Miami Dade College

Nursing

Process:
Diagnosis

Nursing Diagnosis

North American Nursing Diagnosis

Association (NANDA) to develop,
refine, and promote the use of nursing
diagnosis.

Nursing Diagnosis

A statement that identifies the existence

of an undesirable state.
The subject matter of the diagnosis is
derived from areas in which the
diagnostician possesses a level of
expertise.
Iyer/Taptich/Bernochi-Losey

NURSING DIAGNOSIS:

the phase in
which a nurse
determines the
meaning of
assessment
data.

Diagnosis links Assessment

to the rest of Nursing Process

DIAGNOSING:

ANALYZING DATA TO IDENTIFY

ACTUAL OR POTENCIAL PROBLEMS
Self Care Deficit
Constipation
Immobility
Skin breakdown
Ineffective airway
clearance

Types of Nursing Diagnosis:

Actual

Risk

for

Wellness

Diagnostic
Reasoning:

Validation with...
Patient

or
significant
others

Validation with...
Other

professionals

Validation with...
Reference

sources

Diagnostic Statement:
1. The human response

(NANDA)
2. Related / risk factors
3. Patient response

Related Factors:
Physiological
Psychological
Sociocultural
Environmental
Spiritual

Related Factors: Physiological

Risk

for falls
R/T side effects of
medications
aeb unsteady gait,
drowsiness.

Related Factors: Psychological

Altered

role performance
R/T fear of death
aeb avoidance of wife and
other family members.

Related Factors: Sociocultural

Knowledge

deficit
R/T language barrier
aeb unable to follow
medication regime as written,
cannot read & understand
English.

Related Factors: Environmental

Fatigue

R/T sensitivity to light

aeb sleepiness, nodding off,
yawning, inability to
concentrate.

Related Factors: Spiritual

Non-compliance

R/T conflict
between religious beliefs &
health regimen
aeb patient does not follow
dietary regime as prescribed.

Actual Patient Response

As

evidenced by(aeb)
Objective data
Subjective data

Nursing Diagnoses: Application

To Care Planning

Directs the planning process and the

selection of the nursing interventions to
achieve desired outcomes for the
patient.

Nursing Diagnosis

Accurate nursing diagnoses

communicates to other professionals
the patients health care problems and
ensures that relevant and appropriate
nursing interventions are selected.

PLANNING
Development of
strategies to
reinforce
healthy patient
responses

PLANNING - Formal

conscious,
deliberate activity
involving
decision making,
critical thinking,
and creativity.

PLANNING: Informal

Unwritten decisions while

assessing patient

PLANNING Four Stages

1. Setting priorities nsg. diagnosis
2. Developing outcomes ( goals )
3. Developing nursing interventions
4. Documenting the plan

Exercise: Prioritize

Activity intolerance r/t pain lower R

leg

Ineffective breathing pattern r/t

excessive pulmonary secretions

Risk for injury r/t pain R leg

Exercise: Prioritize

Social isolation r/t changes in

body image

Powerlessness r/t scant $

resources

Fluid volume deficit r/t diarrhea

Exercise: Prioritize

Impaired memory r/t disease

process

Altered tissue perfussion r/t injury

R arm

Risk for infection r/t skin

breakdown R arm

2. GOALS: (Outcomes)
1. Must be
realistic
2. Of mutual
agreement
3. Measurable

PLANNING Writing
(Goals)

Outcomes

4. Derived from
nursing diagnosis
5. Provide
direction

Goals: The Patient Will

List 3 S&S of infection today.

Demonstrate dressing change within

48 hours.

Eat 75% of served meals within one

week.

Goals must be SMART

S
M
A
R
T

imple/specific
easurable
cceptable/attainable
ealistic
imed

The Way NOT To Do It..

http://www.nurstoon.com/comic208.html
http
://www.nurstoon.com/comic208.html

PLANNING Interventions/

Characteristics of interventions:
1. Individualized
2. Developed with others
3. Reflect current nursing practice
4. Based on scientific rationale
5. Provides for continuity of care

Documentation

Planning Interventions:
The nurse will

Assessment
Nursing care
Pharmacologic
Nutrition
Diagnostics
Education
Referrals

PLAN OF CARE
INTERVENTIONS:

Derived from the cause, the root,

etiology of the problem

Which Action is Appropriate?

Alterations in nutrition, less than

body requirements r/t pain and
anxiety aeb:
Obj. patient refused lunch.
Sub. Please take the food,
Im in pain.

Which Action is Appropriate?

The nurse will:

Administer/offer pain medication 30
minutes prior to meals.
or
Assist patient with menu selection
today.

Which action is Appropriate?

Alteration in nutrition less than body

requirements r/t dislike of hospital
food aeb:
obj.
Refused lunch.
subj. Please take food away.

Which Action is Appropriate?

The nurse will:

Assist patient with meal tray.
or..
Consult with MD re food from home.

PLANNING - Documentation

Plan of care:
1. Written by an R.N.
2. Initiated following
first patient contact
3. Readily available
4. Current

IMPLEMENTATION:

PUTTING THE
PLAN INTO
ACTION AND
OBSERVING
INITIAL
RESPONSES.

Implementation ANA Standard

Measurement
Criteria:
1. Utilizes evidence
based interventions
specific to
diagnosis
2. Implemented in a
safe and effective
manner.
3. Interventions are
documented.

IMPLEMENTATION - Stages

Preparation

Intervention

Documentation

1.
2.
3.
4.
5.

6.
7.

IMPLEMENTATION:
Interventions - The nurse will:
Assess
Provide Nursing Care
Administer medications
Provide nutrition
Evaluate diagnostic
findings
Instruct/Teach
Refer/Consult

EVALUATION:

DETERMINING IF THE PLAN HAS

WORKED, MAKING NECESSARY
CHANGES.

EVALUATION Steps:
1. Identify criteria
and standards.

4. Document
findings

2. Data collection

5. Terminate,
continue or
modify.

3. Interpret
findings

Implementation/Evaluation
Implementation:
Doing,
Delegating,
Recording

Planning

Evaluation:
Of outcomes,
Care plan,
Nursing care
Assessment

Diagnosis

EVALUATION Modification

When the patient continues to experience

the symptoms associated with the nursing
diagnosis.

On-going evaluation, comparing of the

outcomes with assessment data, making a
judgment about the patients progress may
determine need for revision / modification.

NURSING PROCESS

Identify Phases of Nursing

Process:
1. Analyzing & interpreting data
2. Initiating nursing interventions
3. Performing a physical examination
4. Determining outcomes with patient

Cont.
5. Revising plan of care
6. Interviewing the client
7. Writing a nursing diagnosis
8. Outcomes achieved?

Cont.
9. Developing interventions to achieve
outcomes
10. Recording care given
11. Developing a plan of care

The Case of Fecal

Impaction

Typical Question:

Mr. S. was medicated for abdominal pain (8); one hour later
continued to complain of pain (6). The nurse called the
physician who ordered additional medication. Thirty minutes
after medicated the patient reported pain at (1). Based on your
understanding of the nursing process as responsive to the
changing needs of patients, allowing the nurse to move back
and forth using steps most appropriate to the clients needs,
which steps of the process were used by the nurse in caring for
this patient?
assessment, diagnosis, implementation
implementation, evaluation, modification
assessment, implementation, evaluation
all 5 steps

Which one of the following is an

appropriate etiology for a nursing
diagnosis?

A.
B.
C.
D.

Myocardial infarction
Cardiac catherization
Abnormal blood gas levels
Increased airway secretions

The nurse is observing the new staff

member work with the patient. Of the
following activities, which one has the
greatest possibility of contributing to a
nosocomial infection and requires
correction?

A.

Washing hands before applying dressing

Taping a plastic bag to the bed rail for tissue
disposal
Placing a foley catheter bag on the bed
when moving patient
Using alcohol to cleanse the skin before
starting IV line

B.
C.
D.