Technologies in Nursing Duquesne University

 First introduced in  In 1953 Fry proposed the formulation of nursing diagnosis.  In 1973, the first national conference was held.  In 1982, NANDA was founded.

 Diagnostic reasoning ◦ A process of using assessment data to create a nursing diagnosis  Defining characteristics ◦ Clinical criteria or assessment findings  Clinical criteria ◦ Objective or subjective signs and symptoms

1. Medical diagnosisA. Clinical judgment about the client in response to an actual or potential health problem 2. Nursing diagnosisB. The identification of a disease condition based on specific evaluation of signs and symptoms 3. Collaborative problemC. An actual or potential complication that nurses monitor to detect a change in client status

1. Actual Nursing Diagnosis A. Describe human responses to levels of wellness that have a readiness for enhancement 2. Risk Nursing Diagnosis B. Describes human responses to health conditions/life processes that may develop 3. Wellness Nursing Diagnosis C. Describes human responses to health conditions or life processes

 Problem  Etiology  Signs and Symptoms

 By learning to make accurate nursing diagnoses, your care plan will help communicate the client’s health care problems to other professionals.  A nursing diagnosis will ensure that you select relevant and appropriate nursing interventions.

 Problem—the name or diagnostic label identified from the NANDA list. This may be an actual problem, a risk (potential) problem, or a wellness diagnosis.

 The suspected cause or reason for the response that has been identified from the assessment

 They are stated “as evidenced by (A.E.B.)” or “as manifested by”, followed by a list of subjective and objective data.  “Risk” problems have no evidence statement.

 Ineffective Airway Clearance, related to increased pulmonary secretions and bronchospasm, evidenced by wheezing, tachypnea, and ineffective cough.  Acute pain related to tissue distention and edema as evidenced by reports of severe colicky pain in right flank, elevated pulse and respirations, and restlessness.

 Hyperthermia related to increased metabolic rate and dehydration as evidenced by elevated temperature, flushed skin, tachycardia, and tachypnea.  Risk for infection, related to broken skin, traumatized tissues, decreased hemoglobin, invasive procedures, increased environmental exposure.

 Risk for skin breakdown related to immobility as evidenced by stage III sacral wound (7 X3 cm)

 Pain related to myocardial infarction as evidenced by patient’s report of pain at 9 on the 1-10 pain scale

 Ineffective airway clearance related to pneumonia as evidenced by adventitious breath sounds, sputum production, and abnormal chest x-ray.

 Fluid volume deficit related to blood loss through wound as evidenced by hemoglobin of 8 and hematocrit of 26%

 Fluid volume deficit related to NPO status as evidenced by weight loss

 Diarrhea related to C. Diff as evidenced by 10 stool in one day

 Risk for infection related to invasive procedure (surgery)

 Readiness for enhanced knowledge of disease process.

 Based on a medical diagnosis  Examples: ◦ Risk for pneumonia related to immobility ◦ Risk for DVT related to immobility ◦ Risk for myocardial infarction related to inadequate tissue perfusion

 Written in general terms  Not behavioral in nature  Patient centered  Example: To enhance airway clearance and improve oxygenation

 Actions that the nurse carries out for the client or encourages the client to do for themselves.  Include interdisciplinary actions, but identify them as such.  Includes assessment  Includes teaching the client  Include the rationale for the intervention.

 Specific  Measurable  Attainable  Realistic  Time oriented

◦ The patient will identify four adaptive/protective measures for individual situation by discharge. ◦ The patient will maintain a patent airway, ongoing. (This outcome is stated as “ongoing” and does not include a specific timeframe other than discharge from care. In this example, this is appropriate because the situation may not resolve until the patient’s condition or status changes or discharge has occurred.)

◦ The patient will be free of skin breakdown. (This is another example of an ongoing outcome). ◦ The patient will demonstrate correct insulin administration techniques within 48 hours.  The patient will attain pain relief identified as a “3” on the 0-10 pain scale 30 minutes after being medicated with pain medication.  The patient will maintain an oxygen saturation of 92 or higher.  The patient will not incur a fall.

 Should refer directly to the nursing diagnosis and to the goal.