Diagnosing Diagnosis the statement or conclusion regarding the

Diagnosing • Diagnosis: the statement or conclusion regarding the nature of a phenomenon • Diagnostic labels: Standardised NANDA names for the diagnosis. • Nursing Diagnosis: problem statement (Diagnostic labels + etiology)

• Nursing Diagnoses provide a basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable • Registered nurses are responsible for making nursing diagnoses • Ng Dx. Includes only those health states that nurses educated and licensed to treat.

Types of Ng. Dx. • An actual diagnosis: Present at time of assessment (Ineffective Breathing Pattern) (Anxiety) • A risk Ng. Dx. : CJ that problem does not exist, but risk factors indicate that a problem is likely to develop (Risk for infection)

• A wellness Dx. (Readiness for enhanced family coping) • Possible Ng Dx. : incomplete evidence about a health problem (Possible social isolation related to unknown etiology)

• A syndrome Dx: Associated with a cluster of other DX. (Bed ridden patients= Risk for impaired tissue integrity, risk for infection…. )

Components of Ng Dx • Problem statement (Deficient, Impaired, Decreased, Ineffective) • Etiology (related factors, risk factors) • Defining Ch. (S+S)

EXAMPLE • Ineffective Breathing r/to bed rest and immobility. • Defining Ch. = verbal report of fatigue or weakness, abnormal respiratory rate and respiratory activity, Dyspnea.

Ng Dx and Medical Dx Ng Dx Medical Dx Nurse licensed to treat Physician licensed to treat Describes client’s physical, sociocultural, psychological, and spiritual responses to illness or health problem Refers to disease process

• Dependent functions • Independent functions • Collaborative problem: potential problems that nurses manage using both independent and dependent interventions (Potential complication of HTN: CVA, immobility…. )

Diagnostic Process 1. 2. 3. Analyse data Identify problem Formulate Dx * Elimination: * Decreased Urinary Frequency and amount/ 2 days * Fluid volume deficit * Impaired Urinary elimination r/t insufficient fluids intake, fluid loss, fever, diaphoresis, anorexia

Examples of Ng Dx. • Constipation r/to prolonged (complete) bed rest. Basic two-part Dx. Statement • Noncompliance (diabetic diet) r/to unresolved anger about diagnosis as manifested by (subjective: I forget to take my pills, objective: weight gain of 5 kg. ). Basic three-part Dx. Statement. • Risk for impaired skin integrity (Left lateral ankle) r/to decreased peripheral circulation secondary to diabetes.

. • Fluid replacement r/to fever • Need vs response • Deficient fluid volume r/to fever • Pain r/to sever headache. • Cause and effect • Pain: Sever headache r/to fear of addiction to narcotics

• Impaired skin integrity r/to bad positioning • Judgmental • Impaired skin integrity r/to immobility

• Risk of acute Myocardial infarction • Medical Dx • Potential complication of AMI: Ineffective airway clearance