Diagnosis: Components and Diagnostic Statement Guidelines (Nursing)

by Samantha Rhea, MSN, RN

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    00:01 So now, let's talk about this.

    00:02 There are three different nursing diagnosis.

    00:05 I know this may make it seem more complicated, but these are actually important for you to know as a nurse.

    00:11 And we'll talk through each one of these.

    00:13 So the actual nursing diagnosis is a little bit easier.

    00:17 For example, this describes the actual condition, or the life process here.

    00:22 Such as if you remember, impaired skin integrity.

    00:26 So when we look at the patient, we do an assessment.

    00:29 The patient has a stage one pressure ulcer, for example.

    00:33 That's an actual problem, right? Now, here's a really common one, a risk for nursing diagnosis.

    00:41 Now, it's important that you don't over utilize these because patients are at risk for a lot.

    00:47 Here's a great example of these.

    00:49 Risk for infection, risk for falls, for example.

    00:53 As you can imagine, in hospital, or in nursing, or when you're taking care of patients risk for infection can happen to a lot of them, right? Or risk for falls.

    01:03 That can be many patients that were taken care of.

    01:06 So make sure you use these appropriately.

    01:09 And lastly, there's a health promotion nursing diagnosis.

    01:13 This is really important because we are assessing the readiness, or the well being of our patient.

    01:19 An example of this is readiness for enhanced oh, compliance with your medication, for example.

    01:26 So don't forget, when we're talking about nursing diagnosis, we're looking at the holistic picture of our patient.

    01:33 So now let's look at the nitty gritty here.

    01:36 This is the components of a nursing diagnosis statement.

    01:40 So you're going to hear this a lot, and probably have to formulate this in your nursing care plan, for example, for your school.

    01:47 So let's start first with the nursing diagnosis.

    01:50 If you remember back to NANDA, there are certain ones that are prescribed by NANDA that are specific to a patient's response.

    01:59 Now, we're going to take the nursing diagnosis plus the related to factor.

    02:03 Now, the related to, all you need to know is the related to is the cause of that nursing diagnosis.

    02:10 Next, we're going to have our signs and symptoms of our information.

    02:15 And then this is going to give us a nursing diagnosis.

    02:17 So let's run through a pretty simple example for you.

    02:20 So there's a nursing NANDA diagnosis.

    02:22 We've talked about this previously.

    02:25 Impaired skin integrity.

    02:27 This is an approved NANDA nursing diagnosis.

    02:30 What's the cause of this guy, is right.

    02:33 The cause is abdominal surgery in this particular patient.

    02:38 And we know this, that they have impaired skin integrity.

    02:42 The signs that we have, are a 4 by 4 abdominal incision.

    02:46 And this creates our nursing diagnosis that's specific to our patient.

    02:53 So again, just looking at this slide.

    02:54 We've got our impaired skin integrity.

    02:57 It's caused by that abdominal surgery.

    03:00 And we know this is true by our signs and symptoms are a sign of our 4 by 4 abdominal incision.

    03:07 And again, just know, every nursing statement needs to be specific to your patient.

    03:14 Now, when we're talking about nursing diagnosis.

    03:16 It's also important to consider the patient's culture when we're talking about questions and gathering information.

    03:23 So we may ask, how is this health problem affected you and your family? As you can imagine, when we're talking about any sort of illness, or any sort of patient problem, this can affect the family dynamics greatly and maybe even their role.

    03:38 So also, you want to ask your patient, what do you believe will help, or fix the problem? Now, as you can imagine, every patient's not the same.

    03:47 So maybe what the nurse thinks will help the problem.

    03:50 That may not be what's best for the patient.

    03:52 So make sure you include them in that plan of care.

    03:55 Also, what worries you most about the problem? You want to ask this about your patient, because what you may think as a priority may not be the priority for your patient, right? And also, what practices within your culture are important to you? This is a really important questions because this can change our treatment, it can change our plan of care.

    04:16 So we want to make sure that we're aware of this before we formulate a nursing diagnosis, and carry out treatment for a patient.

    04:24 Now, just key note, guys.

    04:26 Cultural awareness and sensitivity is going to help us be much more accurate in making our nursing diagnosis.

    04:34 Let's take a look of sources of diagnostic error in making a nursing diagnosis.

    04:39 So if you remember this graphic from earlier, this is showing us how we get from a nursing diagnosis with of course starting with assessment, clustering that data, identifying your patient's needs, which of course leads toward nursing diagnosis.

    04:53 So one of the missteps that we can make is when we collect that information, we're doing it in an unorganized manner.

    05:01 The reason why this is a problem, we may fail to cluster data appropriately and make those clinical connections.

    05:08 Also, if we don't validate it that information, that could be inaccurate data.

    05:13 Just remember, when you are collecting data, it is important that you do this correctly.

    05:19 Because if we don't do this or not at all, we're not getting the whole clinical picture.

    05:24 And of course, make sure you include the patient in the plan of care.

    05:28 Because again, what you may perceive as the patient issue may not be the same as your patient.

    05:35 So you've got to make sure that you're working with your patient for an accurate plan of care.

    05:40 And lastly, when we're forming our diagnosis, we need to make sure we're using appropriate, and concise, and appropriate language here.

    05:49 So a few guidelines to remember when we're making a diagnostic statement.

    05:53 We're looking for those patient problems that can be addressed by nursing interventions.

    05:59 The reason why I'm bringing out this point is this has got to be addressed within the nurses scope of practice.

    06:05 And also remember, as you can imagine assessing a patient, they may have a multitude of issues.

    06:11 We need to identify their priority in one patient problem when we're talking about each diagnostic statement.

    About the Lecture

    The lecture Diagnosis: Components and Diagnostic Statement Guidelines (Nursing) by Samantha Rhea, MSN, RN is from the course Nursing Process – Assessment, Diagnosis, Planning, Interventions, and Evaluation.

    Included Quiz Questions

    1. A health promotion nursing diagnosis focuses on a client’s motivation, desire, and readiness to enhance well-being
    2. An actual nursing diagnosis describes a current problem, while a risk for nursing diagnosis describes a potential problem
    3. A risk for nursing diagnosis describes a current problem, while an actual nursing diagnosis describes a potential problem
    4. A health promotion nursing diagnosis describes a current problem, while an actual nursing diagnosis describes a potential problem
    1. Impaired skin integrity related to immobilization as evidenced by stage I pressure ulcer to the coccyx
    2. Impaired bed mobility related to recent hip fracture as evidenced by the client being unable to turn independently in bed
    3. Ineffective coping related to a recent death in the family
    4. Fluid volume excess as evidenced by bilateral lower leg pitting edema
    1. Not being able to cluster data appropriately
    2. Not validating the data collected
    3. Not including the client in the plan of care
    4. Not using specific medical diagnoses in the nursing diagnosis statement
    5. Not using at least two client problems in each diagnostic statement

    Author of lecture Diagnosis: Components and Diagnostic Statement Guidelines (Nursing)

     Samantha Rhea, MSN, RN

    Samantha Rhea, MSN, RN

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