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    Name: Indriyani Eka Lani Oematan Nim:01.2.17.00609 English Courses Resume

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    The document discusses nursing diagnosis, including its definition, components, types (positive and negative), and errors in diagnostic reasoning compared to medical diagnosis. Nursing diagnosis is a clinical judgment about a patient's response to health problems and provides a basis for selecting nursing interventions. It consists of the problem, etiology, and defining characteristics or signs and symptoms.

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    Name: Indriyani Eka Lani Oematan Nim:01.2.17.00609 English Courses Resume

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    Eka Oematan
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    The document discusses nursing diagnosis, including its definition, components, types (positive and negative), and errors in diagnostic reasoning compared to medical diagnosis. Nursing diagnosis is a clinical judgment about a patient's response to health problems and provides a basis for selecting nursing interventions. It consists of the problem, etiology, and defining characteristics or signs and symptoms.

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    The document discusses nursing diagnosis, including its definition, components, types (positive and negative), and errors in diagnostic reasoning compared to medical diagnosis. Nursing diagnosis is a clinical judgment about a patient's response to health problems and provides a basis for selecting nursing interventions. It consists of the problem, etiology, and defining characteristics or signs and symptoms.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    20 views3 pages

    Name: Indriyani Eka Lani Oematan Nim:01.2.17.00609 English Courses Resume

    Uploaded by

    Eka Oematan
    The document discusses nursing diagnosis, including its definition, components, types (positive and negative), and errors in diagnostic reasoning compared to medical diagnosis. Nursing diagnosis is a clinical judgment about a patient's response to health problems and provides a basis for selecting nursing interventions. It consists of the problem, etiology, and defining characteristics or signs and symptoms.

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    © All Rights Reserved
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    Download as docx, pdf, or txt
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    Name : Indriyani Eka Lani Oematan

    Nim :01.2.17.00609
    English Courses
    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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