Nursing process, Nursing Diagnosis
- 1. By :- Baljinder Singh M Sc MSN
- 2. Benefits of using the nursing process for client Continuity of care Prevention of duplication Individualized care Standards of care Increased client participation Collaboration of care
- 3. 5 components of the Nursing Process: 1. Assessment 2. Diagnosis 3. Planning 4. Implementing 5. Evaluating
- 5. 1st Component of the Nursing Process- ASSESSMENT: The first step in the nursing process involves the following: Collecting data. Validating data. Organizing data. Interpreting data. Documenting data
- 6. ASSESSMENT Assessment is obtain information about a patient response to health concerns/illness and their ability to manage these health care issues
- 7. Purpose of Assessment To establish a database concerning a client’s physical, psychosocial, and emotional health. To identify health-promoting behaviors as well as actual and/or potential health problems.
- 8. Types of Assessment Comprehensive - Provides baseline data including complete health history and current needs assessment. Focused - Limited in scope in order to focus on a particular need or concern or potential risk. Ongoing - Includes systematic monitoring and observation related to specific problems.
- 9. Sources of Data Primary Source: The client. Secondary Source: The client’s family members, other health care providers, and medical records.
- 10. Types of Data Subjective: Data from client’s (and sometimes family’s) point of view. Includes feelings, perceptions, and concerns. Collected by the interview. Objective: Also called signs. Observable and measurable data obtained through physical examination and laboratory and diagnostic testing.
- 11. METHOD OF DATA COLLECTION Observation Interview that can be Directive or Non directive Physical examination:- ->Inspection ->Palpation ->percussion ->Auscultation
- 13. Validating Data Validation prevents omissions, misunderstandings, and incorrect inferences and conclusions.
- 14. Organizing Data Collected information must be organized to be useful. Data Clustering is a useful tool to identify issues.
- 15. Interpreting Data Three critical components: Distinguishing between relevant and irrelevant data Determining whether and where there are gaps in the data Identifying patterns of cause and effect
- 16. Documenting Data Assessment data must be recorded and reported. Accurate and complete recording of assessment data is essential for communicating information to health care team.
- 17. NURSING Diagnosis A medical diagnosis is a clinical judgment by the physician that determines a specific disease, condition or pathological state. According to “NANDA” nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.
- 18. Diagnostic Analysis Data validatio n Data Clustering Analysis & Interpretation of data Identification of clients need Formulation of Nursing Diagnosis
- 19. A.Analysis and Interpretation Of Data: After completing the nursing assessment, the nurse proceeds to the process of forming appropriate nursing diagnosis. In the assessment phase, data are initially collected from a variety of source and validated. The nurse then applies reasoning and begins to look for patterns in the assessment data.
- 20. 1. Identify Abnormal Data And Strengths: Identifying abnormal findings and strengths requires the nurse to have and use a knowledge base of anatomy and physiology, psychology and sociology.
- 21. 2. Cluster The Data: In this step the nurse looks at the identified abnormal findings and strengths for cues that are related. Both abnormal cues and strength cues should be clustered and a particular nursing framework should be used as a guide when possible.
- 22. B. Draw inferences and identify the problem Nurse will identify the client health problem and determine what you can treat independently. i.e something that nurse would intervene and treat independently. Another purpose of this step is the referral of identified problems for which the nurse cannot prescribe the definitive treatment. E.g. diabetic client who is having trouble with understanding the exchange diet. Although the nurse has knowledge in this area so she can advice about diet.
- 23. C. Propse possible nursing diagnosis:- After identifying health problem nurse has to frame nursing diagnosis, nursing diagnosis may be wellness diagnosis, risk diagnosis or actual diagnosis.
- 24. Types of Nursing Diagnosis Actual nursing diagnosis: A problem exists; it is composed of the diagnostic label, related factors, and signs and symptoms. Risk nursing diagnosis: A problem does not yet exist, but special risk factors are present. Wellness nursing diagnosis: Indicates client’s desire to attain higher level of wellness in some area of function.
- 25. Nursing Diagnosis is a Two-Part Statement A problem statement or diagnostic label that describes the client’s response to an actual or potential health problem or wellness condition. And the etiology - the related cause or contributor to the problem.
- 26. Nursing Diagnosis Wellness diagnosis Risk diagnosis Actual diagnosis •Opportunity to enhance body image •Opportunity to enhance effective breast feeding •Risk for altered body image •Risk for altered family process •Altered body image related to hand wound that is not healing •Altered family process related to hospitalization
- 27. Nursing Diagnosis Questions Are there problems here? If so, what are the specific problems? What are some possible causes? Is there a situation involving risk factors? What are the risk factors? What are the client’s strengths? What data are available to answer these questions? Is more data needed? If so, what are the possible sources of further data?
- 28. Advantages Of Nursing Diagnosis : Nursing diagnosis is advantageous for both nurses and clients:- 1. They facilitate communication among nurse about the client‘s level of wellness and assist in discharge planning. 2. Nursing diagnosis helps in prioritizing the client‘s needs.
- 29. Cont… 3. nursing diagnosis are also used for charting in the progress notes, writing referrals and providing effective transition of care from one unit to another, from one clinic to another or from the hospital to community. 4. Nursing diagnosis can also serve as focus for quality improvement. When focusing the nursing diagnosis the reviewer can determine whether nursing care was correct and delivered according to standards of practice. 5. Nursing diagnosis is beneficial for the client and family.