Nursing Diagnosis

What is an Actual Nursing Diagnosis?
A diagnoses that is defined by signs and symptoms or by defining characteristics.

This represents a diagnoses that has been validated by the presence of major defining characteristics

What are major defining characteristics in a nursing diagnosis?
Your patients signs and symptoms and your data collection (physical assessment). An example of an actual diagnosis would be impaired gas exchange. So your patient is having reparatory problems. Or activity intolerance. Or fluid volume excesses.
What is a risk nursing diagnosis?
Risk diagnosis are clinical judgments for patients, families, or communities of potential problems that may develop. So our patients are vulnerable to develop these problems. i.e. Risk for constipation
What is a possible nursing diagnosis?
These are statements describing a successful problem for which additional data is needed. Additional data is needed in order to confirm or rule out the suspected problem. i.e Imbalanced nutrition – we need more information to make sure that this is a true statement
What is a wellness nursing diagnosis?
Two cues must be present. Number one the desire for a higher level of wellness number, two an effective present status or function. They are doing pretty well but we are going to teach them a little more. An example is readiness for enhanced breastfeeding.
What is a syndrome nursing diagnosis?
Cluster of actual risk diagnosis that are predicted to be present because of a certain event or situation. Example, rape, trauma syndrome, post trauma syndrome.
What are the three parts of an actual nursing diagnosis?
1. Describe the health state or problem of the client as clearly as possible, the cause
2. Identify the etiological factors believed to be related to the problem as a cause or contributing factor – do not use medical diagnosis
3. Defining characteristics, the subjective and objective data that signal the existence of the actual or potential health problem
Example of actual nursing diagnosis of patient with a fracture
Impaired mobility (which is an actual ND) r/t trauma AEB pain in left leg, swelling, and hematoma, x-ray showing fracture.
How many parts are in a Risk nursing diagnosis?
Two parts, “risk for ___, related to _____”
This diagnosis has to start with “Risk for falls related to history of dizziness”
This nursing diagnosis only has two parts.
How many parts does a wellness diagnosis have?
A wellness diagnosis has one part, “Readiness for enhanced…”
To use this diagnosis, two cues must be present in the patient, 1) a desire for a higher level of wellness 2) an effective present status or function
i.e. Readiness for enhanced breastfeeding
What are the four steps in Planning and Outcome Identification?
1. Set priorities for nursing diagnosis according to Maslow’s
2. Identify and write patient outcomes
3. Select evidence based nursing interventions
4. communicate the plan of care
How do you establish priorities?
1. Use Maslow’s hierarchy of human needs
2. Patient preference – what does the patient want the most
3. Consider future problems – what might be future risks?
Setting priorities according to Maslow’s
Mainly the bottom two tiers, physiological, fluid, food, oxygen and elimination, then safety, security, and shelter
High priority?
Harmful if not treated i.e.-respiration
What problems need immediate attention and which ones can wait?
Medium priority?
i.e. impaired skin integrity, these are immediately life threatening but can become so if left untreated
Low priority?
i.e. disturbed sleep pattern
What is a patient outcome?
care plan has diagnoses and then it has goal that is the general aim that we want to see. Lets say its our mobility patient – we want the patient to mobilize that is our goal. The goal is more general than the outcome
What is a patient outcome? (Expected outcome)
A patient outcome is more specific, We can look at the out come and say, yes the client did meet the outcome or no they did not.
Expected outcomes refers to the more specific, measurable criteria used to evaluate if the goal has been met.
What is the primary purpose of outcome identification?
1. It is to design a plan of care for and with the patient that results in the prevention, reduction, or resolution of patient health problems.
2. Provides direction for nursing interventions
3. sets standards of determining the effectiveness of the interventions
4. Provides opportunity for the nurse to work with the patient to achieve goals
What are nursing interventions?
Nursing interventions are what the nurse does to bring about (facilitate) patient goals
What are the three parts of comprehensive planning?
1. Initial planning
2. Ongoing planning
3. Discharge planning
Initial planning is…
Developed by the nurse who performs the admission assessment
-identify goals and related interventions (sometimes in the hospital nurses use a standardized care plan to get things started)
Ongoing planning is…
Carried out by the nurse that is interacting with the patient, she keeps the plan up to date and changes the plan as the patient progresses
Discharge planning is…
Carried out by the nurse who has worked most closely with the patient and with the case managers and social worker, all nurses
What is the definition of a long-term goal?
A goal that takes more than one week to achieve
What is the definition of a short term goal?
A goal that is immediate or takes up to one week to achieve
Patient goals need to be…
Patient centered, “The patient will…”
Nursing interventions are…
Nurse centered
Patient goals or nursing outcomes are…
Specific to the nursing diagnosis, patient centered (the patient will), mutual (if possible) the patient and nurse should agree on the goal, Measurable, specify a time frame
Characteristics of a nursing plan goals
Answer the question who, what action, under what circumstance, how well, and when. Who would be the client, what action – will ambulate, under what circumstances – with a walker, how well – safely, when – before discharge. (subject, verb, condition, performance criteria, time frame), patient demonstrate walking with a walker safely before discharge
What are some examples of non-measurable terms?
Patient will know
Patient will learn
Patient will understand
What are some examples of measurable terms?
Patient will verbalize
Patient will demonstrate
Patient will identify
Client will perform ROM exercises
Patient will drink 6oz water every hour
Goal is a general statement and the outcome makes it…
measurable and specific
What are nursing interventions?
Things that you, the nurse, can do to bring about the outcome or goal.
Nursing interventions are nurse…
Centered
A nursing intervention is…
Any treatment based on clinical judgements and knowledge that a nurse performs to enhance patient outcomes – these are generally evidenced based. START WITH A VERB (don’t say nurse will)
What suggests the nursing intervention to use?
The cause of the problem or the etiology
Do nurse initiated interventions require a doctors order?
No
What are some examples of nursing interventions?
Turn and reposition the patient
Teach deep breathing after surgery
What is a physician initiated intervention that is carried out by a nurse?
Medication administration
Are nurses liable for all interventions that they carry out?
Yes, nurses are liable and you should question an intervention that seems inappropriate.
Nursing interventions always start with…
A verb and they set the timing and frequency of the actions.

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