NSG 1100 -Nursing Diagnosis

Medical Dx
illnesses/ conditions, verified by medical diagnostic studies
Nsg Dx, rules
address human responses to actual or potential health problems/life processes
focuses on patient responses to illness
PES format
P = Problem/diagnostic label – DX
Based on abnormal assessment data

E = Etiology (pathological cause) – R/T
Not a medical diagnosis, but a condition is OK

S = Supporting data or defining characteristics – AEB (as evidenced by)
symptoms/responses; from abnormal assessment data

Actual Nursing Diagnosis
3 part statement
-Nsg Dx, R/T, and AEB data
-Patient problem that is present at the time of the nursing assessment
-Based on presence of associated signs and symptoms
Risk Nursing Diagnosis
2 part statement – Nursing Diagnosis r/t

No 3rd part (AEB) because no —-symptoms/evidence

-Clinical judgment that a problem does not exist, but the presence of “risk factors” indicates that a problem is likely to develop without intervention

Example Risk Nsg Dx
Risk for constipation
r/t decreased GI motility associated with manipulation of bowel during abdominal surgery, decreased activity, and depressant effect of opioid pain med
Collaborative Diagnosis PC = potential complications
2 part statement (no symptoms)
Medical problems or complications
Require collaborative interventions with physician and health care team
Problem addressed by another discipline that contains a nursing component requiring nursing intervention and/or monitoring
Tend to be specific complications associated with a particular disease
Wellness Nursing Diagnosis
Can be risk or actual
Indicates a healthy response of a patient who desires a higher level of wellness.
Readiness for enhancement
NANDA has some specific wellness diagnoses
Errors in Writing Nsg Dx
Using the medical diagnosis
– Impaired Physical Mobility R/T Stroke

Confusing etiology or evidence with the problem
– Impaired Physical Mobility r/t limping aeb stroke

Lacking specificity
– Impaired Physical Mobility r/t movement aeb inability to move

Planning
The nurse refers to assessment data and nursing diagnosis for formulating goals and nursing interventions to prevent, reduce or eliminate the health problems.
Why Use Nursing Diagnoses
Gives nurses a common language
Promotes identification of appropriate goals
Sets a standard for practice
Offers a quality improvement base
Three Part Diagnostic Label
1. P = Problem Diagnosis
2. E = Etiology( pathophysiological)
3. S = Supporting data – AEB (as evidenced by)
P = Problem Diagnosis
Acute Pain
E = Etiology( pathophysiological)
r/t tissue trauma and reflex muscle spasms associated with coughing, and movement
S = Supporting data – AEB (as evidenced by)
Rates pain at 9 (1-10 scale)
Facial grimacing and grabbing incisional area
Pulse 105, B/P 145/89
Refuses to turn or ambulate
Example – Actual Nsg Dx
Activity intolerance
r/t tissue hypoxia associated with anemia
AEB Hgb 7.5, exertional dyspnea when getting up into the chair, complains of being weak and fatigued, heart rate increases from 80 to 100 upon activity.
Example P.C. Dx
P.C. of hypertension: stroke.

P.C. of surgery: deep vein thrombus

P.C. of pneumonia: respiratory failure

Example Wellness Nsg Dx
Readiness for Enhanced Self Health Management
r/t asking questions about healthy lifestyle changes
Errors in Diagnosing
Overlooking cues
Jumping to conclusions
Neglecting validation
Errors in Writing Diagnoses (2)
Combining two diagnoses
– Impaired skin integrity r/t Impaired physical mobility

Using judgmental language
– Impaired skin Integrity r/t not washing correctly aeb foul odor

Initial Planning
Follows admission assessment
Ongoing Planning
Plan for the current day (changes in patient’s needs, goals and condition)
Discharge Planning
Addresses and plans for needs after hospital; begins with first client contact
Informal Care Plan
-Strategy for action that exists in the nurses mind
Formal Care Plan
– written guide, organized information about patients care
Standardized Care Plan
– formal plan specific to a group of patients
Individualized Care Plan
– tailored to the patients unique needs
Kardex Care Plan
Filing system allows quick reference of a patients care
Student Care Plan
– Learning activity, problem solving technique
Nursing Care Plans
Informal, Formal, Standardized, Individualized, Kardex, Student
Affective Outcome Domains
behavior (words like avoid, manage, display, attend)
Cognitive skills
knowledge, comprehension (words like identify, list, state)
Psychomotor Outcome Domains
– motor skills (words like with ease, independent, grasp)
Develop outcomes
Identify Nursing Diagnoses (current problem based on assessment)

Prioritize Nursing Diagnoses (Maslow theory)

Develop Outcomes (address the problem, is measurable and sensitive to interventions)

Select and write nursing interventions

Consider Patient Safety Goals

Purpose of Outcomes
Directions for planning interventions

Criteria for evaluating progress

Method of determining when problem is resolved

Motivator for patient and nurse

Writing Outcomes
Reflect the nursing diagnosis/address the problem
Positive restatement of the nursing diagnosis
Provide expected patient responses that are specific assessment findings indicating achievement of the outcome
Focused (on patient response not nurse action)
Measurable and concrete, not vague or rely on judgment (such as “improved” or “better”)
Components of Outcomes
Subject – patient
Verb – action patient is to do, learn, experience (show, walk, administer)
Conditions or modifiers – standard by which patient is evaluated or level at which patient will perform; May specify time, speed, accuracy, distance, quality
Time frame/target time for meeting/achieving outcome
Short-term daily outcomes on Plan Of Care
Long-term
Nursing Interventions/Orders
Orders and actions for the Nsg Dx that facilitate meeting outcomes
Start with assessment
Stated in specific terms (what, where, how often)
Individualized to the patient
Writing Outcomes (continued)
Write in terms of observable/measurable patient responses
Time limited or target time – when/how soon response expected to occur
May have more than one desired outcome for each nursing diagnosis
An additional outcome should be written to reflect a teaching intervention