00:01
So now,
let's talk about this.
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There are three different
nursing diagnosis.
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I know this may make it seem
more complicated,
but these are actually
important for you
to know as a nurse.
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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.
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Such as if you remember,
impaired skin integrity.
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So when we look at the patient,
we do an assessment.
00:29
The patient has a stage one
pressure ulcer, for example.
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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.
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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.
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And then this is going to give us
a nursing diagnosis.
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So let's run through
a pretty simple example for you.
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So there's a
nursing NANDA diagnosis.
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We've talked about this
previously.
02:25
Impaired skin integrity.
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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.
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And we know this,
that they have
impaired skin integrity.
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The signs that we have,
are a 4 by 4 abdominal incision.
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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.
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It's caused by that
abdominal surgery.
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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.
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So maybe what the nurse thinks
will help the problem.
03:50
That may not be
what's best for the patient.
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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.
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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.
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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.
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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.
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Just remember,
when you are collecting data,
it is important
that you do this correctly.
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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.
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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.