DIAGNOSIS & PLANNING

1. DIAGNOSIS & PLANNING PROGRAM B GROUP 3 PRODI ILMU KEPERAWATAN UNIVERSITAS ANDALAS TA 2011/2012 1

2. 1.Mimi Masniwati 8. MeldaKartika2. MailaAndraSanti 9. Karmiza3. SilvyEkaPutri 10. UsrianiAndari4. Riadhoh 11. Almira Gandhi5. YanceYulia 12. Nurhamidah6. TutiKusmiati 13. Devi Yunita .A7. RiniHeldina 14. Dian Rilawati 15. Sari Anggreani Mimi Masniwati2. MailaAndraSanti3. SilvyEkaPutri4. Riadhoh5. YanceYulia6. TutiKusmiati7. RiniHeldina8. MeldaKartika9. Karmiza10. UsrianiAndari11. Almira Gandhi12. Nurhamidah13. Devi YunitaAstuti 2

3. The nursing process has spesific steps (5 steps) • Diagnosis is the second phase of the nursing process is analyzing the data and identifying the nursing care problem. • The third, phase of the nursing process, planning client care based on the problemsor diagnoses you have identified 3

4. Nursing Diagnosis • Nursing Diagnosis is a statement about a client’s actual or potential health concerns that can be managed through independent nursing interventions. • Nursing diagnoses are consice, clear, client-centered, client-specific statements. 4

5. Continue… • A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems / life processes.  Nursing diagnoses provide the basic for selection of nursing interventions to achieve outcomes for which the nurse is accountable (NANDA, 1992 p.5) 5

6. Different of Nursing Diagnosis with Medical Dianosis Nursing diagnosis is not to be confused with medical diagnosis. • The nursing diagnosis identifies risks and needs of the patient both in the clinical setting (hospital, for example) and afterward (risks at home) that stem from the medical condition. 6

7. Continue….. • The medical diagnosis is a phrase that identifies as nearly as possible the specific clinical entitiy that is causing illness, such as pulmonary tuberculosis. This doesn't necessarily specify comorbid conditions (problems also present) such as instability from weakness and emaciation which exposes a patient to the risk of falling and sustaining further injury, or immune deficiency resulting from the TB making the activation of shingles more likely. 7

8. Continue….. • The medical diagnosis specifies the pathology, such as respiratory insufficiency from advanced tuberculosis • the nursing diagnosis will focus on the impact of the signs and symptoms on the patient and his/her caregivers 8

9. Continue….. • A medical diagnosis deals with disease or medical condition. A nursing diagnosis deals with human response to actual or potential health problems and life processes. For example, a medical diagnosis of Cerebrovascular Attack (CVA or Stroke) provides information about the patient’s pathology. 9

10. The complimentary nursing diagnoses of Impaired verbal communication, risk for falls, interrupted family processes and powerlessness provide a more holistic understanding of the impact of that stroke on this particular patient and his family – they also direct nursing interventions to obtain patient-specific outcomes. 10

11. Continue…. • Medical diagnosis is specific and related to a pathological disease proces. • Medical diagnoses are relativelly uniform and are treated the same from individual to individual 11

12. These Facts About A Medical Diagnosis • It identifies the disease a person has or is believed to have • Physicians arrive at a medical diagnosis by studying the physiologic manifestations of the illness and establishing its cause and nature • It provides a basis for prognosis (projected client outcome) and medical treatment decisions 12

13. Purposes Of The Nursing Diagnosis • To identify nursing priorities • To direct nursing interventions to meet the client’s high-priority needs • To provide a common language and form a basis for communication and understanding between nursing professionals and the healthcare team 13

14. Continued,,,,, • To formulate expected outcomes for quality assurance requirements of third party payers • To provide a basis of evaluation to determine if nursing care was beneficial to the client and cost effective • To assist in making staff assignments 14

15. Nursing diagnostic • Is based on the client’s physical, sosio cultural, psychological and spiritual response to an illness or healt problem. • Nursing doagnoses will vary according to the client’s state of being nursing diagnoses maybe actual,potensial and risk problem that a client may experience 15

16. Nursing diagnostic statement The formal, written documentation of a nursing diagnosis. It includes the label or diagnosis, the etiology, and the indicators. In the statement, the etiology is preceeded by the phrase "related to." The indicators are the assessment data that led to the diagnosis. They are preceeded by the phrase, "as evidenced by." 16

17. Nursing diagnoses actual potensial risk 17

18. Risk diagnosis - A nursing diagnosis that recognizes a potential problem not an existing problem. The indicators for risk diagnoses are risk factors that are identified through assessment. • ACTUAL DIAGNOSIS- It is a client problem that is present at the time of the nursing assessment. Examples are Ineffective Breathing Pattern and Anxiety. An actual nursing diagnosis is based on the presence of associated signs and symptoms. 18

19. Developing The Diagnostic Statement The three part statement (Gordon,1976) consists of the following components: • Problem The problem statement describes the client’s health problems clearly and concisely. • Etiology The etiology part of the statement states the cause, which may come from physiologic, sosiologic, spiritual or environmental factors. For example: the client with pneumonia, the etiology is increased secretions • Signs and Symptoms 19

20. PLANNING CARE planning is the development of goals to prevent, reduce, or eliminate problems and to identify nursing interventions that will assist clients in meeting these goals. 20

21. Steps in planning care are: 21

22. Next……. 22

23. 3. Selecting nursing interventions 23 Nursing interventions also called nursing orders or nursing actions. Are activities that will most likely produce the desired outcomes (short-term or long –term). Sometimes, the client and nursing staff set specific target dates to achieve certain goals.

24. 4. Writing a nursing care plan 24 The nursing care plan is the formal guideline for directing the nursing staff to provide client care. The nursing care plan usually includes nursing diagnoses or client problems (according to priorities), expected outcomes (short and long term), and nursing orders (activities nurses carry out to help the client achieve goals).

25. Next…. 25 The written care plan is kept in several ways, plans are written on a kardex for each client. the nursing care plan becomes part of the client’s permanent health record. Documentation of a nursing care plan is a requirement of such agencies as the joint commission on accreditation of healthcare organizations.

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