Diagnosis

• Nursing Process


  1. Assessment

  2. Diagnosing

  3. Planning

  4. Implementation

  5. Evaluation

  
• All steps in the nursing process require critical thinking by the nurse
• Apart from understanding nursing diagnoses and their definitions, the nurse promotes awareness of defining characteristics and behaviors of the diagnoses, related factors to the selected nursing diagnoses, and the interventions suited for treating the diagnoses

  
• Nursing diagnosis


  An effective teaching tool to help sharpen problem-solving and critical thinking skills for nursing students
• Purposes of Nursing Diagnosis

  • Helps identify nursing priorities and helps direct nursing interventions based on identified priorities
  • Helps the formulation of expected outcomes for quality assurance requirements of third-party payers
  • Helps identify how a client or group responds to actual or potential health and life processes and knowing their available resources of strengths that can be drawn upon to prevent or resolve problems
  • Provides a common language and forms a basis for communication and understanding between nursing professionals and the healthcare team
  • Provides a basis of evaluation to determine if nursing care was beneficial to the client and cost-effective

  
• Nursing diagnosis


  A clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community

  
• Nursing diagnosis


  Provides the basis for selecting nursing interventions to achieve outcomes for which the nurse has accountability
• Types of Nursing Diagnoses

  • Problem-focused
  • Risk
  • Health promotion
  • Syndrome
  • Possible nursing diagnoses

  
• Components of a Nursing Diagnosis

  • The problem and its definition
  • Etiology
  • Defining characteristics

  
• Problem statement/diagnostic label


  Describes the client's health problem or response to which nursing therapy is given concisely

  
• Etiology


  Identifies one or more probable causes of the health problem, are the conditions involved in the development of the problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client's care

  
• Risk factors


  Forces that put an individual (or group) at an increased vulnerability to an unhealthy condition
• Defining characteristics


  The clusters of signs and symptoms that indicate the presence of a particular diagnostic label
• Diagnostic Process


  1. Data analysis

  2. Identification of the client's health problems, risks, and strengths

  3. Formulation of diagnostic statements
• Data analysis


  Involves comparing patient data against standards, clustering the cues, and identifying gaps and inconsistencies
• Identifying health problems, risks, and strengths

  Determining whether a problem is a nursing diagnosis, medical diagnosis, or a collaborative problem, and identifying the client's strengths, resources, and abilities to cope

  
• Formulating diagnostic statements

  The process of creating diagnostic statements
• Types of Nursing Diagnosis Statements

  • One-part
  • Two-part
  • Three-part (PES format)

  
• Actual or problem-focused nursing diagnoses have three-part statements: diagnostic label, contributing factor ("related to"), and signs and symptoms ("as evidenced by" or "as manifested by")

  
• Health promotion nursing diagnoses and syndrome diagnoses are usually written as one-part statements because related factors are always the same

  
• Problem Focused Diagnosis

  • This  is a client problem present at the time of the nursing assessment.
  • These diagnoses are based on the presence of associated signs and symptoms.
• Risk Nursing Diagnosis

  • These are clinical judgments that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.
  • A risk diagnosis is based on the patient’s current health status, past health history, and other risk factors that may increase the patient’s likelihood of experiencing a health problem.
• Health Promotion Diagnosis

  
  

  • is a clinical judgment about motivation and desire to increase well-being.
  • Additionally, health promotion diagnosis is concerned with the individual, family, or community transition from a specific level of wellness to a higher level of wellness.
• Syndrome Diagnosis

  • clinical judgment concerning a cluster of problem or risk nursing diagnoses that are predicted to present because of a certain situation or event.
• Possible Nursing Diagnosis

  • is not a type of diagnosis as are actual, risk, health promotion, and syndrome.
  • Possible nursing diagnoses are statements describing a suspected problem for which additional data are needed to confirm or rule out the suspected problem.