NCM103: FUNDAMENTAL OF NURSING Nursing Diagnosis: The Action

PRACTICES - RN reviews assessment data to identify

MODULE 2 – NURSING DIAGNOSIS patterns
- Subjective & objective “cues” are organized
into groups that seem to fit together &
FROM ASSESSMENT TO DIAGNOSIS
indicate actual or potential client problems
(nursing dx)
ANALYSIS AND SYNTHESIS OF DATA
- RN makes an educated hunch about which
DIAGNOSIS
nursing diagnoses might fit the cue cluster .
1. Gathering Data
- Review the selected nursing diagnoses to
2. Validating Data
decide which is most accurate.
3. Organizing Data
4. Identify Data
Nursing Diagnosis: The Label
5. Reporting & Recording Data
North American Nursing Diagnosis
Association (NANDA):
NURSES ARE RESPONSIBLE
- official organization responsible for
- “Nurse are responsible and accountable for
developing system of naming & classifying
diagnosing actual and potential health
nursing diagnoses
problem and initiating action to ensure
• Diagnostic label is often called a “NANDA”
appropriate and finely treatment”
• Each NANDA describes the essence of the
problem in as few words as possible.
Has two related meanings
- Nursing diagnosis is a label that describes
NANDA Definitions
the patient’s response to an actual or
- Each NANDA
potential health problem.
-approved nursing diagnosis is accompanied
- Nursing diagnosis is an action: the process of
by a definition that describes its
analyzing assessment data to arrive at a
characteristics:
nursing diagnosis!
Eg. – NANDA: Impaired Physical Mobility
– NANDA Definition: state in which a person
DIFFERENCES: MEDICAL DIAGNOSIS NURSING
experiences or is at risk of experiencing
DIAGNOSIS
limitation of physical movement but is not
MEDICAL
immobile
- Describes a disease or pathology
- Conditions MD treats
Types of Nursing Diagnoses
- MD cares for a pt.:
- Actual nursing diagnoses: patient has
● Congestive Heart Failure (CHF) treats
problem
pathology with meds, oxygen, diet &
- Risk diagnoses: patient is at risk for
fluid restriction
developing the problem (Either begins with
NURSING
“Risk for” or the definition will include “is at
- Describes pt’s response to a health problem
risk for”)
- Situations RNs can treat
- Wellness diagnoses: patient functioning
- Nursing dx: describe pt’s response to CHF:
effectively but desires higher level of wellness
● such as: Anxiety Activity Intolerance,
- Others that you do not need to know: –
Impaired Peripheral Tissue Perfusion,
Possible diagnoses – Syndrome diagnoses –
Powerlessness
Collaborative problems:
COMPONENTS OF NURSING DIAGNOSIS
1) PROBLEM (Label)
2) ETIOLOGY
3) DEFINING CHARACTERISTICS
PROBLEM (Diagnosis Label)
- There are word that have been added to
ome NANDA label to give additional meaning
• e.g. altered, impaired, decrease, ineffective,
acute, chronic, knowledge deficit, effective
breathing patterns
PART OF THE NURSING DIAGNOSIS
ETIOLOGY (Related Factors and risk factor)
- Related Factor
● factors that contributed to the
development of patient’s problem
(nursing dx)
● Is a relationship rather than direct
cause & effect (is ‘related to’ rather
than ‘caused by’)
● Only one of these factors (risk or
related) needs to be present to justify
use of the nursing dx
- Risk Factors
● Factors that increase the possibility of
the patient developing a problem.
COMPONENTS OF NURSING DIAGNOSIS
Defining Characteristics
-These are the signs & symptoms that validate
that an actual nursing diagnosis is present.
1. Major: at least one must be present
to use the nursing diagnosis
2. Minor: may not be present, but if it is,
helps to validate selecting the nursing
diagnosis
• Defining characteristics are not present in
‘Risk’dx because signs & symptoms don’t exist
if the problem hasn’t happened
ACTUAL DIAGNOSTIC STATEMENT
THREE-PART FORMAT
Three parts:
1. NANDA label
2. Related factors (follows NANDA &
linked by the words “related to”)
3. Defining characteristics (follows
related factors & linked by the words
“as manifested
ACTUAL DIAGNOSTIC STATEMENT
Example :
1. ( Label )Impaired Physical Mobility
2. related to (r/t) decreased motor
ability and muscle weakness
3. Defining characteristics) as manifested
by limited ROM
*“Impaired Physical Mobility r/t muscle
weakness AMB limited ROM”
RISK DIAGNOSTIC STATEMENT
Two-Part Format Two parts:
1. NANDA label
2. Risk factors (follows NANDA label and
is linked by the words related to)
*“Risk for Impaired Physical Mobility r/t full
leg cast”
CLARIFYING THE RELATED FACTORS PART OF
THE DIAGNOSTIC STATEMENT
- You will often need to add words to the
‘related to’ portion of an actual or a risk
diagnostic statement to clarify the origin of
the problem
- These words always follow the ‘related to’
and are linked with the words ‘secondary to’
(2°)
*NOTE: This is the only way a medical
diagnosis can ever be inserted into a nursing
dx
Examples: Adding a Secondary Factor to the
‘related to’ part of a Diagnostic Statement for
Clarity
- Impaired Physical Mobility r/t muscle rigidity
and tremors secondary to (2°) Parkinson’s
Disease AMB limited ROM and compromised
ability to move purposefully
- Risk for Impaired Skin Integrity r/t immobility
2° fractured hip
WELLNESS DIAGNOSTIC STATEMENT
- Used when pt doesn’t have a health problem
but can attain higher level of health
- Is a one part statement consisting only of
the NANDA:
● Readiness for Enhanced Parenting
● Readiness for Enhanced Family
Processes
● Readiness for Enhanced Spiritual Well-
Being