302-- Nursing Dx
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Method of caring that provides a framework for nursing practice
(it is Systematic, Patient-centered, and Goal Oriented)
Steps to the Nursing Process
- Assessment --> systematic & continuous
- Outcome Identification and Planning-->
Nurse and patient mutually identify expected outcomes and agree on nursing interventions necessary to meet these outcomes
Outcome Identification & Planning
Nurse implements the plan of care, adapting it to each
individual and documents nursing actions and patient responses
Nurse and patient
Evaluate the effectiveness of the plan based on achievement of outcomes
Determine if the plan should be continued, modified, or terminated
Who first used the term "nursing process"
Who published the first comprehensive book on nursing process.
Described 4 steps: assessment, planning, intervention, evaluation
Yara and Walsh
Who made nursing diagnosis a separate step in the process – leading to the 5 step process we use today.
Gebbie and Lavin
Steps to Nursing Process
Assess patient to determine the need for nursing care
Determine nursing diagnoses for actual and potential health problems
Identify expected outcomes and plan care
Implement the care
Evaluate the care
Purpose of Nursing Diagnoses
Identify how an individual, group, or community responds to actual or potential health and life processes
Identify factors that contribute to or cause health problems (etiologies)
Identify resources or strengths the individual, group or community can draw on to prevent or resolve problems
Types of Nursing Concerns
- *Monitoring for changes in health status
- *Promoting safety and preventing harm, detecting and controlling risks
- *Identifying an meeting learning needs
- *Tailoring treatment and medication regimens for each individual
- *Promoting comfort and managing pain
- *Promoting health and a sense of well-being
- *Recognizing and addressing problems that impede the ability to be independent and live a healthy lifestyle
- *Determining human responses
When was nursing dx introduced as a term
ANA introduced nursing dx into professional nursing officially in
North American Nursing Diagnosis Association (NANDA) came about in
What is the primary responsibility of nursing?
- Collaborative problems
- (With collaborative problems the prescription for treatment comes from nursing, medicine, and other disciplines)
Type of diagnosis that represents a problem validated by the presence of major defining characteristics.
Type of diagnosis.... clinical judgments that an individual, family or community is more vulnerable to develop the problem than others in the same or similar situation.
Type of Diagnosis: ....statements describe a suspected problem of which additional data are needed. Need more information to confirm or rule out the suspected problem.
Possible Nursing Dx
Type of Diagnosis....clinical judgments about an individual group or community in transition from a specific level of wellness to a higher level of wellness. “Readiness for enhanced…”.
Wellness Nursing Dx
Type of Nursing Dx...a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation: “Rape-Trauma syndrome”
Syndrome Nursing Dx.
3 Components to the Nursing Dx. Statement
The etiology directs the nursing intervention
For this semester…try NOT to use a medical diagnosis as your etiology
- Purpose to describe the health state or health problem
- of the patient as clearly and concisely as possible
- (Use NANDA list (p. 274-275) and available in your PDA)
- EtiologyIdentifies the physiologic, psychological, sociologic,
- spiritual and environmental factors believed to be related to the problem as either a cause or a contributing factor
- Defining characteristics
- Subjective and objective data that signal the existence
- of the health problem
- **Not required for a Risk for nursing diagnosis
Problem Statements should be chosen from what list?
Something that is desirable, useful:
Theory of Human Needs comes from...
Factors that affect need satisfaction
- acute/chronic illness
- developmental stage
- self concept
Priortization of Needs:
- Physiological Problems FIRST
- Pyschological Problems Next
How are Oxygen Needs assessed:
- •Pulse Ox
- •Resp. rate
How do we assess a person's fluid status?
- Body wt
- Urine output
- Blood pressure
- Mucous Membranes
- Breath sounds
- Heart Rate, Resp. rate
- Skin turgor
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