contd…. The two parts are joined by the words Related to . By contrast, the phrase Related to merely implies a relationship. For example, constipation related to prolong laxative use, severe anxiety related to threat to physiologic integrity. 31

32. A risk nursing diagnosis is written as  problem/diagnosis  related to (r/t)   x factor/cause. A syndrome nursing diagnosis is written as  problem/diagnosis  related to (r/t)  x factor/cause. 32

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34. Basic three-part statements : The basic three parts nursing diagnosis statement is called the PES format and includes the following: Problem (P): statement of the client’s response (NANDA label) Etiology (E): factors contributing to or probable causes of the response Signs and symptoms (S): defining characteristics manifested by the client 34

35. Contd….. Actual nursing diagnoses can be documented by using the three-part statement because the signs and symptoms have been identified. This format cannot be used for risk diagnoses because the client does not have signs and symptoms of the diagnosis. The PES format is especially recommended for beginning diagnosticians because the signs and symptoms validate why the diagnosis was chosen and the make the problem statement more descriptive. 35

36. An actual nursing diagnosis is written as  the problem/diagnosis  related to (r/t)  x factor/cause  as evidenced by  data/observations . 36

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38. Contd….. For example, low self-esteem related to feeling of rejection by husband as manifested by hypersensitivity to criticism; states “I don’t know if I can manage by myself” and rejects positive feedback, altered body temperature related to inflammation as evidence by hot to touch. Activity intolerance related to imbalance between oxygen supply and demand secondary to COPD as manifested by tachypnea, shortness of breath and O 2 Sat. of 85 after ambulating to rest room .   38

39. One-Part Statements: Some diagnostic statements, such as wellness diagnoses consist of a NANDA label only. As the diagnostic labels are refined, they tend to become more specific, so that nursing interventions can be derived from the label itself. Therefore , an etiology may not be needed. NANDA has specified that any new wellness diagnoses will be developed as one-part statements beginning with the words Readiness for Enhanced followed by the desired higher level wellness for example, Readiness for Enhanced parenting. 39

40. Avoiding Errors in Diagnostic Reasoning Some error is inherent in any human undertaking, and diagnosis is no exception. However , it is important that nurses make nursing diagnoses with a high level of accuracy. Nurses can avoid some common errors of reasoning by recognizing them and applying the appropriate critical-thinking skills. Error can occur at any point in the diagnostic process: data collection, data interpretation, and data clustering. 40

41. Contd… The following suggestions help to minimize diagnostic error: Verify: Hypothesize possible explanations of data, but realize that all diagnoses are only tentative until they are verified. Begin and end the diagnostic process by talking with the client and family. Build a good knowledge base and acquire clinical experience. Have a working knowledge of what is normal: nurses need to know the population norms for vital signs, laboratory tests, speech development, and breath sound so on. 41