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    Resume Irena Siska Manalu

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    Irena Siska Manalu
    This document contains information about nursing diagnosis including: 1. Nursing diagnoses can be positive (actual or risk) or negative (health promotion). Positive diagnoses describe existing or potential problems, while negative diagnoses focus on wellness. 2. Components of a nursing diagnosis include the problem/diagnostic label, etiology/related factors, and defining characteristics/signs and symptoms. Etiology identifies contributing causes. 3. Nursing diagnoses use a problem-focused approach centered on the patient's responses and needs, whereas medical diagnoses identify underlying pathologies. Errors can occur when the perspectives are confused.

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    Resume Irena Siska Manalu

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    Irena Siska Manalu
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    This document contains information about nursing diagnosis including: 1. Nursing diagnoses can be positive (actual or risk) or negative (health promotion). Positive diagnoses describe existing or potential problems, while negative diagnoses focus on wellness. 2. Components of a nursing diagnosis include the problem/diagnostic label, etiology/related factors, and defining characteristics/signs and symptoms. Etiology identifies contributing causes. 3. Nursing diagnoses use a problem-focused approach centered on the patient's responses and needs, whereas medical diagnoses identify underlying pathologies. Errors can occur when the perspectives are confused.

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    This document contains information about nursing diagnosis including: 1. Nursing diagnoses can be positive (actual or risk) or negative (health promotion). Positive diagnoses describe existing or potential problems, while negative diagnoses focus on wellness. 2. Components of a nursing diagnosis include the problem/diagnostic label, etiology/related factors, and defining characteristics/signs and symptoms. Etiology identifies contributing causes. 3. Nursing diagnoses use a problem-focused approach centered on the patient's responses and needs, whereas medical diagnoses identify underlying pathologies. Errors can occur when the perspectives are confused.

    Copyright:

    © All Rights Reserved
    37 views3 pages

    Resume Irena Siska Manalu

    Uploaded by

    Irena Siska Manalu
    This document contains information about nursing diagnosis including: 1. Nursing diagnoses can be positive (actual or risk) or negative (health promotion). Positive diagnoses describe existing or potential problems, while negative diagnoses focus on wellness. 2. Components of a nursing diagnosis include the problem/diagnostic label, etiology/related factors, and defining characteristics/signs and symptoms. Etiology identifies contributing causes. 3. Nursing diagnoses use a problem-focused approach centered on the patient's responses and needs, whereas medical diagnoses identify underlying pathologies. Errors can occur when the perspectives are confused.

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    of 3

    Nama : Irena Siska Manalu

    Nim :01.2.17.00610

    Mata Kuliah : Bahasa Inggris

    Resume

    A. Nursing Diagnosis

    A clinical judgement about individual, family, or community responses to actual or


    potential health problems/ life process’. A nursing diagnosis provides the basis for selection
    of nursing interventions to achieve outcome for which the nurse’s accountable. Professional
    nurses are responsible for making diagnosis. It derived from existing evidences about the
    client It is potentially amenable to nursing therapy It is the basis for planning and carrying out
    nursing

    Nursing Diagnosis are divided into two. That is negative and positive.

    a. Positive :
     Actual Nursing Diagnosis : A clinical judgement about human experience/
    responses to health conditions/ life processes that exist in an individual,
    family or community. Actual client problem present at the time of
    assessment. It is based on the presence of sign and symptoms.
    E.g: Ineffective breating pattern, Disturbed sleep patter.
     Risk Nursing Diagnosis : It is a clinical judgement that a problem doesn’t
    exist but the presence of risk factors indicates that a problem is likely to
    develop unless nurses intervene.’ No subjective or objective cues
    E.g : A client with DM or compromised immune system is at high risk
    than others. Risk for infection. Risk for injury
    b. Negative :
     Health Promotion Nursing Diagnosis : Describes human responses to level
    of wellness in an individual, family, or community that have a readiness
    for enhancement’ Clinical judgement about a person’s, families or
    communities motivation and desire to increase well being.
     E.g: -Readiness for enhanced family coping
    -Readiness for enhanced self est.

    B. Componen Nursing Diagnosis


    1. Problem (Diagnostic Label) / Definition
    The problem statement describes the client health problem or response for which
    nursing therapy is given. The diagnostic label should be specific
    2. Etiology (Related Factors or Risk Factors)
    Identifies one or more probable cause of the health problem, gives directions to the
    required nursing therapy. Enables the nurses to individualized client care.

    Problem Etiology
    Constipation Long term laxative use, inactivity and insufficient fluid
    intake
    Anxiety Threat to physiologic integrity Possible cancer diagnosis

    3. Defining Characteristic
    The cluster of signs and symptoms that indicate the presence of a particular diagnostic
    label.
    ❖ Actual diagnosis 🡪 client signs and symptoms
    ❖ Risk diagnosis 🡪 no subjective signs are present

    Basic Two Parts:

    1. Problem 🡪 statement of the client response

    2. Etiology 🡪 factors contributing to or probable causes of the responses ‘related to’ phrase
    implies a relationship

    E.g: -Constipation related to insufficient fluid intake

    -Pain related to presence of surgical incision

    Basic Three Parts :


    Also calles PES (Problem, Etiology, Signs and symptoms) format. Actual nursing diagnoses
    can be documented by using the three part statement. Not used for risk diagnosis.

    E.g: - Pain r/t surgical incision as evidenced by verbalization

    - Hypertermia r/t underlying infectious process as evidenced by temperature 100 F.

    C. Errors In Diagnostic Reasoning

    Nursing Diagnosis Vs Medical Diagnosis


    Nursing Diagnosis Medical Diagnosis
    Care focused Etiology focused
    Identifies risk and problems of the patient Identifies as nearly possible the specific
    clinical entity that is causing illness
    Focused on the signs and symptoms on the The medical diagnosis specify the
    patient and his /her care givers pathology
    Focused on the person and their Focuses on illness
    physiological / psychologic all responses
    to illness
    Eg : Ineffective denial related to difficulty Eg : Myocardial infarction
    coping with new diagnosis of “heart
    attack”

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