Analysis- Nursing Diagnosis

1. Analysis- Nursing Diagnosis

2. Definition of Nursing Diagnsis • A nursing diagnosis is a statement of the high risk or actual problems in the client’s health status that the nurse is licensed and competent to treat

3. Components of Analysis Phase • 3 major components of analysis phase: • Analysis and interpretation of data • Validation of data • Clustering of data • Identification of problems/health care needs • Formulation of nursing diagnosis statement

4. Nursing Diagnostic Statement • Derived from actual or potential problems • Derived from physiological, sociocultural, developmental, and spiritual dimensions of client • Focus: Helping client to achieve a maximal level of wellness and highest level of independence

5. Nursing Diagnosis vs Medical Diagnosis • Medical diagnosis deals with disease or medical condition or pathology (treating or curing) • Nursing diagnosis deals with human response to bio-psycho-social stressors and/or health problems that a nurse is licensed and competent to treat

6. Advantages of Nursing Diagnosis • For client- individualization of care, appropriate selection of interventions, establishment of goals • For nursing- facilitates communication, documentation, and continuity of care among health care providers

7. Sources of error • Errors in data collection • Errors in data analysis • Clustering errors • Incorrect diagnostic statement • Common error, however, if correct steps are followed this will not occur

8. Nursing Diagnostic Statement Diagram #___ ___________ r/t __________ e/b _____________ Priority Patient’s this is the cause these are signs/ symptoms needs/problem (etiology) that come from the assess- ment (what you see that supports the problem) r/t= related to e/b or m/b= evidenced by or manifested by Patient’s needs/problem= NANDA approved statement found in book

9. Example Statements #1 Pain r/t tissue damage e/b patient complains of pain at level of 7 out of 10 #2 Constipation r/t poor fiber intake e/b no bowel movement for 3 days and abdominal distention #3 Risk for injury r/t generalized weakness

10. Parts of Nursing Diagnostic Statement • Problem • Actual- firm diagnosis supported by nurse’s findings (validated) • High risk- has risk factors but does not have signs and symptoms, more vulnerable to develop problems • Possible- tenative- additional data needed to confirm or rule out problem

11. Parts of Nursing Diagnostic Statement • Qualifiers/ Modifiers • Impaired • Altered • Decreased • Possible • Ineffective • High risk

12. Parts of Nursing Diagnostic Statement • Related to (r/t) • Educated guess as to what factors are contributing to or causing the problem • Placed between problem and etiology to indicate relationship between them • Can not be a medical diagnosis • Must be modifiable by nursing interventions • Must be able to do something about it • Will be in one of five categories: • Environmental, situational, psychological, pathophysical, and maturational

13. Parts of Nursing Diagnostic Statement • Evidenced by (e/b) or Manifested by (m/b): • Signs and symptoms (assessment data) that led to your nursing diagnosis. • Examples: • SOB while walking • Client stating food intake is poor • Client states they are in pain • Client hasn’t had bowel movement in 3 days • Client has open wound on buttocks

14. Case Study Mrs. Angela Garcia is a 46-year-ol Hispanic woman who works as an x-ray technician at a busy local hospital. She is being seen in the orthopedic clinic for complaints of steadily worsening pain in her right knee. The pain began 4 months ago when she fell and hyperextended the knee. Mrs. Garcia reports that the pain is more intense with weight-bearing activities, including running, standing, and playing tennis. Because of this, she has been limiting her physical activities. She also reports the recent onset of painful muscle spasms in the right leg, both with activity and at rest. The pain and muscle spasms are disrupting her sleep and making it difficult for her to work. At home she has terated the discomfort with acetaminophen and stretching exercises but has experienced no relief. On physical examination you notice a marked limp with walking, decreased extension in the right knee, and a reluctance to allow her knee to be touched or manipulated. The knee is slightly swollen and warm to the touch. During the x-ray examination of the knee, she grimaces in pain when placed in a kneeling position. Mrs. Garcia’s medical diagnosis is patellar tenonitis, and she is started on a regimen of non-steroidal anti-inflammatory drug (NSAID). As her nurse, you want to use the most accurate nursing diagnosis as a basis for her nursing care. To begin the process of identifying a nursing diagnosis, you first cluster the significant assessment data.