nursing process diagnosing
TRANSCRIPT
NURSING PROCESS
PREPARED AND PRESENTED BY
MRS.S.ANUKRISHNAN,
VICE PRINCIPAL CUM HOD OBG NURSING,
P.D.BHARATESH COLLEGE OF NURSING,
HALAGA, BELGAUM.
INTRODUCTION
Second phase of the Nursing Process.
Nurses use critical thinking skills to interpret assessment
data and identify client strengths & problems.
Diagnosing is the pivotal step in the nursing process.
All activities preceding this phase are directed toward
formulating the nursing diagnosis.
All the care planning activities following this phase are
based on the nursing Diagnoses.
The identification & development of nursing Diagnosing
began formally in 1973.
NORTH AMERICAN NURSING DIAGNOSING ASSOCIATION
NANDA: - is to define, refine & promote
taxonomy of Nursing Diagnostic terminology of
general use to professional nurses.
Taxonomy - is the classification system
Currently NANDA approved more than 150
Nursing Diagnosis labels for clinical use & testing.
In 2000 taxonomy I revised & now referred to as
Taxonomy II.
DEFINITION
“It is a clinical judgment about individual,
family or community responses to actual and
potential health problems/life processes.
Nursing diagnoses provide the basis for
selection of nursing interventions to achieve
outcomes for which the nurses are
accountable”.
TYPES OF NURSING DIAGNOSES
1. Actual Nursing Diagnosis
2. Risk Nursing Diagnosis
3. Wellness Diagnosis
4. Possible Nursing Diagnosis
5. Syndrome Diagnosis
ACTUAL NURSING DIAGNOSIS
Actual Nursing Diagnosis is a client problem that
is present at the time of the Nursing
assessment.
The actual Nursing Diagnosis is based on the
presence of associated signs & symptoms.
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.
RISK NURSING DIAGNOSIS It is a clinical judgment that a problem doesn’t
exist, but the presence of risk factors indicates
that a problem is likely to develop unless nurses
intervene.
Eg. A client with Diabetes Mellitus or a
compromised immune system is at high risk than
others.
Therefore the nurse would appropriately use the
label risk for infection to describe the client’s
health status.
WELLNESS DIAGNOSIS
Describes human responses to levels of wellness
in an individual, family or community that have a
readiness for enhancement.
Eg.
i) Readiness for enhanced spiritual well being
ii) Readiness for enhanced family coping.
POSSIBLE NURSING DIAGNOSIS is one in which evidence about a health problem
is incomplete or unclear.
For Eg. Elderly widow who lives alone admitted
in hospital have no visitors & is pleased with
attention and conversation from the nursing
staff. Until more data are collected, the nurse
may write a Nursing Diagnosis of :
i) Possible social Isolation Related to unknown
etiology.
A SYNDROME DIAGNOSIS
is a diagnosis associated with a Cluster of other
diagnoses.
Eg. Risk for disuse syndrome – experienced by
bed ridden patient.
1. Impaired physical mobility 2. Impaired gas
exchange 3. Risk for impaired tissue integrity 4.
Risk for Activity intolerance 5. Risk for constipation
6. Risk for infection 7. Risk for injury 8. Risk for
powerlessness
COMPONENTS OF NANDA NURSING DIAGNOSIS
A nursing Diagnosis has 3 components.
1. The problem and its definition
2. The etiology
3. The defining characteristics.
Each component serves a specific purpose.
1] THE PROBLEM (DIAGNOSTIC LABEL) AND ITS DEFINITION
Describes the clients health problem or response
for which nursing therapy is given.
It describes the client’s health status clearly &
concisely in few words.
Purpose is to direct the formation of client goals
and desired outcomes.
It may also suggest some nursing interventions.
To be clinically useful,
diagnostic labels need to be specific;
when the words specify follows a NANDA Label, the
nurse states the area in which the problem occurs.
For eg.
Deficient knowledge (specify) Medication
Deficient knowledge (Dietary adjustments).
Qualifiers are words that have been added to some NANDA
Labels to give additional meaning to the diagnostic
statement; for eg.
Deficient (inadequate in amount quality or degree not
sufficient, incomplete)
Impaired (Made worse, weakened, damaged, reduced,
deteriorated)
Decreased (lesser in size amount or degree)
Ineffective (not producing the desired coping)
Compromised (to make Vulnerable to threat)
Each Diagnostic label approved by NANDA carries a
definition that clarifies its meaning.
2] ETIOLOGY
The etiology component of a nursing diagnosis
identifies one or more probable cause of the health
problem,
gives direction to the required nursing therapy and
enables the nurse to individualize the client’s care.
Eg. of problems having different etiologies and
different interventions
Problem Client Etiology Nursing Intervention
Constipation
A Long termlaxative use
Gradual withdraw of laxatives- teach components of high fiber diet.
B Inactivity &insufficient fluid intake
- exercise information about daily schedule - types of fluid he likes - Plan to include sufficient amount of fluid in his diet.
Ineffective Breast Feeding
A Breast engorgement
-massage of breast before feeding- use hot packs- hot shower before nursing infant
B Inexperience and lack of knowledge
- Advice to feed infant on demand - Show her how infant is sucking & swallowing - demonstrate different holding positions for feedings.
3] DEFINING CHARACTERISTICS
Defining Characteristics are the client’s signs & symptoms.
That indicates the presence of a particular diagnostic
label.
For Actual Nursing Diagnosis the defining
characteristics are the client’s signs & symptoms.
For Risk Nursing Diagnosis no subjective & objective
signs are present.
Thus the factors that cause the client to be more than
“normally” vulnerable to the problem form the etiology of
a risk nursing diagnosis.
Characteristics are listed separately according to whether
they are subjective or objective in nature.
DIFFERENCE BETWEEN MEDICAL & NURSING DIAGNOSES
Sl No. Nursing Diagnoses Medical Diagnoses
1 It is a statement of Nursing judgment Medical Diagnoses is made by physician
2 Refers to a condition that Nurses are licensed to treat
Refers to a condition that only a physician can treat.
3 Nursing Diagnoses describe a client’s physical, socio-cultural, psychologic, and spiritual responses to an illness or health problem.
Medical Diagnoses refers to disease processes
4 It changes depend upon the response of the client to an illness & health problem.
Fairly uniform from one client to another
5 Nursing Diagnoses change as the client responses change.
Medical Diagnose remains same for as long as the disease process is present.
THE DIAGNOSTIC PROCESS
The Diagnostic Process uses 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
breaking down of the whole into its parts.
Synthesis – is the opposite that is the putting
together of parts into the whole.
The diagnostic process is used continuously by
most nurses.
An experienced nurse may enter a client’s room
and immediately observe significant data and
draw conclusions about the client.
As a result of attaining knowledge skill and
expertise in the practice setting, the expert nurse
may seem to perform these mental processes
automatically.
Novice nurses, however, need guidelines to
understand and formulate nursing diagnoses.
THE DIAGNOSTIC PROCESS
The diagnostic process has 3 steps:-
1] Analyzing data
2]Identifying health problems, risks and
strengths.
3] Formulating Diagnostic statements.
Assessing a. Collect datab. Organize datac. Validate datad. Document data
Diagnosinga. Analyze datab. Identify health
problems, risks and strength,
c. Formulating nursing diagnosis
1] ANALYZING DATA
In analyzing data following steps are
involved.
A. Compare data against standards (identify
significant cues)
B. Cluster cues (generate tentative hypotheses)
C. Identify gaps & inconsistencies.
For experienced nurses, these activities
occur continuously rather than sequentially.
A. COMPARING DATA AGAINST STANDARDS
A Standard or Norm is generally accepted
measure, model rule, or pattern.
Eg. of Standards
Growth and Development patterns
Normal vital signs
Laboratory values.
B. CLUSTER CUES
It is a process of determining the relatedness of
facts and determining whether data are
significant.
C. IDENTIFY GAPS & INCONSISTENCIES
Skillful assessment minimizes the gaps &
inconsistencies, conflicting data's.
Possible sources are measurement error,
expectation and unreliable report.
It helps to have final check to ensure the data are
complete and correct.
Eg. Patient reports not having seen a Doctor in 15
years, yet during Physical Examination he states “My
doctor takes my BP every year”.
All inconsistencies must be clarified before valid
pattern “Validating data”.
2] IDENTIFYING HEALTH PROBLEMS, RISKS & STRENGTHS
After data are analyzed, the nurse and client
can together identify strengths & problems.
That is after gaping and clustering the data, the
nurse and client together identify problems that
support tentative actual, risk, and possible
diagnoses.
EG. OF A CLIENT WITH PNEUMONIASl
No. Client cue clusters
1 a) No appetite since having “Cold”
b) Has not eaten today, Last fluids at noon today
c) Nauseated x 2 days
Imbalanced Nutrition: Less that Body Requirements related to decreased appetite & Nausea, & increased metabolism (Strength: - Normal Weight for Height.)
EG. OF A CLIENT WITH PNEUMONIASl
No. Client cue clusters
2 a) Last fluids at noon today
b) Oral temperature 39.40c (1030 F)
c) Skin lot & pale, checks flushed
d) Dry mucous membrane
e) Poor skin turgorf) Decreased Urinary
frequency x 2 days
Deficient fluid volume related to intake insufficient to replace fluid loss secondary to fever, diaphoresis, anorexia
EG. OF A CLIENT WITH PNEUMONIASl
No. Client cue clusters
3 Difficulty in sleeping because of cough, “Can’t breathe while lying down”
Disturbed sleep pattern related to cough, pain, orthopnea, fever, and diaphoresis.
EG. OF A CLIENT WITH PNEUMONIASl
No. Client cue clusters
4 a) States “I feel Weak” b) Short of breath on
exertionc) Radial pulses weak,
regulard) Pulse rate – 92 bt/mte) States “I can think
ok, just weak”
Activity Intolerance related to general weakness imbalance between O2 supply / demand
Strength: - No musculoskeletal impairment, normal energy level is Satisfactory, exercises regularly.
EG. OF A CLIENT WITH PNEUMONIASl
No. Client cue clusters
5 Reports pain in chest especially when coughing
Acute pain related to cough secondary to inflammation of lung parenchyma.Strength:-No cognitive or sensory deficits.
EG. OF A CLIENT WITH PNEUMONIASl
No. Client cue clusters
6 a) Husband out of town; will be back tomorrow afternoon b) Child with neighbor until husband returns.
Interrupted family processes related to mother’s illness & temporary unavailability of father to provide child care. Strength :- Neighbors available & willing to help.
EG. OF A CLIENT WITH PNEUMONIASl
No. Client cue clusters
7 a) Anxious :- “I can’t breathe”
b) Facial muscles tense,c) Tremblingd) States “I’ll never get
caught up”e) Husband out of town;
will be back tomorrow afternoon.
f) Child with neighbor house
g) Express “concern” & “Worry”
Anxiety related to difficulty breathing, inability to work, and child care.
EG. OF A CLIENT WITH PNEUMONIASl
No. Client cue clusters
8 a) Radial pulse weak, regular pulse rate 92 b) Skin hot, pale, and moistc) Respirations shallow, chest expansion, 3cm d) Productive cough e) Thick pale pink sputum f) Inspiratory crackles auscultated through out. Right upper & lower lungs. g) Diminished breath sounds an ® side h) Mucous membranes pale, dry
Ineffective Airway clearance related to viscous secretions & shallow chest expansion secondary to pain, fluid volume deficit & fatigue.
DETERMINING STRENGTHS
Eg. of strengths
Weight is with in normal as per age & Height –
Enables client to cope with surgery.
Absence of allergies & Non smoker.
It can be found in the nursing assessment record
(health, home life, Education, recreation,
exercise, work, family & friends religious beliefs,
sense of humour)
3] FORMULATING DIAGNOSTIC STATEMENTS
Most Nursing Diagnoses are written as two part
or three part statements, but there are variations
of these.
1. Basic two part statements
2. Basic three part statements
3. One part statements
4. Variations of Basic formats.
5. Collaborative problems.
BASIC TWO PART STATEMENTS
The basic two part statement includes the following.
1] Problem (P) :- Statement of the client’s response
(NANDA Label)
2] Etiology (E) :- Factors contributing to or probable
cause of responses.
The two parts are joined by the words related to rather
than due to.
The phrase due to implies that one part causes or is
responsible for the other part.
By contrast, the phrase related to merely implies a
relationship.
EG. OF TWO PART STATEMENTS
Problem Related to Etiology
Constipation Related to Prolonged
Laxative use
Ineffective
Breast Feeding
Related to Breast
engorgement
Some NANDA Labels contain the word specify. For these
the nurse must add words to indicate the problem more
specifically.
Eg. Noncompliance (specify)
Noncompliance (Diabetic Diet) related to denial of
having disease.
For ease in alphabetizing, many NANDA lists are
arranged with qualifying words after the main word (Eg.
Infection, Risk For).
Avoid writing Diagnostic statements in that manner
instead, write them as they would be stated in normal
conversation (Eg. Risk for infection)
BASIC THREE PART STATEMENTS
The three part Diagnostic Statements called the
PES format and includes the following:
1] Problem (P) :- Statement of the client’s response
(NANDA Label)
2] Etiology (E) :- Factors contributing to or probable
cause of the response.
3] S/S (S) :- Defining characteristics manifested by
the client.
Actual nursing diagnoses can be documented by
using the three part statement
because the signs & symptoms have been
identified.
This format cannot be used for risk diagnoses
because the client doesn’t have signs & symptoms
of the diagnosis.
EG. OF 3 PART STATEMENT Problem Related
ToEtiology As manifested
bySigns & symptoms
Situational Low Self Esteem
Related to Rejection by husband
As manifested by States that “I don’t know if I can manage by myself”Rejects positive feed back.
Hyperthermia Related to Bacterial infection As manifested by Elevated body temperature. 1000FIncreased pulse rate 92bt/mt Increased R.R 30br/mtDry lips . States Fatigue, tired.Feels so Hot Reduced Skin turgor.
Ineffective breathing pattern
Related to Viscious secretions
As manifested by Viscious secretions, shallow chest expansion.
ONE PART STATEMENTS
Wellness diagnoses and Syndrome nursing
diagnoses.
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.
The wellness diagnoses statement begins with
words Readiness for Enhanced (Parenting, Spiritual
well being, Effective breast feeding, Health seeking
behaviors, Anticipatory Grieving Low fat Diet.)
GUIDELINES FOR WRITING A NURSING DIAGNOSTIC STATEMENT
Sl No.
Correct statement Incorrect
1 State in terms of problem, not a need.
Deficient fluid volume related to fever
Fluid replacement (need) related to fever.
2 Word the statement so that it is legally advisable
Impaired skin integrity related to immobility (legally acceptable)
Impaired skin integrity related to improper positioning (implies legal liability)
3 Use nonjudgmental statements
Spiritual distress related to inability to attend church services secondary to immobility (Nonjudgmental)
Spiritual distress related to strict rules necessitating church attendance
GUIDELINES FOR WRITING A NURSING DIAGNOSTIC STATEMENT
Sl No.
Correct statement Incorrect
4 Make sure that both elements of the statement don’t say the samething.
Impaired skin integrity (ulcer in sacral area) related to immobility.
Impaired skin integrity related to ulceration of sacral area.
5 Be sure that cause and effect are correctly stated (that is the etiology causes the problem)
Pain severe head ache related to fear of addiction to narcotics
Pain related to severe head ache.
GUIDELINES FOR WRITING A NURSING DIAGNOSTIC STATEMENT
Sl No.
Correct statement Incorrect
6 Word the diagnosis specifically and precisely to provide direction for planning nursing intervention
Impaired oral mucus membrane related to decreased salivation secondary to radiation of neck. (specific)
Impaired oral mucus membrane related to noxious agent (vague)
7 Use nursing terminology rather than medical terminology to describe the client response & its cause.
Risk for ineffective airway clearance related to accumulation of secretions in lungs (nursing terminology)
Risk for pneumonia (Medical Terminology)
CONCLUSION Definition Types of Nursing Diagnoses –Actual, Risk, Wellness, Possible and
Syndrome
Components of NANDA nursing diagnosis- Problem, Etiology, Defining characteristics
Difference between medical and nursing diagnoses Diagnostic process-
Analyzing data - Compare data against standards (identify
significant cues), Cluster cues (generate tentative hypotheses) ,
Identify gaps & inconsistencies. Identifying health problems risk and its strengths
Formulating diagnostic statements - Basic two part, Basic three part,
One part, Variations of Basic formats, Collaborative problems.
Guidelines for writing a nursing diagnostic statement