Nursing process/diagnosis

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Nursing Diagnosis: clinical judgement about individual, family or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat

Formulating a nursing diagnosis

1. identify the appropriate diagnosis

2. identify related factors

3. list the defining characteristics

Diagnostic reasoning: analytical process for determining a patient's health problems.

- necessary before you decide of solutions and implement action

- begins when you interact with a patient or make physical/behavioral observations

Inference: process of drawing conclusions from related pieces of evidence and previous experience with the evidence

- form patterns of information from data before making a diagnosis

Assessment: deliberate and systematic collection of information about a patient to determine the patient's current and past health functional status and his or her present and past coping patterns.

- collect information from a primary source and secondary sources

- the interpretation and validation of data to ensure a complete database

subjective data: patient's verbal descriptions of their health problems

objective data: observations or measurements of a patient's health status

Medical diagnosis: identification of a disease condition based on a specific evaluation f physical signs and symptoms, a patient's medical history and the results of diagnostic tests and procedures

- stays constant as a condition remains

diagnosis: clinical judgement made on the basis of information

Nursing diagnosis: clinical judgement concerning a human response to health conditions/ life processes or vulnerability for that response by an individual, family or community that a nurse is licensed and competent to treat

- ever changing based on the patient's needs

collaborative problem: actual or potential physiological complication that nurses monitor to detect the onset of change in a patient's health status

- intervene in collaboration as a partnership between a team of health care providers

problem- focused nursing diagnosis: clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family or community.

Risk nursing diagnosis: clinical judgment concerning the vulnerability of an individual, family, group,or community for developing an undesirable human response to health conditions/ life processes.

health promotion nursing diagnosis: patient's motivation and desire to increase well-being and actualize human health potential.

Nursing diagnosis

1.chooses diagnostic label

2.consider

3.review

4.cluster

Critical thinking:

- analyze information

- can the diagnosis change with a nursing intervention

- are the defining characteristics in the assessment?

- is the problem acute, chronic, intermittent or continuous?

- what is the age of the client

- position/rank the health status

- connect the signs and symptoms with "AEB"

Creating a diagnosis

- what best describes the limits of the diagnosis

- anticipatory, compromised, decreased, deficit, impaired for example

- what part or region of the body is involved

- auditory, bowel, cerebral, intracranial, oral, skin, visual?

- can this diagnostic concept stand alone?

- related factors (Etiology)

- may cause or contribute to the nursing diagnosis

- can be environmental, physiological, psychological, sociocultural or spiritual

Activity intolerance for example:

- verbal report of fatigue or weakness

- abnormal heart rate

- exertional discomfort or dyspnea

- ECG changes reflecting dysrhythmias or ischemia

Activity intolerance related factors:

- bed rest or immobility

- generalized weakness

- sedentary lifestyle

- imbalance between oxygen supply and demand

Nursing diagnoses:

- may have two or three parts

- two parts consists or nursing diagnosis and the "related to" statement

- three parts consists of the nursing diagnosis, the "related to" statement and the defining characteristics

- also referred to as the PES system: Problem, Etiology and Symptoms

PES example

activity intolerance r/t imbalance between oxygen supply and demand. patient reports fatigue, abnormal heart rate in response to activity and exertional dyspnea