Nursing Diagnosis

Nursing Diagnosis

Nursing Diagnosis

A nursing diagnosis such as acute pain or nausea is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat. What makes the nursing diagnostic process unique is having patients involved, when possible, in the process. North American Nursing Diagnosis Association International (NANDA-I) - group that researches and creates nursing diagnosis

PES format

The PES format creates a diagnosis that is more patient specific. PES stands for Problem, Etiology, and SymptomsP (problem): NANDA-I label (ex. impaired physical mobility)E (etiology or related factor): (ex. incisional pain)S (symptoms or defining characteristics): briefly lists defining characteristics that show evidence of the health problem (ex. evidenced by restricted turning and positioning PES diagnostic statement: impaired physical mobility related to incisional pain, evidenced by restricted turning and positioning

Sources of Diagnostic Error

Collecting lack of knowledge or skill inaccurate data missing data disorganization Interpreting inaccurate interpretation of cues failure to consider conflicting cues using an insufficient number of cues using unreliable or invalid cues failure to consider cultural influences or developmental stages Clustering  insufficient cluster of cues premature or early closure incorrect clustering  Labeling wrong diagnostic label selected  evidence that another diagnosis is more likely condition a collaborative problem failure to validate nursing diagnosis with patient failure to seek guidance

Nursing Diagnostic Process and Critical thinking

Nursing Process - ongoing process Assessment  Diagnosis Planning Implementation  Evaluation  Knowledge - underlying disease process, normal growth and development, normal physiology and psychology, normal assessment findings, health promotion.Standards - ANA scope of Nursing Practice, intellectual standards of measurement, patient-centered careAttitudes - critical thinking (ex. perseverance, confidence)Experience - previous patient care experience, validation of assessment findings, observation of assessment techniques

Purpose of Planning

ordering of nursing diagnoses helps nurses anticipate and sequence interventions  classification of priorities patient-centered care ethical care set time limits with goals  measurable criteria 

Goals of Care

Patient-centered goal short term goal long term goal partner with patient  measurable and reasonalbe goals

Nursing Outcomes

nursing sensitive patient outcome is a measurable patient, family, or community state behavior, or perception largely influenced by and sensitive to nursing interventions 

Domains of Nursing Practice

the helping role the teaching-coaching function the diagnostic and patient monitoring function effective management of rapidly changing situations administering and monitoring therapeutic interventions and regimens  monitoring and ensuring the quality of health care practices  organizational and work role competencies