Dwida Rizki Pradiptasiwi

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DIAGNOSIS

What is Nursing Diagnosis?

North American Nursing Diagnosis Association Nursing diagnosis is a clinical judgment
about individual, family, or community responses to actual or potential health
problems/life process. Nursing diagnosis provides the basis for selection of nursing
interventions to achieve outcomes for which the nurse is accountable (NANDA, 1990)

Why introduce standardized language at the undergraduate level?

- Creates an awareness of Nursing Language
- Supports the learning of the nursing process
- Provides consistency between practicum
- Develops critical thinking skills
- Improves Communication
- Research Based

Components of Nursing Language

NANDA : Nursing Diagnosis: Definitions and Classification
NIC : Nursing Interventions Classification
NOC : Nursing Outcomes Classification

Types of Nursing Diagnosis

1. Actual diagnosis
Describes health conditions that exist and supported by defining characteristics
Ex: Anxiety related to cardiac surgery as evidence by rapid speech, pacing

An actual nursing diagnosis use

Three Part Statement : - Label: Anxiety
- Related factor: cardiac surgery
- Sign & symptoms of diagnosis: rapid speech, pacing

2. Risk diagnosis
a. Risk diagnosis
a clinical judgment that an individual, family, or community is more vulnerable
to develop the problem than others in the same or similar situation
b. High risk diagnosis
Have additional risk factors that make patient more vulnerable for the problem to
occur

3. Wellness diagnosis
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a clinical judgment about an individual, group, or community in transition from

specific level of wellness to higher level of wellness

To have wellness nursing diagnosis should be:

- Desire for increase wellness
- Effective present status or function

Ex: Readiness for enhanced family process

Note: “In wellness nursing diagnosis only use One-part statement”

4. Syndrome diagnosis
a. In medicine:
Syndromes cluster signs and symptoms, not diagnosis

b. In nursing:
syndrome nursing diagnosis comprise a cluster of predicted actual or high-risk
nursing diagnosis related to a certain event or situation.

What do you Need to Make Nursing Diagnosis?

1. Enough assessment: patient history, physical examination, activity, perception, etc
2. Diagnostic data: laboratory data, X-ray, etc
3. Knowledge and experience

Nursing diagnosis
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- The nursing process has five steps: data collection, diagnosis, planning, implementation,
and evaluation.
- In theory, these phases are limited; however, in practice, they represent a group of
interdependent actions and then, in turn, when evaluating the patient, hypotheses emerge
and lead to diagnoses that determine the care, which will be implemented and re-
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evaluated

Objectives: to identify the prevalent nursing diagnoses (ND) in the hospitalized elder
care; to compare the prevalent ND with the duration of hospital stay and with the
prescribed cares for their respective diagnoses.
Method: Transversal historical study carried through in Porto Alegre, by analyzing
patient records age 60 years old.
Results: 1665 records were analyzed; the four prevalent NANDA nursing diagnosis –
were: bathing/Hygiene, Imbalanced Nutrition – Risk for Infection and Ineffective
Breathing Patterns.
The main cares were: aiding bed bath, communicating diet acceptance, implementing
routines of care in venous puncture and checking respiratory pattern.
Conclusion: four prevalent ND were identified with the appropriate prescribed care.
However, other care could have been established as a priority.