NURSING PROCESS
-Mrs. Sheetal Sameer Kothare
Leelabai Thackersey College of Nursing
Nursing diagnosis
• A nursing diagnosis is a clinical judgment concerning human
response to health conditions/life processes, or a vulnerability for that
response, by an individual, family, group, or community.
• Nursing diagnoses are developed based on data obtained during the
nursing assessment and enable the nurse to develop the care plan.
Nursing diagnosis -purpose
• Identify nursing priorities
• Formulation of expected outcomes
• Identify how a client or group responds to actual or potential health and life
processes
• Knowing their available resources of strengths that can be drawn upon to
prevent or resolve problems
• Provides a common language and forms a basis for communication and
understanding between nursing professionals and the healthcare team.
• Provides a basis of evaluation to determine if nursing care was beneficial to
the client and cost-effective.
• For nursing students, nursing diagnoses are an effective teaching tool to
help sharpen their problem-solving and critical thinking skills.
Difference between Medical and Nursing
Diagnoses
• Nursing diagnosis are matters that hold a distinct and precise action
that is associated with what nurses have autonomy to take action about
with a specific disease or condition. This includes anything that is a
physical, mental, and spiritual type of response. Hence, a nursing
diagnosis is focused on care.
• A medical diagnosis, on the other hand, is made by the physician or
advance health care practitioner that deals more with the disease,
medical condition, or pathological state only a practitioner can treat
(Focused on treatment).
Nursing Diagnosis Medical diagnosis
Ineffective airway clearance Pneumonia
Disturbed body image Amputation
Risk for unstable blood glucose Diabetes Mellitus
Impaired urinary elimination Post- op Prostatectomy
Self-care deficit: dressing and Cerebrovascular accidents
grooming
NANDA International (NANDA-I)
North American Nursing Diagnosis Association
(NANDA)-International
As of 2018, NANDA-I has approved 244 diagnoses for
clinical use, testing, and refinement.
Classification of Nursing Diagnoses (Taxonomy II)
Nursing Process-five stages
• Assessment,
• Diagnosing,
• Planning,
• Implementation, and
• Evaluation
Nursing process
• In 1958, Ida Jean Orlando started the nursing process that still guides
nursing care today.
• Defined as a systematic approach to care using the fundamental
principles of critical thinking, client-centered approaches to treatment,
goal-oriented tasks, evidence-based practice (EDP) recommendations,
and nursing intuition.
Assessment
• The first step and involves critical thinking skills and data collection;
subjective and objective.
• Subjective data involves verbal statements from the patient or
caregiver.
• Objective data is measurable, tangible data such as vital signs, intake
and output, and height and weight.
Diagnosis
• The North American Nursing Diagnosis Association (NANDA) provides
nurses with an up to date list of nursing diagnoses.
• A nursing diagnosis encompasses Maslow's Hierarchy of Needs and helps
to prioritize and plan care based on patient-centered outcomes.
Maslow's Hierarchy of Needs
• Basic Physiological needs: Airway (suction)-breathing (oxygen)-circulation (pulse,
cardiac monitor, blood pressure) (ABC's), Nutrition (water and food), elimination
(Toileting), sleep, sex, shelter, and exercise.
• Safety and Security: Injury prevention (side rails, call lights, hand hygiene, isolation,
suicide precautions, fall precautions, car seats, helmets, seat belts), fostering a climate of
trust and safety (therapeutic relationship), patient education (modifiable risk factors for
stroke, heart disease).
• Love and Belonging: Foster supportive relationships, methods to avoid social isolation
(bullying), employ active listening techniques, therapeutic communication, sexual
intimacy.
• Self-Esteem: Acceptance in the community, workforce, personal achievement, sense of
control or empowerment, accepting one's physical appearance or body habitus.
Planning
• The planning stage is where goals and outcomes are formulated that
directly impact patient care based on EDP guidelines.
• Goals should be:
-Specific
-Measurable or Meaningful
-Attainable or Action-Oriented
-Realistic or Results-Oriented
-Timely or Time-Oriented
Implementation
This step involves action or doing and the actual carrying out of nursing
interventions outlined in the plan of care.
e.g. applying a cardiac monitor or oxygen, direct or indirect care,
medication administration, standard treatment protocols and EDP
standards.
Evaluation
This final step of the nursing process is vital to a positive patient
outcome. Reassessment may frequently be needed depending upon
overall patient condition. The plan of care may be adapted based on new
assessment data.
Problem-Focused Nursing Diagnosis
• Also known as actual diagnosis.
• It has three components: (1) nursing diagnosis, (2) related factors,
and (3) defining characteristics.
• Examples :
Ineffective breathing pattern
Anxiety
Acute pain
Impaired skin integrity
Risk Nursing Diagnosis
• The individual (or group) is more susceptible to develop the problem than
others in the same or a similar situation because of risk factors.
• Components of a risk nursing diagnosis include: (1) risk diagnostic label,
and (2) risk factors.
• Examples:
Risk of Falls
Risk for Injury
Health promotion diagnosis
• Also known as wellness diagnosis.
• Health promotion diagnosis is concerned in the individual, family, or community
transition from a specific level of wellness to a higher level of wellness.
• Components of a health promotion diagnosis generally include only the diagnostic
label or a one-part-statement.
• Examples:
Readiness for Enhanced Spiritual Well Being
Readiness for Enhanced Family Coping
Readiness for Enhanced Parenting
Syndrome Diagnosis
• A syndrome diagnosis is a clinical judgment concerning with a
cluster of problem or risk nursing diagnoses that are predicted to
present because of a certain situation or event.
• One-part statement
• Examples:
Chronic Pain Syndrome
Post-trauma Syndrome
Frail Elderly Syndrome
Possible Nursing Diagnosis
• A possible nursing diagnosis is not a type of diagnosis as are actual,
risk, health promotion, and syndrome. Possible nursing diagnoses are
statements describing a suspected problem for which additional data
are needed to confirm or rule out the suspected problem.
• Examples:
Possible Chronic Low Self-Esteem
Possible Social Isolation.
Components of a Nursing Diagnosis
(1)the problem and its definition,
(2)the etiology, and
(3) the defining characteristics.
How to write statement of Nursing
Diagnosis as per NANDA-I?
Problem and Definition or the diagnostic
label
• It has two parts: qualifier and focus of the diagnosis.
• Qualifiers (also called modifiers) are words that have been added to
some diagnostic labels to give additional meaning, limit or specify the
diagnostic statement. Exempted in this rule are one-word nursing
diagnoses (e.g., Anxiety, Fatigue, and Nausea) where their qualifier
and focus are inherent in the one term.
Qualifier Focus of the Diagnosis
Deficient Fluid volume
Imbalanced Nutrition: Less Than Body Requirements
Impaired Gas Exchange
Ineffective Tissue Perfusion
Risk for Injury
Etiology (related to)
• The etiology, or related factors and risk factors, component of a
nursing diagnosis label identifies one or more probable causes of the
health problem.
• Nursing interventions should be aimed at etiological factors in order to
remove the underlying cause of the nursing diagnosis.
Defining characteristics (as evidenced by)
• Defining characteristics are the clusters of signs and
symptoms that indicate the presence of a particular
diagnostic label.
extremities
One-Part Nursing Diagnosis
• One-Part Nursing Diagnosis Statement- Health promotion nursing
diagnoses
• Examples:
Readiness for Enhance Breastfeeding
Readiness for Enhanced Coping
Rape Trauma Syndrome
Two-Part Nursing Diagnosis Statement
• Risk and possible nursing diagnoses have two-part statements.
• The first part is the diagnostic label and the second is the validation for a
risk nursing diagnosis or the presence of risk factors.
• Examples:
Risk for Infection related to compromised host defenses
Risk for Injury related to abnormal blood profile
Possible Social Isolation related to unknown etiology
Three-part Nursing Diagnosis Statement
• Examples:
Impaired Physical Mobility related to decreased muscle control as
evidenced by inability to control lower extremities.
Acute Pain related to tissue ischemia as evidenced by statement of “I
feel severe pain on my chest!”
Variations on Basic Statement Formats
• Using “secondary to” to divide the etiology into two parts to make the
diagnostic statement more descriptive and useful. Following the
“secondary to” is often a pathophysiologic or diseases process or a
medical diagnosis. For example, Risk for Decreased Cardiac
Output related to reduce preload secondary to myocardial infarction.
• Using “complex factors” when there are too many etiologic factors or
when they are too complex to state in a brief phrase. For
example, Chronic Low Self-Esteem related to complex factors.
Variations on Basic Statement Formats
• Using “unknown etiology” when the defining characteristics are
present but the nurse does not know the cause or contributing factors.
For example, Ineffective Coping related to unknown etiology.
• Specifying a second part to the general response or NANDA label to
make it more precise. For example, Impaired Skin Integrity (Right
Anterior Chest) related to disruption of skin surface secondary to burn
injury.
Nursing Diagnosis List-Refer the link given
below
https://nurseslabs.com/nursing-diagnosis/
Self Study Assignment
Click on the link given below, study the mind map on respiratory
distress syndrome and write nursing care plan based on nursing
process.
Link:
https://www.mindmeister.com/1008643386/acute-respiratory-
distress-syndrome
Thank you
