Nursing DiagnosisNursing Diagnosis

Definition of Nursing Definition of Nursing DiagnsisDiagnsis

•A nursing diagnosis is a A nursing diagnosis is a statement of the high risk or statement of the high risk or actual problems in the client’s actual problems in the client’s health status that the nurse is health status that the nurse is licensed and competent to treatlicensed and competent to treat

Components of Analysis Components of Analysis PhasePhase• 3 major components of analysis 3 major components of analysis

phase:phase:– Analysis and interpretation of dataAnalysis and interpretation of data

•Validation of dataValidation of data

•Clustering of dataClustering of data

– Identification of problems/health care Identification of problems/health care needsneeds

– Formulation of nursing diagnosis Formulation of nursing diagnosis statementstatement

Nursing Diagnostic Nursing Diagnostic StatementStatement

• Derived from actual or potential Derived from actual or potential problemsproblems

• Derived from physiological, Derived from physiological, sociocultural, developmental, and sociocultural, developmental, and spiritual dimensions of clientspiritual dimensions of client

• Focus: Focus: Helping client to achieve a Helping client to achieve a maximal level of wellness and maximal level of wellness and highest level of independencehighest level of independence

Categories ofnursing diagnoses

Nursing diagnoses?Nursing diagnoses?What’s up with that?What’s up with that?

• Nursing diagnoses are what you get when you finish Nursing diagnoses are what you get when you finish your assessment and look at your data.your assessment and look at your data.

• Nursing diagnoses describe patient needs or Nursing diagnoses describe patient needs or responses to health conditions and treatmentsresponses to health conditions and treatments

• Nursing diagnoses reflect the patient’s level of Nursing diagnoses reflect the patient’s level of health or response to disease, emotional state, health or response to disease, emotional state, socio-cultural phenomenon, or developmental stagesocio-cultural phenomenon, or developmental stage

Medical vs. nursing Medical vs. nursing diagnosesdiagnoses

• MedicalMedical diagnosis- diagnosis- Identifies disease or Identifies disease or pathologypathology

• NursingNursing diagnosis- diagnosis- Identifies patient’s response Identifies patient’s response to said disease or pathologyto said disease or pathology

• MedicalMedical diagnosis goal- diagnosis goal- to cure the disease to cure the disease

• Nursing diagnosis goal-Nursing diagnosis goal- to direct the nursing plan to direct the nursing plan of care to meet the patient’s needsof care to meet the patient’s needs

This nurse is validating the cues collected from this

client during the assessment phase.

Nursing diagnosesNursing diagnoses

• Help facilitate communication between members Help facilitate communication between members of the nursing staffof the nursing staff

• Help prioritize the needs of the patientHelp prioritize the needs of the patient

• Help to guide chartingHelp to guide charting

In practice, you…In practice, you…

• Do your assessment and think “My patient is in Do your assessment and think “My patient is in pain!”pain!”

• Take your impressions and put fancy labels on Take your impressions and put fancy labels on them like “impaired comfort” or “acute pain”them like “impaired comfort” or “acute pain”

• Those are nursing diagnoses in a nutshellThose are nursing diagnoses in a nutshell

You got to stick with You got to stick with NANDA!NANDA!• Unfortunately, you are not allowed to make up new Unfortunately, you are not allowed to make up new

and creative nursing diagnoses for your patientsand creative nursing diagnoses for your patients

• No matter how much your patient merits a nursing No matter how much your patient merits a nursing diagnosis of “persistent stupidity” or “constant diagnosis of “persistent stupidity” or “constant whining” you just whining” you just can’tcan’t do it! do it!

• Some authors like Carpenito have developed Some authors like Carpenito have developed nursing diagnoses similar to NANDA’s, but the nursing diagnoses similar to NANDA’s, but the OU OU SON professors require SON professors require onlyonly NANDA diagnoses NANDA diagnoses for for your care plans and papersyour care plans and papers

Writing nursing diagnosesWriting nursing diagnoses

• The first part is the NANDA nursing diagnosis statementThe first part is the NANDA nursing diagnosis statement

• If your patient doesn’t meet the criteria for the diagnosis If your patient doesn’t meet the criteria for the diagnosis yet, you put “Risk for…” in front of the diagnosisyet, you put “Risk for…” in front of the diagnosis– Risk for nauseaRisk for nausea– Risk for deficient fluid volumeRisk for deficient fluid volume

• After the diagnosis, you put why you chose the diagnosis After the diagnosis, you put why you chose the diagnosis for the patient with a “related to” (R/T) statement…for the patient with a “related to” (R/T) statement…– Risk for nausea R/T side effects from chemotherapy medicationsRisk for nausea R/T side effects from chemotherapy medications– Risk for deficient fluid volume R/T poor fluid intake and high Risk for deficient fluid volume R/T poor fluid intake and high

temperaturetemperature– Sleep deprivation R/T busy ICU environmentSleep deprivation R/T busy ICU environment

Writing “related to” Writing “related to” statementsstatements• Don’tDon’t put medical diagnoses or diagnostic tests put medical diagnoses or diagnostic tests

like pneumonia, hip fracture, or angioplasty in the like pneumonia, hip fracture, or angioplasty in the “related to” statement.“related to” statement.

• DoDo put factors that you can take care of with put factors that you can take care of with nursing interventions… nursing interventions…

BADBAD BETTER!!BETTER!!

Impaired gas exchange R/T Impaired gas exchange R/T increased blood CO2 levelsincreased blood CO2 levels

Impaired gas exchange R/T Impaired gas exchange R/T shallow breathing postopshallow breathing postop

Diarrhea R/T Diarrhea R/T C. difficileC. difficile infectioninfection

Diarrhea R/T food Diarrhea R/T food intoleranceintolerance

Acute pain Acute pain R/T hip fracture R/T hip fracture Acute pain R/T swelling and Acute pain R/T swelling and tissue damagetissue damage

More examples…More examples…

BadBad Good Good Why??Why??Risk for Risk for aspiration R/T aspiration R/T strokestroke

Risk for Risk for aspiration R/T aspiration R/T impaired impaired swallowingswallowing

Nurses can work with Nurses can work with patients to improve patients to improve swallowing abilityswallowing ability

Acute pain R/T Acute pain R/T hip fracturehip fracture

Acute pain R/T Acute pain R/T tissue damage tissue damage and swelling in and swelling in right hipright hip

Nurses can give Nurses can give medications to help medications to help relieve pain from tissue relieve pain from tissue damage, and provide ice damage, and provide ice to reduce swellingto reduce swelling

Risk for falls R/T Risk for falls R/T Multiple Multiple SclerosisSclerosis

Risk for falls R/T Risk for falls R/T poor balance and poor balance and leg weaknessleg weakness

Nurses can help patients Nurses can help patients with transfers to with transfers to compensate for poor compensate for poor balance and weaknessbalance and weakness

Care Plan Formats

After the R/T statement…After the R/T statement…

• After you say why you chose the diagnosis for the After you say why you chose the diagnosis for the patient with the “related to” statement, include an “as patient with the “related to” statement, include an “as evidenced by” statement that includes specific signs evidenced by” statement that includes specific signs and symptoms of the particular patientand symptoms of the particular patient

• This step is not needed when there is only “Risk for …” This step is not needed when there is only “Risk for …” diagnoses, as the patient is only at risk for the diagnoses, as the patient is only at risk for the condition and has not actually developed it yetcondition and has not actually developed it yet

• You can use “AEB” for “as evidenced by” so that you You can use “AEB” for “as evidenced by” so that you don’t need to write it out don’t need to write it out

AEB statementsAEB statements

• Don’tDon’t include prejudicial statements such as: include prejudicial statements such as:

– Risk for impaired skin integrity R/T Risk for impaired skin integrity R/T poor hygiene poor hygiene habits, AEB foul stench from perineal areahabits, AEB foul stench from perineal area

• Instead, you could use:Instead, you could use:

– Risk for impaired skin integrity R/T Risk for impaired skin integrity R/T inability to inability to reach perineal area to clean, AEB patient reach perineal area to clean, AEB patient verbalized need for nursing assistance with verbalized need for nursing assistance with perineal careperineal care

Diagnostic testing…Diagnostic testing…

• Don’t use diagnostic tests Don’t use diagnostic tests specificallyspecifically in nursing in nursing diagnoses like:diagnoses like:

– Anxiety R/T Anxiety R/T cardiac catheterizationcardiac catheterization, AEB patient , AEB patient statements of uneasiness and nervously pacing floorstatements of uneasiness and nervously pacing floor

• Instead, focus on patient responses to the tests:Instead, focus on patient responses to the tests:

– Anxiety R/T Anxiety R/T awaiting of cardiac catheterization awaiting of cardiac catheterization results, AEB patient statements of uneasiness results, AEB patient statements of uneasiness and nervously pacing floorand nervously pacing floor

Phrasing diagnosesPhrasing diagnoses

• Don’t use blaming phrases or ones that could Don’t use blaming phrases or ones that could imply negligence or malpractice, like:imply negligence or malpractice, like:– Excess fluid volume R/T IV infused too quicklyExcess fluid volume R/T IV infused too quickly– Acute pain R/T improper placement of epidural Acute pain R/T improper placement of epidural

cathetercatheter

• Don’t overload diagnoses…Don’t overload diagnoses…– Constipation and abdominal pain should be 2 Constipation and abdominal pain should be 2

different nursing diagnosesdifferent nursing diagnoses– Noncompliance and knowledge deficit should Noncompliance and knowledge deficit should

be 2 different diagnosesbe 2 different diagnoses