Technologies in Nursing
Duquesne University
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First introduced in 1950.
In 1953 Fry proposed the formulation of
nursing diagnosis.
In 1973, the first national conference
was held.
In 1982, NANDA was founded.
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Diagnostic reasoning
◦ A process of using assessment data to create
a nursing diagnosis
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Defining characteristics
◦ Clinical criteria or assessment findings
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Clinical criteria
◦ Objective or subjective signs and symptoms
1. Medical diagnosis
2. Nursing diagnosis
A. Clinical judgment
about the client in
response to an actual or
potential health problem
B. The identification of a
disease condition based
on specific evaluation of
signs and symptoms
3. Collaborative problem C. An actual or potential
complication that nurses
monitor to detect a
change in client status
1. Actual Nursing
Diagnosis
A. Describe human responses
2. Risk Nursing
Diagnosis
B. Describes human
3. Wellness Nursing
Diagnosis
C. Describes human
to levels of wellness that have
a readiness for enhancement
responses to health
conditions/life processes that
may develop
responses to health conditions
or life processes
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Problem
Etiology
Signs and Symptoms
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By learning to make accurate nursing
diagnoses, your care plan will help
communicate the client’s health care
problems to other professionals.
A nursing diagnosis will ensure that you
select relevant and appropriate nursing
interventions.
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Problem—the name or diagnostic label
identified from the NANDA list. This may
be an actual problem, a risk (potential)
problem, or a wellness diagnosis.
 The
suspected cause or reason for
the response that has been
identified from the assessment
 They
are stated “as evidenced
by (A.E.B.)” or “as manifested
by”, followed by a list of
subjective and objective data.
 “Risk” problems have no
evidence statement.
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Ineffective Airway Clearance, related to
increased pulmonary secretions and
bronchospasm, evidenced by wheezing,
tachypnea, and ineffective cough.
Acute pain related to tissue distention and
edema as evidenced by reports of severe
colicky pain in right flank, elevated pulse and
respirations, and restlessness.
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Hyperthermia related to increased metabolic
rate and dehydration as evidenced by
elevated temperature, flushed skin,
tachycardia, and tachypnea.
Risk for infection, related to broken skin,
traumatized tissues, decreased hemoglobin,
invasive procedures, increased environmental
exposure.
 Risk
for skin breakdown
related to immobility as
evidenced by stage III sacral
wound (7 X3 cm)
 Pain
related to myocardial
infarction as evidenced by
patient’s report of pain at 9 on
the 1-10 pain scale
 Ineffective
airway clearance
related to pneumonia as
evidenced by adventitious breath
sounds, sputum production, and
abnormal chest x-ray.
 Fluid
volume deficit related to
blood loss through wound as
evidenced by hemoglobin of 8
and hematocrit of 26%
 Fluid
volume deficit related to
NPO status as evidenced by
weight loss
 Diarrhea
related to C. Diff as
evidenced by 10 stool in one
day
 Risk
for infection related to
invasive procedure (surgery)
 Readiness
for enhanced
knowledge of disease process.
Based on a medical diagnosis
 Examples:
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◦ Risk for pneumonia related to immobility
◦ Risk for DVT related to immobility
◦ Risk for myocardial infarction related to
inadequate tissue perfusion
 Written
in general terms
 Not behavioral in nature
 Patient centered
 Example: To enhance airway
clearance and improve
oxygenation
Actions that the nurse carries out for
the client or encourages the client to
do for themselves.
 Include interdisciplinary actions, but
identify them as such.
 Includes assessment
 Includes teaching the client
 Include the rationale for the
intervention.
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 Specific
 Measurable
 Attainable
 Realistic
 Time
oriented
◦ The patient will identify four
adaptive/protective measures for individual
situation by discharge.
◦ The patient will maintain a patent airway,
ongoing. (This outcome is stated as
“ongoing” and does not include a specific
timeframe other than discharge from care.
In this example, this is appropriate because
the situation may not resolve until the
patient’s condition or status changes or
discharge has occurred.)
◦ The patient will be free of skin breakdown.
(This is another example of an ongoing
outcome).
◦ The patient will demonstrate correct insulin
administration techniques within 48 hours.
 The patient will attain pain relief identified as a
“3” on the 0-10 pain scale 30 minutes after
being medicated with pain medication.
 The patient will maintain an oxygen saturation
of 92 or higher.
 The patient will not incur a fall.
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Should refer directly to the nursing diagnosis
and to the goal.