nursing diagnoses tutorial
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The NURSING
DIAGNOSES StatementNursing 50
April 27, 2006
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What is a Nursing DiagnosisStatement?
A clinical judgmentabout actual orpotential health
problems or lifeprocesses
A standardizedstatement by NANDA
(North AmericanNursing DiagnosisAssociation)
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NANDA
You can find NANDAapproved nursing diagnosesin a nursing diagnosis book
There is a list in the Appendix
of the Nursing Process inAction text (but that is anoutdated list!!)
You can use a nursingreference card from Taberswhich also includes the latestNANDA approved nursingdiagnosis list
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NANDA Approved Nursing Dx isNOT a Medical Dx
Remember that anursing diagnosis isNOT the same as amedical diagnosis
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Nursing Diagnosis vs MedicalDiagnosis
Hypotension -- Medical Diagnosis
Tissue perfusion, ineffective (cardiopulmonary)Nursing Diagnosis
Congestive heart failure -- Medical Diagnosis
Cardiac output, decreased -- Nursing Diagnosis
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Nursing Diagnosis StatementThe Three Parts
Starts with a NANDAapproved nursingdiagnosis (Problem)
HasE
tiology or R/T(related to) phase oretiology
Has Symptom section
which gives definingcharacteristics orsymptoms you identify inthe assessment of thepatient
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Any other parts???
You may (but dont haveto) add a furtherdescriptor to the end of
your nursing diagnosisstatement
Secondary To (2)followed by a medical
diagnosis that furtherdescribes the etiology orsymptoms
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Problem
Use the exact NANDA wording to state theproblem
Examples Poor sleep pattern -- wrong
Sleep Pattern, disturbed -- correct
Poor circulation -- wrong
Tissue perfusion, ineffective(cardiopulmonary) -- correct
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Etiology
This is the related to phrase thatdescribes the cause or contributor to theproblem
The etiology is usually at the cellular level
Think to yourself what is going on inside that causes the
problem?
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Etiology
Indicates what may be causing or
contributing to the nursing diagnosis
Helps you plan your nursing interventions
(NICs) If due to impaired venous and arterial
circulation you could elevate and extremity
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Etiology what does this part looklike?
Examples for Tissue perfusion, ineffective
(peripheral),
R/T poor circulation -- Wrong
R/T poor blood flow due to congested veins andarteries and cellular damage in tissuesCorrect
R/T edema in LLLWrong
R/T interruption of arterial flow and venous flow andimbalance of interstitial fluids -- Correct
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So far, what would this look like?
Tissue perfusion, ineffective (peripheral),R/T interruption of arterial and venous flow& imbalance of interstitial fluids,
Now you are ready to add on the last partof the nursing diagnosis statement
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Symptoms
This is the defining characteristics you identify inthe patient assessment
It is your as evidenced by statement (AEB)
Examples Edema
Positive Homans sign
Poor hair distribution on extremities
Skin discoloration Skin temperature changes
Diminished pulses
Abnormal labs that back you up
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Symptoms
The third part of a three-part nursingdiagnosis statement
AEB is used to connect this section to theR/T section (second-part of nursingdiagnosis statement)
It is what you assessed that got you tochoose the nursing diagnosis to beginwith!
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Symptoms
So lets finish that nursing diagnosis
statement!
Tissue perfusion, ineffective (peripheral),R/T interruption of arterial and venous flow& imbalance of interstitial fluids,AEB LLEedema, weak peripheral pulses, and lowalbumin level.
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Could we add the 2 part???
Yes, it adds clarity and strength to theentire nursing diagnosis statement
Remember this part is where you can puta medical diagnosis
Example
2 DM type II
2 Htn
2 CHF
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All together now!
Tissue perfusion, ineffective (peripheral),R/Tinterruption of arterial and venous flow &imbalance of interstitial fluids,AEB LLE edema,
weak peripheral pulses, and low albumin level,2 to DM type II and PVD.
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YOU DID IT!!!
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Tips
Practice, practice, practice!
Get to know the referencebook you will be using
Nursing Diagnosis Handbook
Textbook
Always be precise when youwrite out the nursing diagnosisso it gets familiar.
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Using Nursing Diagnoses Books
Books are different, so decide if in yourbook you will be looking up a
Symptom Dyspnea
Fatigue
Dysrhythmia
Or a medical diagnosis
COPD
Diabetes Mellitus Type II
First degree AV Block
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STEP ONE:Find the Assessment Finding
For example, you findthat your patient has
had a stroke. There is weakness
There is difficultyswallowing
There is anxiety
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NowSTEP TWO
Based on the
assessment findingyou will need to findthe appropriatenursing diagnosis or
diagnoses
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Weakness
Weakness is a symptom not anursing diagnosis
From the symptom of
weaknesswhat nursingdiagnosis would be appropriate?
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Possible Nursing Diagnoses forWeakness
Disuse Syndrome, risk for
Mobility, impaired bed
Mobility, impaired wheelchair
Walking, impaired
Transfer Ability, impaired
Falls, risk for
Injury, risk for
Mobility, impaired physical
Skin Integrity, risk for impaired
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Choosing the Nursing Diagnosis
Out of all those listed for weakness
Which one meets your specific patient needsthe best?
Which one is most important in regards toyour patient?
Any of them A-B-C related? (always mostimportant)
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After you choose
You need to then put onthe next two parts of thenursing diagnosis
statement Etiology (R/T statement)
Symptoms (AEBstatement)
Add the Secondary To(2) if applicable andhelpful for clarity
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Lets Try Another Example
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Difficulty Swallowing (Dysphagia)
Dysphagia is a symptom, nota nursing diagnosis.
From the symptom ofdysphagiawhat nursing
diagnosis would be
appropriate?
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Possible Nursing Diagnoses forDysphagia
Swallowing, impaired
Aspiration, risk for
Sensory perception, disturbed (gustatory)
Self-care deficit: feeding
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Choosing the Nursing Diagnosis
Out of all those listed for dysphagia
Which one meets your specific patient needsthe best?
Which one is most important in regards toyour patient?
Any of them A-B-C related? (always most
important)
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After you choose
You need to then put onthe next two parts of thenursing diagnosis
statement Etiology (R/T statement)
Symptoms (AEBstatement)
Add the Secondary To(2) if applicable andhelpful for clarity
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Lets Try One More
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Anxiety
Anxiety is a symptom, and anursing diagnosis! (just tothrow you a curve!)
From the symptom ofanxietywhat nursing
diagnosis would beappropriate?
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Possible Nursing Diagnoses forAnxiety
Anxiety (specify level)
Anxiety, deathCoping, ineffective
Grieving, dysfunctional
Spiritual Distress Spiritual Distress, risk for
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After you choose
You need to then put onthe next two parts of thenursing diagnosis
statement Etiology (R/T statement)
Symptoms (AEBstatement)
Add the Secondary To(2) if applicable andhelpful for clarity
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Anything Else?
When care planning: Now that you have your three-part nursing
diagnosis statement (and maybe a secondaryto statement) you are ready to decide on NOC (Nursing Outcomes Classifications)
What you want your patient outcome to be
NIC (Nursing Interventions Classifications) What your intervention is to get the patient to that
outcome
NOCs and NICs will be covered in depth in aseparate tutorial
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Also!
When care planning
Dont forget toevaluate if youroutcomes wereachieved
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In summary
A nursing diagnosis statementhas at least three parts
P choose the nursing diagnosis
label based on the problem E the etiology of the problem,
listed as a R/T statement
S the symptoms you assess that
back you up 2 statement (medical diagnosis) if
it adds clarity to your nursingdiagnosis statement and has directcorrelation
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Practice and you will be a winner
with nursing diagnoses statements!