Miami Dade CollegeNursing Process: Diagnosis

Nursing DiagnosisNorth American Nursing Diagnosis Association (NANDA) to develop, refine, and promote the use of nursing diagnosis.

Nursing DiagnosisA statement that identifies the existence of an undesirable state.The subject matter of the diagnosis is derived from areas in which the diagnostician possesses a level of expertise. Iyer/Taptich/Bernochi-Losey

NURSING DIAGNOSIS:

the phase in which a nurse determines the meaning of assessment data.

Diagnosis links Assessment to the rest of Nursing Process

DIAGNOSING:ANALYZING DATA TO IDENTIFY ACTUAL OR POTENCIAL PROBLEMS Self Care Deficit Constipation Immobility Skin breakdown Ineffective airway clearance

Types of Nursing Diagnosis:Actual

Risk for

Wellness

Diagnostic Reasoning:

Validation with...Patient or significant others

Validation with...Other professionals

Validation with...Reference sources

Diagnostic Statement: 1. The human response (NANDA) 2. Related / risk factors

3. Patient response

Related Factors:PhysiologicalPsychologicalSocioculturalEnvironmentalSpiritual

Related Factors: PhysiologicalRisk for falls R/T side effects of medications aeb unsteady gait, drowsiness.

Related Factors: PsychologicalAltered role performance R/T fear of death aeb avoidance of wife and other family members.

Related Factors: SocioculturalKnowledge deficit R/T language barrier aeb unable to follow medication regime as written, cannot read & understand English.

Related Factors: EnvironmentalFatigue R/T sensitivity to light aeb sleepiness, nodding off, yawning, inability to concentrate.

Related Factors: SpiritualNon-compliance R/T conflict between religious beliefs & health regimen aeb patient does not follow dietary regime as prescribed.

Actual Patient ResponseAs evidenced by(aeb)

Objective data

Subjective data

Nursing Diagnoses: Application To Care PlanningDirects the planning process and the selection of the nursing interventions to achieve desired outcomes for the patient.

Nursing DiagnosisAccurate nursing diagnoses communicates to other professionals the patients health care problems and ensures that relevant and appropriate nursing interventions are selected.

PLANNINGDevelopment of strategies to reinforce healthy patient responses

PLANNING - Formalconscious, deliberate activity involving decision making, critical thinking, and creativity.

PLANNING: InformalUnwritten decisions while assessing patient

PLANNING Four Stages1. Setting priorities nsg. diagnosis

2. Developing outcomes ( goals )

3. Developing nursing interventions

4. Documenting the plan

Exercise: PrioritizeActivity intolerance r/t pain lower R leg

Ineffective breathing pattern r/t excessive pulmonary secretions

Risk for injury r/t pain R leg

Exercise: PrioritizeSocial isolation r/t changes in body image

Powerlessness r/t scant $ resources

Fluid volume deficit r/t diarrhea

Exercise: PrioritizeImpaired memory r/t disease process

Altered tissue perfussion r/t injury R arm

Risk for infection r/t skin breakdown R arm

2. GOALS: (Outcomes)1. Must be realistic

2. Of mutual agreement

3. Measurable

PLANNING Writing (Goals) Outcomes

4. Derived from nursing diagnosis

5. Provide direction

Goals: The Patient WillList 3 S&S of infection today.

Demonstrate dressing change within 48 hours.

Eat 75% of served meals within one week.

Goals must be SMARTS imple/specificM easurableA cceptable/attainableR ealisticT imed

The Way NOT To Do It..

http://www.nurstoon.com/comic208.htmlhttp://www.nurstoon.com/comic208.html

PLANNING Interventions/ DocumentationCharacteristics of interventions: 1. Individualized 2. Developed with others 3. Reflect current nursing practice 4. Based on scientific rationale 5. Provides for continuity of care

Planning Interventions:The nurse willAssessmentNursing carePharmacologicNutritionDiagnosticsEducationReferrals

PLAN OF CARE INTERVENTIONS:Derived from the cause, the root, etiology of the problem

Which Action is Appropriate?Alterations in nutrition, less than body requirements r/t pain and anxiety aeb: Obj. patient refused lunch. Sub. Please take the food, Im in pain.

Which Action is Appropriate?The nurse will: Administer/offer pain medication 30 minutes prior to meals. or Assist patient with menu selection today.

Which action is Appropriate?Alteration in nutrition less than body requirements r/t dislike of hospital food aeb: obj. Refused lunch. subj. Please take food away.

Which Action is Appropriate?The nurse will:

Assist patient with meal tray. or.. Consult with MD re food from home.

PLANNING - DocumentationPlan of care: 1. Written by an R.N.

2. Initiated following first patient contact

3. Readily available

4. Current

IMPLEMENTATION:PUTTING THE PLAN INTO ACTION AND OBSERVING INITIAL RESPONSES.

Implementation ANA StandardMeasurement Criteria: 1. Utilizes evidence based interventions specific to diagnosis 2. Implemented in a safe and effective manner. 3. Interventions are documented.

IMPLEMENTATION - StagesPreparation

Intervention

Documentation

IMPLEMENTATION:Interventions - The nurse will:

AssessProvide Nursing CareAdminister medicationsProvide nutritionEvaluate diagnostic findingsInstruct/TeachRefer/Consult

EVALUATION:DETERMINING IF THE PLAN HAS

WORKED, MAKING NECESSARY

CHANGES.

EVALUATION Steps: 1. Identify criteria and standards.

2. Data collection

3. Interpret findings 4. Document findings

5. Terminate, continue or modify.

Implementation/Evaluation

EVALUATION Modification When the patient continues to experience the symptoms associated with the nursing diagnosis.

On-going evaluation, comparing of the outcomes with assessment data, making a judgment about the patients progress may determine need for revision / modification.

NURSING PROCESS

Identify Phases of Nursing Process: 1. Analyzing & interpreting data

2. Initiating nursing interventions

3. Performing a physical examination

4. Determining outcomes with patient

Cont. 5. Revising plan of care

6. Interviewing the client

7. Writing a nursing diagnosis

8. Outcomes achieved?

Cont. 9. Developing interventions to achieve outcomes

10. Recording care given

11. Developing a plan of care

The Case of Fecal Impaction

Typical Question:Mr. S. was medicated for abdominal pain (8); one hour later continued to complain of pain (6). The nurse called the physician who ordered additional medication. Thirty minutes after medicated the patient reported pain at (1). Based on your understanding of the nursing process as responsive to the changing needs of patients, allowing the nurse to move back and forth using steps most appropriate to the clients needs, which steps of the process were used by the nurse in caring for this patient?assessment, diagnosis, implementationimplementation, evaluation, modificationassessment, implementation, evaluationall 5 steps

Which one of the following is an appropriate etiology for a nursing diagnosis?

A. Myocardial infarctionB. Cardiac catherizationC. Abnormal blood gas levelsD. Increased airway secretions

The nurse is observing the new staff member work with the patient. Of the following activities, which one has the greatest possibility of contributing to a nosocomial infection and requires correction?

Washing hands before applying dressingTaping a plastic bag to the bed rail for tissue disposalPlacing a foley catheter bag on the bed when moving patient Using alcohol to cleanse the skin before starting IV line

*Actual- a judgment that is clinically validated.Risk- human responses that may develop in a vulnerable person.Possible- a suspected problem for which current and available data are insufficient to validate the problem.Syndrome- a cluster of nursing diagnosis that go together to present a clinical picture.