1. Nursing Diagnosis

2. Definition of Nursing Diagnsis
A nursing diagnosis is a statement of the high risk or actual problems in the client’s health status that the nurse is licensed and competent to treat

5. Components of Analysis Phase
3 major components of analysis phase:
Analysis and interpretation of data
Validation of data
Clustering of data
Identification of problems/health care needs
Formulation of nursing diagnosis statement

10. Nursing Diagnostic Statement
Derived from actual or potential problems
Derived from physiological, sociocultural, developmental, and spiritual dimensions of client
Focus: Helping client to achieve a maximal level of wellness and highest level of independence

11. Categories of nursing diagnoses

12. Nursing diagnoses? What’s up with that?
Nursing diagnoses are what you get when you finish your assessment and look at your data.
Nursing diagnoses describe patient needs or responses to health conditions and treatments
Nursing diagnoses reflect the patient’s level of health or response to disease, emotional state, socio-cultural phenomenon, or developmental stage

13. Medical vs. nursing diagnoses
Medical diagnosis- Identifies disease or pathology
Nursing diagnosis- Identifies patient’s response to said disease or pathology
Medical diagnosis goal- to cure the disease
Nursing diagnosis goal- to direct the nursing plan of care to meet the patient’s needs

16. This nurse is validating the cues collected from this client during the assessment phase.

18. Nursing diagnoses
Help facilitate communication between members of the nursing staff
Help prioritize the needs of the patient
Help to guide charting

19. In practice, you…
Do your assessment and think “My patient is in pain!”
Take your impressions and put fancy labels on them like “impaired comfort” or “acute pain”
Those are nursing diagnoses in a nutshell

20. You got to stick with NANDA!
Unfortunately, you are not allowed to make up new and creative nursing diagnoses for your patients
No matter how much your patient merits a nursing diagnosis of “persistent stupidity” or “constant whining” you just can’t do it!
Some authors like Carpenito have developed nursing diagnoses similar to NANDA’s, but the OU SON professors require only NANDA diagnoses for your care plans and papers

21. Writing nursing diagnoses
The first part is the NANDA nursing diagnosis statement
If your patient doesn’t meet the criteria for the diagnosis yet, you put “Risk for…” in front of the diagnosis
Risk for nausea
Risk for deficient fluid volume
After the diagnosis, you put why you chose the diagnosis for the patient with a “related to” (R/T) statement…
Risk for nausea R/T side effects from chemotherapy medications
Risk for deficient fluid volume R/T poor fluid intake and high temperature
Sleep deprivation R/T busy ICU environment

23. Writing “related to” statements
Don’t put medical diagnoses or diagnostic tests like pneumonia, hip fracture, or angioplasty in the “related to” statement.
Do put factors that you can take care of with nursing interventions…
BAD
BETTER!!
Impaired gas exchange R/T increased blood CO2 levels
Impaired gas exchange R/T shallow breathing postop
Diarrhea R/T C. difficile infection
Diarrhea R/T food intolerance
Acute pain R/T hip fracture
Acute pain R/T swelling and tissue damage

24. More examples… Bad Good Why?? Risk for aspiration R/T stroke
Risk for aspiration R/T impaired swallowing
Nurses can work with patients to improve swallowing ability
Acute pain R/T hip fracture
Acute pain R/T tissue damage and swelling in right hip
Nurses can give medications to help relieve pain from tissue damage, and provide ice to reduce swelling
Risk for falls R/T Multiple Sclerosis
Risk for falls R/T poor balance and leg weakness
Nurses can help patients with transfers to compensate for poor balance and weakness

26. Care Plan Formats

27. After the R/T statement…
After you say why you chose the diagnosis for the patient with the “related to” statement, include an “as evidenced by” statement that includes specific signs and symptoms of the particular patient
This step is not needed when there is only “Risk for …” diagnoses, as the patient is only at risk for the condition and has not actually developed it yet
You can use “AEB” for “as evidenced by” so that you don’t need to write it out

28. AEB statements Don’t include prejudicial statements such as:
Risk for impaired skin integrity R/T poor hygiene habits, AEB foul stench from perineal area
Instead, you could use:
Risk for impaired skin integrity R/T inability to reach perineal area to clean, AEB patient verbalized need for nursing assistance with perineal care

29. Diagnostic testing…
Don’t use diagnostic tests specifically in nursing diagnoses like:
Anxiety R/T cardiac catheterization, AEB patient statements of uneasiness and nervously pacing floor
Instead, focus on patient responses to the tests:
Anxiety R/T awaiting of cardiac catheterization results, AEB patient statements of uneasiness and nervously pacing floor

30. Phrasing diagnoses
Don’t use blaming phrases or ones that could imply negligence or malpractice, like:
Excess fluid volume R/T IV infused too quickly
Acute pain R/T improper placement of epidural catheter
Don’t overload diagnoses…
Constipation and abdominal pain should be 2 different nursing diagnoses
Noncompliance and knowledge deficit should be 2 different diagnoses