Nursing process diagnosis

• Nursing Process

  The nursing process consists of five steps: Assessment, Diagnosis, Planning, Implementation, Evaluation

  
• ADPIE

  An easy way to remember the components of the nursing process
• Nursing Process

  1. Assessment

  2. Diagnosis

  3. Planning

  4. Implementation

  5. Evaluation

  
• Nursing Process

  • Nurses use critical thinking skills to interpret assessed data and identify client problems
  • Diagnosing involves analyzing data, identifying health problems, risks, and strengths, and formulating diagnostic statements about a patient's potential or actual health problem
  • More than one diagnosis is sometimes made for a single patient

  
• NANDA (North American Nursing Diagnosis Association)

  Defines a list of nursing diagnosis
• Nursing Diagnosis


  Consists of 3 parts: Problem, Etiology, Signs and Symptoms
• Nursing Diagnosis

  • Acute pain related to abdominal surgery as evidenced by patient discomfort and pain scale
• Medical Diagnosis

  Nursing Diagnosis
• Nursing Care Process

  1. Nursing Diagnosis

  2. Goals and Outcomes Criteria

  3. Nursing Actions and Nursing Orders

  4. Rationale of Nursing Orders

  5. Evaluation

  
• Evaluation

  • Goal met
  • Goal partially met
  • Goal not met
• Types of Nursing Orders

  • Independent
  • Dependent
  • Interdependent/Collaborative
• Nursing orders are based on scientific basis, cues, and nursing diagnosis
• Patient-centered nursing involves understanding patients as individuals with unique experiences, beliefs, values, preferences, and goals.
• Nurses are responsible for providing holistic care that addresses physical, emotional, social, spiritual, cultural, and environmental factors affecting health.
• Sign and synptoms:

  Defining characteristics manifested by clients
• Problem:

  Statement of clients health problem
• Etiology:

  Causes of health problem