Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Nursing Diagnosis Definition of Nursing Diagnsis • A nursing diagnosis is a statement of the high risk or actual problems in the client’s health status that the nurse is licensed and competent to treat Components of Analysis Phase • 3 major components of analysis phase: – Analysis and interpretation of data • Validation of data • Clustering of data – Identification of problems/health care needs – Formulation of nursing diagnosis statement Nursing Diagnostic Statement • Derived from actual or potential problems • Derived from physiological, sociocultural, developmental, and spiritual dimensions of client • Focus: Helping client to achieve a maximal level of wellness and highest level of independence Categories of nursing diagnoses Nursing diagnoses? What’s up with that? • Nursing diagnoses are what you get when you finish your assessment and look at your data. • Nursing diagnoses describe patient needs or responses to health conditions and treatments • Nursing diagnoses reflect the patient’s level of health or response to disease, emotional state, socio-cultural phenomenon, or developmental stage Medical vs. nursing diagnoses • Medical diagnosis- Identifies disease or pathology • Nursing diagnosis- Identifies patient’s response to said disease or pathology • Medical diagnosis goal- to cure the disease • Nursing diagnosis goal- to direct the nursing plan of care to meet the patient’s needs This nurse is validating the cues collected from this client during the assessment phase. Nursing diagnoses • Help facilitate communication between members of the nursing staff • Help prioritize the needs of the patient • Help to guide charting In practice, you… • Do your assessment and think “My patient is in pain!” • Take your impressions and put fancy labels on them like “impaired comfort” or “acute pain” • Those are nursing diagnoses in a nutshell You got to stick with NANDA! • Unfortunately, you are not allowed to make up new and creative nursing diagnoses for your patients • No matter how much your patient merits a nursing diagnosis of “persistent stupidity” or “constant whining” you just can’t do it! • Some authors like Carpenito have developed nursing diagnoses similar to NANDA’s, but the OU SON professors require only NANDA diagnoses for your care plans and papers Writing nursing diagnoses • The first part is the NANDA nursing diagnosis statement • If your patient doesn’t meet the criteria for the diagnosis yet, you put “Risk for…” in front of the diagnosis – Risk for nausea – Risk for deficient fluid volume • After the diagnosis, you put why you chose the diagnosis for the patient with a “related to” (R/T) statement… – Risk for nausea R/T side effects from chemotherapy medications – Risk for deficient fluid volume R/T poor fluid intake and high temperature – Sleep deprivation R/T busy ICU environment Writing “related to” statements • Don’t put medical diagnoses or diagnostic tests like • pneumonia, hip fracture, or angioplasty in the “related to” statement. Do put factors that you can take care of with nursing interventions… BAD Impaired gas exchange R/T increased blood CO2 levels BETTER!! Impaired gas exchange R/T shallow breathing postop Diarrhea R/T C. difficile infection Diarrhea R/T food intolerance Acute pain R/T hip fracture Acute pain R/T swelling and tissue damage More examples… Bad Risk for aspiration R/T stroke Good Risk for aspiration R/T impaired swallowing Why?? Nurses can work with patients to improve swallowing ability Acute pain R/T hip Acute pain R/T Nurses can give medications fracture tissue damage and to help relieve pain from swelling in right hip tissue damage, and provide ice to reduce swelling Risk for falls R/T Multiple Sclerosis Risk for falls R/T poor balance and leg weakness Nurses can help patients with transfers to compensate for poor balance and weakness Care Plan Formats After the R/T statement… • After you say why you chose the diagnosis for the patient with the “related to” statement, include an “as evidenced by” statement that includes specific signs and symptoms of the particular patient • This step is not needed when there is only “Risk for …” diagnoses, as the patient is only at risk for the condition and has not actually developed it yet • You can use “AEB” for “as evidenced by” so that you don’t need to write it out AEB statements • Don’t include prejudicial statements such as: – Risk for impaired skin integrity R/T poor hygiene habits, AEB foul stench from perineal area • Instead, you could use: – Risk for impaired skin integrity R/T inability to reach perineal area to clean, AEB patient verbalized need for nursing assistance with perineal care Diagnostic testing… • Don’t use diagnostic tests specifically in nursing diagnoses like: – Anxiety R/T cardiac catheterization, AEB patient statements of uneasiness and nervously pacing floor • Instead, focus on patient responses to the tests: – Anxiety R/T awaiting of cardiac catheterization results, AEB patient statements of uneasiness and nervously pacing floor Phrasing diagnoses • Don’t use blaming phrases or ones that could imply negligence or malpractice, like: – Excess fluid volume R/T IV infused too quickly – Acute pain R/T improper placement of epidural catheter • Don’t overload diagnoses… – Constipation and abdominal pain should be 2 different nursing diagnoses – Noncompliance and knowledge deficit should be 2 different diagnoses