NURSING PROCESS DIAGNOSIS PHASE

NURSING DIAGNOSIS PHASE

• Nursing diagnosis is the process of identifying the actual and potential health problems and labelling with a concise statement that describes the clinical judgment about the client’s problems or life processes
• It provides basis for the selection of nursing intervention to achieve the outcomes for which the nurse is accountable
• It describes the health states that nurses can legally diagnose and treat, also identify collaborative problems and treat with other health care providers
• During the diagnostic process the nurse identifies both nursing diagnosis and collaborative problems that necessitates nursing intervention.

DATA ANALYSIS & PROBLEM IDENTIFICATION

• The diagnosis phase begins with the clustering of information and ends with an evaluative judgment about patients health status.
• This judgment is reached after analyzing the assessment data
• The information are clustered and sorted by determining the client’s strengths and unmet needs
• After thorough analysis of all the available information, a final judgment is made based on the client’s health status.
• The problems that requires nursing intervention or nursing assistance to resolve the potential or actual problems are identified.

NANDA NURSING DIAGNOSIS

• The North American Nursing Diagnosis Association (NANDA) is a body of professionals that manages an official list of nursing diagnoses.
• It is an essential and useful tool that promotes patient safety by standardizing evidence-based nursing diagnoses.
• NANDA is comprised of goal-oriented nurses who are committed to continually increasing the quality of patient care while promoting and improving levels of patient safety.
• Health care facilities keep a standardized NANDA nursing diagnosis list on site at each patient care unit.
• Commonly, the list of Nursing diagnoses are kept in access with the Nurses to enable them to have easy access to a course of care to be implemented for the client

FORMULATION OF DIAGNOSTIC STATEMENTS (LABELS)

• One-part Statement:
  • One part statement is used for wellness diagnosis
  • A Wellness diagnosis is identified when Individual moves from a specific level of wellness to higher level of wellness
  • E.g. Label begins with Readiness for Enhanced Nutrition.
• Two-Part Statement:
  • In Two part Statement identifying only the problem & Etiology is acceptable if the signs & symptoms data are easily accessible to other Nurses caring for the patient
  • E.g. Risk of Aspiration related to Impaired swallowing
  • Imbalanced Nutrition less than body Requirements related to limited Income for food purchases.
• Three-Part Statement:
  • Three part statement identifies the critical thinking process that occurs in making Judgement about client’s Health Status
  • When writing a 3-part statement the problem- Etiology – Signs & symptoms format is used
  • E.g. PES Format Problem (P)- used to label the term that reflects the pattern of cues –(PAIN)
  • Etiology (E)- a brief description about the probable cause of the problem- (related to Surgical Incision, Pressure or Edema)
  • Signs & Symptoms (S)-the list of the clusters of the objective & Subjective Data that lead the nurse to pinpoint the problem- (as evidenced by facial grimaces, incision etc.)

PES Format for labelling Diagnostic Statements

• Identifying the Problem (P):
  • The Nursing Diagnosis accepted by NANDA International were organized as taxonomy in which diagnoses, interventions & outcomes can be placed together to facilitate their use in clinical area.
  • Taxonomy is simply the classification of things in an ordered system based on their natural relationships
  • The framework of taxonomy is a useful guide for identification of problems or needs when clustering common pattern of responses.
• Etiology (E)
  • The Etiology of a Nursing Diagnosis is Identified in the Diagnostic Statement
  • The Etiology or cause of the problem provides direction for managing the problem
  • The Etiology can be a pathophysiologic, maturational, situational or treatment related factor but should be something the Nurses can treat
  • The Etiology should not be the primary Medical Diagnosis but may be identified secondary to a medical problem
  • The Etiology is written after the diagnostic Label.
• Signs & Symptoms:
  • Signs & symptoms are also called as defining Characteristics, which are the clinical cues that in a cluster indicate the Nursing Diagnoses
  • Critical Defining Characteristics must be present in the assessment data to make an accurate Nursing Diagnosis
  • Major Defining Characteristics are those signs & symptoms that are usually present when the Diagnosis exists
  • At least one Critical & Major defining Characteristics must be present to have an actual Nursing Diagnosis
  • Minor Defining Characteristics must also be identified and are evidence of possible Nursing Diagnosis
  • The Signs & symptoms are included in the diagnostic Statement using the phrase as “evidenced by”.

COLLABORATIVE PROBLEMS

• These are actual or potential complications of a disease or treatment that the Nurses treat with other health care providers
• During the diagnosis phase of the Nursing Process, the Nurse the risks for physiologic complications in addition to the actual Nursing Diagnosis
• Identification of collaborative problems requires knowledge of pathophysiology & possible complications of Medical treatment
• Nurses Prescribe interventions by interdependent role to prevent, detect & manage the collaborative problems.