Formulating a Nursing Diagnosis.pdf

Formulating a Nursing Diagnosis.pdf - Formulating a Nursing...

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Formulating a Nursing Diagnosis Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which you, as a nurse, are accountable (NANDA International, 2012). A nursing diagnosis focuses on a patient's actual or potential response to a health problem rather than on the physiological event, complication, or disease. A nurse cannot independently treat a medical diagnosis such as a tumor of the prostate. Collaborative problems occur or probably will occur in association with a specific disease, trauma, or treatment (Carpenito-Moyet, 2009). You need nursing knowledge to assess a patient's specific risk for these problems, identify the problems early, and take preventive action (Fig. 17-3). Critical thinking is necessary in identifying nursing diagnoses and collaborative problems so you appropriately individualize care for your patients. Types of Nursing Diagnoses FIND in your ACKLEY Nursing Diagnosis Handbook NANDA-I (2012) identifies three types of nursing diagnoses: actual diagnoses, risk diagnoses, and health promotion diagnoses. An actual nursing diagnosis describes human responses to health conditions or life processes that exist in an individual, family, or community. Defining characteristics support the diagnostic judgment (NANDA International, 2012). The selection of an actual diagnosis indicates that there are sufficient assessment data to establish the nursing diagnosis. Tonya assessed Mr. Jacobs as having discomfort from the prostatectomy incision with a severity rated at 7 on a 10-point rating scale. The pain increased with movement. As a result of the pain, Mr. Jacobs has limited movement in bed. Acute pain is an actual nursing diagnosis. Examples of other actual diagnoses include: •Wandering •Impaired social interaction •Stress urinary incontinence A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community (NANDA International, 2012). These diagnoses do not have related factors or defining characteristics because they have not occurred yet. Instead a risk diagnosis has risk factors. Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem. For example, after Mr. Jacobs’ surgery, the presence of his incision, an open wound, poses a risk for a hospital-acquired infection. The key assessment for a risk diagnosis is the presence of risk factors (e.g., an incision and the hospital environment) that support a patient's vulnerability. The risk factors are the diagnostic-related factors that help i n planning preventive health care measures. In Mr. Jacobs’ case risk for infection is appropriate for his condition. Other examples of risk nursing diagnoses include: •Risk for loneliness •Risk for acute confusion
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A health promotion nursing diagnosis is a clinical judgment of a person's, family's, or community's
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