nursing diagnoses tutorial

8/2/2019 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






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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






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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!

nursing diagnoses tutorial

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