1. Diagnosing
Diagnosis: the statement or conclusion regarding the nature of a phenomenon
Diagnostic labels:Standardised NANDA names for the diagnosis.
Nursing Diagnosis: problem statement (Diagnostic labels + etiology)

2. Nursing Diagnoses provide a basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable
Registered nurses are responsible for making nursing diagnoses
Ng Dx. Includes only those health states that nurses educated and licensed to treat .

3. Types of Ng. Dx.
An actual diagnosis: Present at time of assessment (Ineffective Breathing Pattern) (Anxiety)
A risk Ng. Dx. : CJ that problem does not exist, but risk factors indicate that a problem is likely to develop (Risk for infection)

4. A wellness Dx. (Readiness for enhanced family coping)
Possible Ng Dx. : incomplete evidence about a health problem (Possible social isolation related to unknown etiology)

5. A syndrome Dx: Associated with a cluster of other DX
A syndrome Dx: Associated with a cluster of other DX. (Bed ridden patients= Risk for impaired tissue integrity, risk for infection….)

6. Components of Ng Dx
Problem statement (Deficient, Impaired, Decreased, Ineffective)
Etiology (related factors, risk factors)
Defining Ch.Ch. (S+S)

7. EXAMPLE Ineffective Breathing r/to bed rest and immobility.
Defining ChCh. = verbal report of fatigue or weakness, abnormal respiratory rate and respiratory activity, Dyspnea.

8. Ng Dx and Medical Dx Ng Dx Medical Dx Nurse licensed to treat
Physician licensed to treat
Describes client’s physical, socio-cultural, psychological, and spiritual responses to illness or health problem
Refers to disease process

9. Dependent functions
Independent functions
Collaborative problem: potential problems that nurses manage using both independent and dependent interventions (Potential complication of HTN: CVA, immobility….)

10. Diagnostic Process Analyse data Identify problem Formulate Dx
* Elimination:
* Decreased Urinary Frequency and
amount/ 2 days
* Fluid volume deficit
* Impaired Urinary elimination r/t insufficient fluids intake, fluid loss, fever, diaphoresis, anorexia

11. Examples of Ng Dx.
Constipation r/to prolonged (complete) bed rest. Basic two-part Dx. Statement
Noncompliance (diabetic diet) r/to unresolved anger about diagnosis as manifested by (subjective: I forget to take my pills, objective: weight gain of 5 kg.). Basic three-part Dx. Statement.
Risk for impaired skin integrity (Left lateral ankle) r/to decreased peripheral circulation secondary to diabetes.

13. Fluid replacement r/to fever .
Need vs response
Deficient fluid volume r/to fever
Pain r/to sever headache.
Cause and effect
Pain: Sever headache r/to fear of addiction to narcotics

14. Impaired skin integrity r/to bad positioning
Judgmental
Impaired skin integrity r/to immobility

15. Risk of acute Myocardial infarction
Medical Dx
Potential complication of AMI: Ineffective airway clearance