Nursing Diagnosis

Prepared by-: Taghreed hamza hawsawi

RN- BSN Nursing Educator

Outline

Introduction Definition Steps of formulating nursing

diagnosis Category of nursing diagnosis Type of nursing diagnosis summary Reference

Introduction -:

diagnosis :- 1. determination of the nature of a

cause of a disease.2. a concise technical description of

the cause, nature, or manifestations of a condition, situation, or problem.

Definition : physical diagnosis

differential diagnosis

medical diagnosis

clinical diagnosis

diagnosis based on information

obtained by inspection, palpation,

percussion, and auscultation

the determination of

which one of several diseases

may be producing the

symptoms

diagnosis based on information from sources

such as findings from a physical examination, interview with the patient or family or both, medical history of the patient

and family, and clinical findings as reported by

laboratory tests and radiologic

studies

diagnosis based on signs,

symptoms, and laboratory

findings during life

Definition :

a statement of a health problem or of a potential problem in the client's health status that a nurse is licensed and competent to treat.

The process of assessing potential or actual health problems, including those pertaining to an individual patient, a family or community, that fall within the scope of nursing practice; a judgment or conclusion reached as a result of such assessment or derived from assessment data.

formulation of a nursing diagnosis

1. A database is established by collecting information from all available sources:-

a. including interviews with the client and the client's family

b. a review of any existing records of the client's health

c. observation of the client's response to any alterations in health status, a physical assessment, and a consultation with others concerned in the client's care. The database is continually updated.

formulation of a nursing diagnosis

2.The second step includes analysis of the client's responses to the problems, healthy or unhealthy, and classification of those responses as psychologic, physiologic, spiritual, or sociologic.

3. The third step is the organization of the data so that a tentative diagnostic statement can be made that summarizes the pattern of problems discovered.

formulation of a nursing diagnosis

4.confirmation of the sufficiency and accuracy of the database by evaluation of the appropriateness of the diagnosis to nursing intervention and by the assurance that, given the same information, most other qualified practitioners would arrive at the same nursing diagnosis.

category of nursing diagnosis -:

Part 1 the term that concisely describes

Part 3 the problem, the probable cause of the problem

Part 3 the defining characteristics of the problem.

Type of nursing diagnosis -:

1- ACTUAL: This diagnosis has 3 parts and follows the PES format.

It will actually paint a picture of the existing health problem. The evidence in this diagnostic statement must be specific.

Example: Impaired gas exchange r/t status of

secretions associated with difficulty coughing up secretions from fatigue .

1. Large amounts thick green-yellow sputum 2. Frequent coughing with expectoration of sputum 3. Crackles throughout both lung fields 4. O2 sat of 90% without oxygen

Type of nursing diagnosis -:

RISK: This diagnosis indicates from the data,

a strong likelihood that it will occur if actions are not taken.

The Risk diagnosis only has 2 parts. It can be used with any NANDA diagnosis.

Example: Risk for falls r/t to unsteady

gait

Type of nursing diagnosis -:

POTENTIAL COMPLICATION: This is also known as a collaborative diagnosis. This

is a problem the nurse cannot treat independently. Nursing care will focus on monitoring and preventing

the problem. A collaborative diagnosis can be written as a one or two part statement.

Example: P.C of surgery: Hemorrhage or P.C. of chronic

obstructive pulmonary disease: respiratory failure

Summary

Merely a nursing diagnosis label that you make up that “sounds like” it explains what you are seeing in your patient.

Another way of explaining the medical diagnosis, or of renaming a medical condition.

Something that “goes with a particular medical diagnosis”.

A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.” (Herdman, 2012, p. 515).

  The medical diagnosis provides one important piece of data, but it does not provide anywhere near the depth of information necessary for making an accurate nursing care

References -: