Nursing Diagnoses New

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Outline

Introduction
Objective
Definition of concepts
Nursing diagnoses Vs Medical diagnoses
Components of nursing diagnosis
Types of nursing diagnosis
Collaborative problem

Summary NURSING diagnosis 2


Introduction
Transition from assessment to nursing diagnoses

Data Data Organizing


data in Making inferences
collection validation
cluster

Writing nursing diagnostic Consult


Statement NANADA

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Session objectives

After completing this session, the trainees will be able


to
• Describe nursing diagnoses

• Distinguish nursing diagnoses from medical


diagnoses
• Identify Collaborative problems

• Formulate various kinds of nursing diagnoses


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Definition of concepts

Nursing Diagnosis

 Is a clinical judgment about individual, family, or

community responses to actual or potential health

problems/life processes.

 Nurses legally prescribe definitive interventions

independently for these problems

 Provide the basis for selection of nursing interventions


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Definitions cont’d..

NANDA: North American Nursing Diagnoses


Association
• It is a professional organization of nurses that
standardizes nursing terminology that develops
researches, disseminates and refines the nomenclature,
criteria, and taxonomy of nursing

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Breakout

Exercise 3.1: Nursing diagnoses Vs Medical


diagnosis ?
Instruction : Make 4 groups
Discuss

Time allotted: 5 min


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Nursing Diagnosis Vs Medical Diagnosis

Nursing Diagnosis Medical Diagnosis

Within the scope of nursing Within the scope of medical


practice practice

Identify responses to health and Focuses on curing pathology


illness

Stays the same as long as the Can change from day to day
disease is present

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Nursing Diagnosis Vs Medical Diagnosis

Nursing Diagnosis Medical Diagnosis

Focus on human response Focus on diseases

Treatment initiated By Treatment directed


independently by nurses primarily by physician and can
be carried out by nurse

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Components of a nursing diagnosis

1. Diagnostic label: descriptive words and diagnostic

focus

– The name of the nursing diagnosis listed in

NANDA.

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Components of a nursing diagnosis
Descriptive words Diagnostic focus
• Pain
• Acute
• Fluid volume
• Chronic • Body image
• Deficient
• Disturbed
• Dysfunctional
• Enhanced, etc

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Components of a nursing diagnosis

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Components of a nursing diagnosis
2. Related factors
– Related factors are etiologies, circumstances, facts, or

influences that have some type of relationship with the

nursing diagnosis (e.g., cause, contributing factor).

– Linked with problem by Related to

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Components of a nursing
diagnosis….
3. Defining characteristics:

• Signs and symptoms/ subjective and objective

data/clinical manifestations

• Joined to the first components with the

connecting phrase “as evidenced by” (AEB).


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Types of nursing diagnosis

1. Actual nursing diagnosis

2. Risk nursing diagnosis

3. Possible nursing diagnosis

4. Wellness nursing diagnosis :

5. Syndromic nursing diagnosis


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Types of nursing diagnosis cont’d

1.Actual nursing diagnosis:


• a problem that has been validated by the presence of
major defining characteristics.

2. Risk diagnosis

 Shows vulnerability to develop the problem

 is likely to develop if you do not intervene to prevent

it

 It is characterized by the presence of risk factors

rather than defining characteristics


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Types of nursing diagnosis…
3.Possible nursing diagnosis:

when not enough evidence supports the presence

of the problem but the nurse thinks that is highly

probable and wants to collect more information.

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Types of nursing diagnosis…
4. Wellness nursing diagnosis

 Shows transition from a specific level of wellness to

a higher level of wellness.


 Two cues required : a desire for increased wellness

and effective present status or function

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Wellness nursing diagnosis…

 useful for healthy clients, such as school children

or new parents, who require teaching for health


promotion, disease prevention, and personal
growth.
These types of diagnostic statements do not

contain related factors, but rather contain the


label only.

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Types of nursing diagnosis cont’d

5. Syndromic nursing diagnosis


 A cluster or group of nursing diagnoses that
almost always occur together.
EG.
• Rape Trauma Syndrome
• Disuse Syndrome
• Post-trauma Syndrome
• Relocation Stress Syndrome

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Rules for Writing Diagnostic
Statements
1. Actual Diagnoses-
• using the PRS /PES format (Problem, Related
factors, and Signs and Symptoms). Use the words
“related to” and “As evidenced by” to link the parts.

Diagnostic Related Related Defining


label As evidenced /as
to factor characteristics
Or manifested by
Or Or
Problem Etiology Sign and
symptoms

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Rules for Writing Diagnostic Statements
2. High Risk/potential Nursing Diagnoses

• Use a two-part statement, using “related to” to link


the potential problem with the risk factors present.

Risk for
Or Diagnostic Risk factor
Related to
High risk label Or
for Or Etiology
Problem

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High Risk/potential Nursing
Diagnoses…
The statement should answer the question, “What

can I do about this problem?” The second part

of the statement (related factors) directs

interventions. If not possible, the problem directs

the intervention.

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High Risk/potential Nursing
Diagnoses…
Examples:

Right: High Risk for Ineffective Airway Clearance

related to copious thick secretions.

Wrong: High Risk for Ineffective Airway

clearance related to Pneumonia

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Rules for Writing Diagnostic Statements
3. Possible Diagnoses:

 list suspected problem and cause

Diagnostic
Possible label
Related to
Or
Etiology
Problem

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Rules for Writing Diagnostic
Statements for ND
Example: Possible altered sexuality patterns related

to possible fear of transmitting the herpes Virus

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Rules for Writing Diagnostic Statements
4. Wellness nursing diagnosis :

Readiness for
enhanced Diagnostic focus

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Rules for Writing Diagnostic Statements

5. Syndrome nursing diagnosis :

…Syndrome

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Avoiding Errors in Writing Diagnostic Statements

1. Don’t write the diagnostic statement in such a

way that it may be legally incriminating.

• For example, Incorrect- High risk for injury

related to lack of side rails on bed.

• Correct- High risk for injury related to

disorientation.
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Avoiding Errors in Writing
Diagnostic Statements

2. Don’t state the nursing diagnosis using medical


diagnostic terminology; focus on the person’s
response to the medical problems.
• For example: Incorrect- Mastectomy related to
cancer.
• Correct- High Risk for Self-concept Disturbance
related to effects of mastectomy.

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Avoiding Errors in Writing
Diagnostic Statements …

3. Don’t rename a medical problem to make it sound

like a nursing diagnosis.

For Example: Incorrect: Alteration in

Hemodynamics related to hypervolemia.

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Avoiding Errors in Writing Diagnostic
Statements …

4. Don’t state the nursing diagnosis based on a value


judgment. For example:
Incorrect- Spiritual Distress related to atheism as
evidenced by statements that she has never believed
in God.
5. Don’t state two problems at the same time. For
example:
Incorrect- Pain and Fear related to diagnostic
procedures
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Breakout

Group Activities
Instruction : Make 4 groups
Refer exercise on participant manual on page 199
Identify correctly stated nursing diagnosis
Discuss and present
Time allotted: 8 min
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Collaborative problems
• Collaborative problems are complications from a
disease, test, or treatment that nurses cannot treat
independently.
• Nurses focus mainly on monitoring and preventing
such problems.
• Alerts the nurse that the client is either experiencing
or is at high risk to experience the problem.

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Collaborative Problems/Complications…
The focus of nursing accountability for collaborative
problems is three- folds.
Detecting and reporting early signs and symptoms
of potential complications
Implementing Physician prescribed interventions;
Initiating interventions within the nursing domain
to manage the problem.

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Collaborative Problems/Complications…

Ex. Potential complications: paralytic ileus related


to back surgery.
• Arrhythmia, stroke, congestive heart failure
related to MI.

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Nursing Diagnosis versus collaborative
problems
Nursing Diagnosis Collaborative
Problems/Medical
diagnosis
 Focuses on identifying  Focuses on identifying
and treating actual or problems with structure or
potential unhealthy function of organs or
responses to diseases or systems.
life changes.  Related signs and symptoms
 Related signs and don’t respond to nurse-
symptoms respond toNURSING diagnosis
prescribed interventions
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Breakout

Group Activities
Instruction : Make 4 groups

Refer exercise on participant manual on page


Discuss and present
Differentiate nursing Diagnoses from
Collaborative Problems
Time allotted: 5 min

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Breakout

Group Activities
Instruction : Make 4 groups
Refer case study from clinical practice
Discuss and present
Questions
1. List summary of subjective and objective data noted in the case
study
2. Formulate nursing diagnoses
Time allotted: 20 min

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Summary

• Actual nursing diagnosis has three parts


 PES

• Risk diagnosis has two parts


 Risk for P E

• Collaborative problems
 Resolved by both nurse initiated and physician
initiated interventions

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