NANDA - I unit 15 copy.pdf

NURSING DIAGNOSIS. DEFINITIONS a statement of a health problem or of a potential problem in the client's health status that a nurse is licensed and competent to treat.  A nursing diagnosis (NDx) may be part of the nursing process and is a clinical judgment concerning human response to heal...

NURSING DIAGNOSIS. DEFINITIONS a statement of a health problem or of a potential problem in the client's health status that a nurse is licensed and competent to treat.  A nursing diagnosis (NDx) may be part of the nursing process and is a clinical judgment concerning human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.  DEFINITIONS  Nursing diagnosis is defined as “a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.” (Herdman, 2012, p. 515).  A NURSING DIAGNOSIS IS NOT:  Merely a label that you make up that “sounds like” it explains what you are seeing in your patient.  Another way of explaining the medical diagnosis, or of renaming a medical condition.  Something that “goes with a particular medical diagnosis” CONT..  Theyare not medical treatment prescribed by physician  They not diagnostic studies  Theyare not the problems that the nurse experiences while caring for the patient WHAT ARE THEY?..  Theyare the patient’s actual and potential health problems that are amenable to resolution by independent nursing actions  Nursing diagnoses that are stated in terms of specific problems of the patient will guide the nurse in the development of care plans  PURPOSES o Helps identify nursing priorities and help direct nursing interventions based on identified priorities.  Helps the formulation of expected outcomes for quality assurance requirements of third-party payers.  Nursing diagnoses help 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. CONT..  Provides a common language and forms a basis for communication and understanding between nursing professionals and the health care team.  Provides a basis of evaluation to determine if nursing care was beneficial to the client and cost-effective.  For nursing students, nursing diagnoses are an effective teaching tool to help sharpen their problem-solving and critical thinking skills.  CONT…  It fostered the development of autonomy and accountability in nursing  It helps to delineated to scope of practice.  standards of practice have become increasingly more definitive and collaboration of nursing with other disciplines has been facilitated  DIFFERENCE BETWEEN MEDICAL AND NURSING DIAGNOSES ❑ Nursing diagnosis applies to the label when nurses assign meaning to collected data appropriately Labeled with NANDA - I (North American Nursing Diagnosis Association) approved nursing diagnosis. For example, during the assessment, the nurse may recognize that the client is feeling anxious, fearful, and finds it difficult to sleep. it is those problems which are labeled with nursing diagnoses: respectively, anxiety, fear, and disturbed sleep pattern.  CONT.. A medical diagnosis, on the other hand, is made by the physician or advance health care practitioner that deals more with the disease, medical condition, or pathological state only a practitioner can treat. Moreover, through experience and know-how, the specific and precise clinical entity that might be the possible cause of the illness will then be undertaken by the doctor, therefore, providing the proper medication that would cure the illness. CONT..  Examples of medical diagnoses are Diabetes Mellitus, Tuberculosis, Amputation, Hepatitis, and Chronic Kidney Disease. The medical diagnosis normally does not change.  Nurses are required to follow the physician’s orders and carry out prescribed treatments and therapies TYPES OF NURSING DIAGNOSES  The four types of NANDA nursing diagnosis are , 1.Actual (Problem-Focused), 2.Risk, 3.Health promotion, and 4.Syndrome. Here are the four categories of nursing diagnosis provided by the NANDA-I system. CONT.. A problem-focused diagnosis (also known as actual diagnosis) is a client problem that is present at the time of the nursing assessment. These diagnoses are based on the presence of associated signs and symptom.  Examples of actual nursing diagnosis are,  Ineffective Breathing Pattern  Anxiety  Acute Pain  Impaired Skin Integrity. CONT…  Problem-focused nursing diagnoses have three components: (1) nursing diagnosis, (2) related factors, and (3) defining characteristics. CONT..  Risk Nursing Diagnosis  The second type of nursing diagnosis is called risk nursing diagnosis. These are clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. The individual (or group) is more susceptible to develop the problem than others in the same or a similar situation because of risk factors. CONT…  Components of a risk nursing diagnosis include:  (1) risk diagnostic label, and  (2) risk factors.  Examples are:  Risk for Falls  Risk for Injury CONT…  Health Promotion Diagnosis  Health promotion diagnosis (also known as wellness diagnosis) is a clinical judgment about motivation and desire to increase well- being. Health promotion diagnosis is concerned in the individual, family, or community transition from a specific level of wellness to a higher level of wellness. CONT…  Components of a health promotion diagnosis generally include only the diagnostic label or a one-part-statement.  Examples are:  Readiness for Enhanced Spiritual Well Being  Readiness for Enhanced Family Coping  Readiness for Enhanced Parenting  CONT…  Syndrome Diagnosis  A syndrome diagnosis is a clinical judgment concerning with a cluster of problem or risk nursing diagnoses that are predicted to present because of a certain situation or event.  They, too, are written as a one-part statement requiring only the diagnostic label.  Examples of a syndrome nursing diagnosis are:  Chronic Pain Syndrome  Post-trauma Syndrome  Frail Elderly Syndrome POSSIBLE NURSING DIAGNOSIS o A possible nursing diagnosis is not a type of diagnosis as are actual, risk, health promotion, and syndrome. o Possible nursing diagnoses are statements describing a suspected problem for which additional data are needed to confirm or rule out the suspected problem. o Examples include  Possible Chronic Low Self-Esteem  Possible Social Isolation.  COMPONENTS OF A NURSING DIAGNOSIS A nursing diagnosis has typically three components: (1) the problem and its definition, (2) the etiology, and (3) the defining characteristics.  THE PROBLEM STATEMENT o The problem statement, or the diagnostic label, describes the client’s health problem or response for which nursing therapy is given as concisely as possible o A diagnostic label usually has two parts: qualifier and focus of the diagnosis. o Qualifiers (also called modifiers) are words that have been added to some diagnostic labels to give additional meaning, limit or specify the diagnostic statement.. CONT..  Exempted in this rule are one-word nursing diagnoses (e.g., Anxiety, Fatigue, Nausea) where their qualifier and focus are inherent in the one term  PROBLEMS TO AVOID IN WRITING THIS PART o DO NOT use the medical diagnosis  Must be a problem the nurse and/or client can change to do something about  Relating the problem to an unchangeable situation  Don’t confuse the etiology with the problem  Focus on the human responses to the problem  Avoid the use of one piece of assessment data as a NDX (EDEMA) CONT…  Be specific  Don’t combine NDX  Don’t relate one NDX to another. There is a different related to factor if this is a valid NDX  Nursing interventions should not be included in the NDX  Keep your language non-judgmental  Don’t make assumptions or statements you can’t prove with assessment data  Be sure your statement is legally advisable  CONT.. Qualifier Focus of the Diagnosis Deficient Fluid volume Nutrition: Less Than Imbalanced Body Requirements Impaired Gas Exchange Ineffective Tissue Perfusion Risk for Injury  ETIOLOGY  The etiology, or related factors and risk factors, component of a nursing diagnosis label 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. Nursing interventions should be aimed at etiological factors in order to remove the underlying cause of the nursing diagnosis. Etiology is linked with the problem statement with the phrase “as related to”. PROBLEMS TO AVOID IN WRITING THIS PART  DO NOT use the medical diagnosis  Must be a problem the nurse and/or client can change to do something about  DEFINING CHARACTERISTICS Defining characteristics are the clusters of signs and symptoms that indicate the presence of a particular diagnostic label. In actual nursing diagnoses, the defining characteristics are the identified signs and symptoms of the client. For risk nursing diagnosis, no signs and symptoms are present therefore the factors that cause the client to be more susceptible to the problem form the etiology of a risk nursing diagnosis. Defining characteristics are written “as evidenced by” or “as manifested by” in the diagnostic statement. CONT..  Must have at least the major defining characteristics as listed in the taxonomy and minor characteristics will help support the nursing diagnosis HOW TO WRITE A NURSING DIAGNOSIS? Diagnostic statements can be one-part, two-part, or three- part statements. A common format used when writing or formulating nursing diagnosis is the PES format  ONE-PART NURSING DIAGNOSIS STATEMENT ❖ Health promotion nursing diagnoses are usually written as one-part statements because related factors are always the same: motivated to achieve a higher level of wellness though related factors may be used to improve the of the chosen diagnosis. ❖ Syndrome diagnoses also have no related factors. ❖ Examples of one-part nursing diagnosis statement include:  Readiness for Enhance Breastfeeding  Readiness for Enhanced Coping  Rape Trauma Syndrome TWO-PART NURSING DIAGNOSIS STATEMENT  Risk and possible nursing diagnoses have two- part statements: the first part is the diagnostic label and the second is the validation for a risk nursing diagnosis or the presence of risk factors. It’s not possible to have a third part for risk or possible diagnoses because signs and symptoms do not exist. Examples of two-part nursing diagnosis statement include:  Risk for Infection related to compromised host defenses  Risk for Injury related to abnormal blood profile  Possible Social Isolation related to unknown etiology THREE-PART NURSING DIAGNOSIS STATEMENT  Anactual or problem nursing diagnosis have three-part statements: diagnostic label, contributing factor (“related to”), and signs and symptoms (“as evidenced by”). Three-part nursing diagnosis statement is also called the PES format which includes the Problem, Etiology, and Signs and Symptoms. CONT…  Examples of three-part nursing diagnosis statement include:  Impaired Physical Mobility related to decreased muscle control as evidenced by inability to control lower extremities.  Acute Pain related to tissue ischemia as evidenced by statement of “I feel severe pain on my chest!”  Variations in writing nursing diagnosis statement formats include the following:  Using “secondary to” to divide the etiology into two parts to make the diagnostic statement more descriptive and useful. Following the “secondary to” is often a pathophysiologic or diseases process or a medical diagnosis. For example, Risk for Decreased Cardiac Output related to reduced preload secondary to myocardial infarction  NANDA INTERNATIONAL  NANDA nursing diagnosis list is made by NANDA International which stands for North American Nursing Diagnosis Association.  This association was founded in 1982 for the purpose of standardising the nursing terminology.  The association develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnoses CONT…  The term nursing diagnosis was first mentioned in the nursing literature in the 1950s.  In 1973, NANDA’s first national conference was held to formally identify, develop, and classify nursing diagnoses. Subsequent national conferences occurred in 1975, in 1980, and every two years thereafter.  In recognition of the participation of nurses in the United States and Canada, in 1982 the group accepted the name North American Nursing Diagnosis Association (NANDA).  Taxonomy II has three levels: domain, classes, and nursing diagnoses. CLASSIFICATIONS Taxonomy I Taxonomy II Has 3 levels Domain , classes , and nursing diagnosis Domain 1 : Health promotion Domain 2: Nutrition Domain 3: Elimination and Exchange Domain 4: Activity / Rest Domain 5: Perception and cognition CONT…  Domain 6: Self perception  Domain 7: Role relationships  Domain 8: Sexuality  Domain 9: Coping stress tolerance  Domain 10: Life principles  Domain 11: Safety and protection  Domain 12: Comfort  Domain 13: Growth and development  Example for classes Domain 12:Comfort Class 1 : physical comfort class 2 : environmental comfort class 3: social comfort CONT…  Class 1 : physical comfort ( of domain 12)  Impaired comfort 00214  Readiness for enhanced comfort 00183  Nausea 00134  Acute pain 00132  Chronic pain 00133  Labor pain 00256  Chronic pain syndrome 00255  NURSING DIAGNOSIS LIST  Activity Intolerance: Insufficient physiologic or psychological energy to endure or complete required or desired daily activities.  Acute Confusion: Abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness, or the sleep/wake cycle.  Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months.  Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.  Bowel Incontinence: Change in normal bowel habits characterized by involuntary passage of stool  Caregiver Role Strain: Difficulty in performing family caregiver role.  Chronic Confusion: An irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli, decreased capacity for intellectual thought processes, and manifested by disturbances of memory, orientation, and behavior.  Chronic Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage…a duration of greater than 6 months.  Constipation: Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool.  Constipation: Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool.  Decreased Cardiac Output: Inadequate blood pumped by the heart to meet the metabolic demands of the body.  Deficient Fluid Volume: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium.  Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.  Diarrhea: This nursing diagnosis is defined as passage of loose, unformed stools.  Disturbed Body I mage: Confusion in mental picture of one’s physical self.  Excess Fluid Volume: Increased isotonic fluid retention.  Fatigue: An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at usual level.  Fear: Response to perceived threat that is consciously recognized as danger.  Grieving: A normal complex process that includes emotional, physical, spiritual, social, and intellectual responses and behaviors by which individuals, families, and communities incorporate an actual, anticipated, or perceived loss into their daily lives.  Hopelessness: Subjective state in which an individual sees limited or no alternatives or personal choices available and is unable to mobilize energy on own behalf.  Hyperthermia: Body temperature elevated above normal range.  Hypothermia: Body temperature below normal range.  Imbalanced Nutrition: Less Than Body Requirements: Intake of nutrients insufficient to meet metabolic needs.  Imbalanced Nutrition: More Than Body Requirements: Intake of nutrients that exceeds metabolic needs.  Impaired Gas Exchange: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.  Impaired Oral Mucous Membrane: Disruption of the lips and/or soft tissue of the oral cavity.  Impaired Physical Mobility: Limitation in independent, purposeful physical movement of the body or of one or more extremities.  Impaired Swallowing: Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function.  Impaired Tissue (Skin) Integrity: Damage to mucous membrane, corneal, integumentary, or subcutaneous tissues.  Impaired Urinary Elimination: Dysfunction in urinary elimination  Impaired Verbal Communication: Decreased, reduced, delayed, or absent ability to receive, process, transmit, and use a system of symbols.  Ineffective Airway Clearance: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway.  Ineffective Breathing Pattern: Inspiration and/or expiration that does not provide adequate ventilation.  Ineffective Coping: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources.  Ineffective Tissue Perfusion: Decrease in oxygen, resulting in failure to nourish tissues at capillary level.  Latex Allergy Response: A hypertensive reaction to natural latex rubber products.  Nausea: An unpleasant, wavelike sensation in the back of the throat, epigastrium, or throughout the abdomen that may or may not lead to vomiting.  Powerlessness: Perception that one’s own action will not significantly affect an outcome; a perceived lack of control over a current situation or immediate happening.  Rape Trauma Syndrome: Sustained maladaptive response, violent sexual penetration against the victim’s will and consent.  Risk for Aspiration: At risk for entry of gastrointestinal secretions, oropharyngeal secretion, solids, or fluids into tracheobronchial passages.  Risk for Electrolyte Imbalance: At risk for change in serum electrolyte levels that may compromise health.  Risk for Falls: Increased susceptibility to falling that may cause physical harm.  Risk for Impaired Skin Integrity: At risk for skin being adversely altered.  Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.  Risk for Suicide: At risk for self-inflicted, life- threatening injury.  Risk for Unstable Blood Glucose Level: Risk for variation of blood glucose/sugar levels from the normal range.  Urinary Incontinence, Stress: Sudden leakage of urine with activities that increase intraabdominal pressure.  Urinary Incontinence, Urge: Involuntary passage of urine occurring soon after a strong sense of urgency to void.  Urinary Retention: Incomplete emptying of the bladder. THANK YOU