Nurse Caring Concepts 1A
N N ursing Process N
Step 2: Nursing Diagnosis
Step 3: Outcome Identification
Week 6 September 22, 2003
What Is Nursing Diagnosis (Dx)?
• Has two related meanings:
– Nursing diagnosis is an action: the
process of analyzing assessment data to
arrive at a….nursing diagnosis!
– Nursing diagnosis is a label that
describes the patient’s response to an
actual or potential health problem
Medical Diagnosis Nursing Diagnosis
• Describes a disease or • Describes pt’s response to
pathology
a health problem
• Conditions MD treats • Situations RNs can treat
• MD cares for a pt with • Nursing dx describe pt’s
Congestive Heart
response to CHF: such as:
Failure (CHF) - treats Anxiety; Activity
pathology with meds,
Intolerance, Impaired
oxygen, diet & fluid
Peripheral Tissue
restriction
Perfusion, Powerlessness
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Nursing Diagnosis: The Action
• RN reviews assessment data to identify patterns
• Subjective & objective “cues” are organized
into groups that seem to fit together & indicate
actual or potential client problems (nursing dx)
• RN makes an educated hunch about which
nursing diagnoses might fit the cue cluster
• Review the selected nursing diagnoses to decide
which is most accurate
Nursing Diagnosis: The Label
• North American Nursing Diagnosis
Association (NANDA): official organization
responsible for developing system of naming &
classifying nursing diagnoses
• Diagnostic label is often called a “NANDA”
• Each NANDA describes the essence of the
problem in as few words as possible.
– Acute Pain
NANDA Definitions
• Each NANDA-approved nursing diagnosis is
accompanied by a definition that describes its
characteristics:
– NANDA: Impaired Physical Mobility
– NANDA Definition: state in which a person
experiences or is at risk of experiencing
limitation of physical movement but is not
immobile
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Types of Nursing Diagnoses
• Actual nursing diagnoses: patient has problem
• Risk diagnoses: patient is at risk for developing
the problem (Either begins with “Risk for” or
the definition will include “is at risk for”)
• Wellness diagnoses: patient functioning
effectively but desires higher level of wellness
• Others that you do not need to know:
– Possible diagnoses
– Syndrome diagnoses
– Collaborative problems:
Parts of a Nursing Diagnosis:
Defining Characteristics
• These are the signs & symptoms that validate
that an actual nursing diagnosis is present.
– Major: at least one must be present to use the
nursing diagnosis
– Minor: may not be present, but if it is, helps
to validate selecting the nursing diagnosis
• Defining characteristics are not present in ‘Risk’
dx because signs & symptoms don’t exist if the
problem hasn’t happened
Parts of a Nursing Diagnosis:
Related Factors or Risk Factors
• Related Factors: factors that contributed to the
development of patient’s problem (nursing dx)
• Risk Factors: factors that increase the
possibility of the patient developing a problem
• Is a relationship rather than direct cause &
effect (is ‘related to’ rather than ‘caused by’)
• Only one of these factors (risk or related) needs
to be present to justify use of the nursing dx
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Nursing Diagnosis Action Revisited
• Make a hunch about which diagnosis might fit
• Read the diagnosis definition to see if it fits
• Check out the defining characteristics
• Major: one must be present
• Minor: if present may help confirm hunch
• Rule out any diagnosis for which your patient
does not meeting the defining characteristics
Formulating the Diagnostic
Statement
• After identifying the best NANDA to describe
your patient’s problem...
• You need to formulate a “diagnostic statement”
– An actual diagnosis has a three-part statement
– A risk diagnosis has a two part statement
– A wellness diagnosis has a one part statement
Actual Diagnostic Statement
Three-Part Format
Three parts:
1
NANDA label
2 Related factors (follows NANDA & linked
by the words “related to”)
3 Defining characteristics (follows related
factors & linked by the words “as manifested
by”)
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Actual Diagnostic Statement Example
1 Impaired Physical Mobility
2 related to (r/t) decreased motor agility and
muscle weakness
3 as manifested by (AMB) limited ROM
“Impaired Physical Mobility r/t muscle weakness
AMB limited ROM”
Risk Diagnostic Statement
Two-Part Format
Two parts:
1 NANDA label
2 Risk factors (follows NANDA label and is
linked by the words related to)
Risk Diagnostic Statement
Example
1 Risk for Impaired Physical Mobility
2 related to (r/t) full leg cast
“Risk for Impaired Physical Mobility
r/t full leg cast”
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Clarifying the Related Factors
Part of the Diagnostic Statement
• You will often need to add words to the ‘related
to’ portion of an actual or a risk diagnostic
statement to clarify the origin of the problem
• These words always follow the ‘related to’ and
are linked with the words ‘secondary to’ (2°)
• NOTE: This is the only way a medical diagnosis
can ever be inserted into a nursing dx statement
Examples: Adding a Secondary
Factor to the ‘related to’ part of a
Diagnostic Statement for Clarity
• Impaired Physical Mobility r/t muscle rigidity
and tremors secondary to (2°) Parkinson’s
Disease AMB limited ROM and compromised
ability to move purposefully
• Risk for Impaired Skin Integrity r/t immobility
2° fractured hip
Wellness Diagnostic Statement
•
Used when pt doesn’t have a health problem
but can attain higher level of health
• Is a one part statement consisting only of the
NANDA:
– Readiness for Enhanced Parenting
– Readiness for Enhanced Family Processes
– Readiness for Enhanced Spiritual WellBeing
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Step 3 of the Nursing Process:
Outcome Identification
• NANDA label describes human responses that
are problems. Usually, the healthy alternative
is goal that patient wants to achieve
• To identify a goal, ask yourself:
– If the problem were solved (actual nsg dx)
or prevented (risk nsg dx), how will patient
look or behave?
– What will I see, hear, palpate or observe?
• Establish goals with patient if possible
Types of Goals
• Goals can be:
– Long term goal: objective expected to be
achieved over weeks or months
– Short-term goal: a stepping stone on the
way to reaching long-term goal
Long Term Goal Characteristics
• Is a broad statement that reflects:
– Resolution of a problem
– Progress towards resolution of a problem
– Prevention of a problem
• Should be attainable and realistic for the
patient
• Is expected to be achieved during length of
stay in facility
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Short Term Goal Characteristics
• Must describe a measurable behavior that
nurse can validate by seeing or hearing or that
patient can measure subjectively and describe
• Only one action verb allowed per goal
Short term goal should be:
• Attainable & realistic during your time with pt
• Specific in time - when is it to have occurred?
• Specific as to who or what is to achieve goal
• Specific in content - what is to occur?
Example of Long & Short Term Goals
• Impaired Tissue Integrity r/t destruction of
tissue 2° pressure and friction AMB stage II
pressure ulcer on coccyx
• Long term goal: “Patient’s pressure ulcer will
heal”
• Short term goal: “Patient will demonstrate 3
measures that she can do to prevent pressure
ulcers during my shift”
Example of Long & Short Term Goals
• Fear r/t anticipated dependence 2° nursing home
rehab admit AMB statement “I am afraid that I
will never go home”
• Long term goal: Patient will report an increase
in psychological comfort
• Short term goals:
– Patient will discuss fears with RN during
today (9/22)
– Patient’s pulse & respiratory rate will be
WNL following discussion with RN
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Nursing Process Terminology Tips
• Nursing Diagnosis is also called:
– NANDA
– Diagnostic label
• Defining Characteristics are also called:
– Cues
– Subjective & objective assessment data
– Signs & symptoms (S/Sx)
• Related factors & risk factors are also called:
– Etiology (Origin)
– Contributing factors
• Goals = outcomes = objectives
Your first step in care planning!
• For clinical, identify two nursing diagnoses for
your primary patient; actual or risk
• Write a diagnostic statement for each one
(remember: risk is 2-part & actual is 3-part)
• For each diagnostic statement, identify a long
term goal & a short term goal
• Write these on a copy of your Cuesta Care Plan
form & turn in to your clinical instructor first
thing in the morning on your clinical day
Cuesta Nursing Care Plan
Due 9/23 or 9/24
P
R
Nursing Diagnosis
Outcome Criteria
Diagnostic Statement # 1
Long term goal # 1
Short term goal # 1
Diagnostic Statement # 2
Long term goal # 2
Short term goal # 2
M Interventions
O
T
C
Evaluation
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