Prepared by: Pracy cheung

The North American Nursing Diagnosis Association (NANDA) defined nursing diagnosis as: a clinical judgment about individual, family, or community responses to actual or potential health problems / life process. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. (NANDA, 1990)

Stages of nursing process

Assessment (1) Evaluation (5) Diagnosis (2)

Implementation (4)

Planning (3)
3

Nursing diagnosis is the 2nd step of the nursing process In this step, nurses analyze data collected during the assessment stage (stage 1) and evaluate the clients health status Nurses will then conclude the results from the data analysis to decide, whether or not, to make a nursing diagnosis

FIVE types of nursing diagnoses: 1) Actual 2) Risk 3) Possible 4) Wellness 5) Syndrome

THREE types of diagnostic statements consisting of: 1) ONE part (Label) diagnostic statement 2) TWO parts (label + contributing factors) 3) THREE parts (label + contributing factors + signs / symptoms)

One-part statement e.g. Self-care, Readiness for Enhanced Two-part statement e.g. Risk For Impaired skin integrity related to immobility and injury Three-part statement e.g. Impaired skin integrity related to prolonged immobility secondary to fractured pelvis, as evidenced by a 2-cm sacral lesion

e.g. Impaired skin integrity related to prolonged immobility secondary to fractured pelvis, as evidenced by a 2-cm sacral lesion

Problem (Diagnostic Label)

related to

Contributing factors

as evidenced by

Signs and symptoms

(Part I )
Impaired skin integrity

(Part II)
fractured pelvis & sacral lesion

(Part III)
Immobility

Refers to a problem that has been validated by the presence of major defining characteristics Three- parts nursing diagnostic statements FOUR components: 1) Label 2) Definition 3) Defining characteristics 4) Related factors

1) Label clear, concise that convey the meaning of the nursing diagnosis 2) Definition add clarity to the diagnostic label & to differentiate the particular nursing diagnoses from other similar diagnoses

3) Defining

characteristics ~ signs & symptoms that represent the nursing diagnoses ~ major defining characteristics (must be present) ~ minor defining characteristics (may be present)

4) Related factors ~ contributing factors that influenced the change in clients health status

A 50-year-old man, Dave, was admitted to the A & E because of acute chest pain. Cardiac surgery had been arranged after a series of investigations & examinations by case doctor. Dave was then transferred to a surgical ward afterwards. He appeared very restless and paced ups and downs for most of the time. Occasional shortness of breath was also noted. His speech content was always rapid, and slurred

Question:

What is your actual nursing diagnosis to Dave?

Actual Nursing Diagnosis: Anxiety related to cardiac surgery as evidenced by restlessness, rapid speech, and pacing.

Label: anxiety Related (Contributing) factors: Cardiac surgery Defining characteristics (major): Exhibits the signs & symptoms (restlessness, rapid speech & pacing) for (80% -100%) Signs & symptoms: restlessness, rapid speech, & pacing

Defined as a clinical judgment that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation. (NANDA, 1990) at risk or risk for is used commonly in clinical settings e.g. 1) Falls, Risk for 2) Skin Integrity, Risk for Impaired 3) Suicide, Risk for

Risk for Impaired Skin Integrity related to immobility secondary to pain as evidenced by 2-cm erythematous sacral lesion
Label & definition: Risk for impaired skin integrity Defining characteristics: immobility + pain (major + minor) Related factors: 2-cm erythematous sacral lesion

Statements that describe a suspected problem which required additional data before making the conclusion Consists of two-part statements Example: Possible Disturbed Self-Concept related to recent loss of responsibilities secondary to worsening of multiple sclerosis Normally considered as tentative nursing diagnosis before making an Actual or Risk Nursing Diagnosis

Refers to a clinical judgment about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness. (NANDA, 1992) Two cues should be present: 1) desire for increased wellness 2) effective present status or function One part statement containing the label only No related factors are required e.g. (1) Self-care, Readiness for Enhanced (2) Coping, Readiness for Enhanced Family

A cluster of actual or risk nursing diagnoses Usually a one-part diagnostic statement Example: Rape Trauma Syndrome Anxiety (actual nursing diagnosis) related to Insomnia (actual nursing diagnosis) related to Fear (actual nursing diagnosis) related to Suicide, Risk for (risk nursing diagnosis) related to Sexuality patterns, Risk for (risk nursing diagnosis) related to..

Refer to physiological complications that nurses monitor to detect onset or changes in status Associated with a specific pathology or treatment All collaborative problems should begin with the diagnostic label Potential Complication (PC)

e.g. Potential Complication: Hypertension Potential Complication: Asthma Potential Complication: Peptic Ulcer Potential Complication: Hemorrhage Potential Complication: Infection Potential Complication: Urinary Retention Potential Complication: Hypovolemia / Shock Potential Complication: Gastrointestinal Bleeding

Data collection derives from TWO formats: 1) baseline / screening assessment 2) focus (ongoing) assessment 1) Baseline / screening assessment ~ collecting data during initial contact with the client + / family (e.g. on admission) ~ use of assessment tools to aid data collection (e.g. assessment forms, admission documents, questionnaires) ~ questioning (e.g. open-ended questions; close-ended questions) ~ Gordons Functional Health Pattern (11 catergories) provides an excellent format for data collection (refer to
lecture on Oct 25 2011)

Planning (2)
2) Focus (ongoing) assessment
~ acquisition of selected or specific data determined by nurse, client, or family
Initial Assessment Assessment Nursing Diagnosis Planning

Focus Assessment

Consists of THREE components: 1) Establish a priority set of nursing diagnoses 2) Design client goals and nursing goals (long term & short term goals) 3) Prescribe nursing interventions

Priority diagnoses Nursing Diagnoses or collaborative problems that, if not managed now, will deter clients progress to achieve outcomes or will negatively affect clients functional status Non-priority diagnoses Nursing Diagnoses / collaborative problems for which treatment can be delayed without compromising clients existing functional status

Client goals outcome criteria Standard of measures used to evaluate clients progress (outcome) or the nurses performance (process) Both client goals & nursing goals should be MEASURABLE Client goals serve to measure the effectiveness of the nursing care plan * If clients goals are NOT attained, nurses should evaluate the goal attainability and reformulate the care plan

Long term goals an objective that the client is expected to achieve over weeks / months Short term goals an objective that the client is expected to achieve in a few days, or as a stepping stone towards the long-term goal Example: Suicide, Risk for (nursing diagnosis) Goals: Client will state she wants to live (Long term goal) Client will discuss feelings of pain (Short term goal) Client will have no suicidal contract with nurse by the end of first session (Short term goal)

Expected outcomes should be SMART:

Specific Measurable Achievable Realistic Timeline

Nursing Diagnosis: Self-care deficit, bathing related to prolonged immobility & pain Goal: Client will report reduced pain and improved mobility by discharge (long term goal) Individualized goals: 1) Client will be able to take a bath without assistance (short term goal) 2) Client will report reduced pain (<5 on 0 to 10 scale) (short term goal) 3) Client will remain out of bed from 11am to 2 pm and from 5pm to 9 pm daily (short term goal)

Implement -> take necessary nursing actions / interventions to achieve the nursing goals Require Skills + knowledge to implement nursing interventions by: assisting the client to identify risks or health problems assisting / encourage the client to perform the activity teaching client to gain knowledge /information regarding their health problems / manage their health problems assisting the clients to make decisions about their own health care providing treatment actions and options to resolve, reduce, or remove health problems consulting and / referring client to other health care team members to facilitate recovery (e.g. referral to physiotherapy for walking exercise; referral to chaplaincy for spiritual distress)

Includes THREE considerations: 1) Evaluate clients status 2) Evaluate clients progress towards goal achievement 3) Evaluate the status of the nursing care plan e.g. if the nursing goal is the client will walk unaided to and from his bedside to the hallway by 1 Nov 2011. -> evaluate how far did the client walk? did he require any walking aids / assistance?

Evaluate in a systematic manner starting from 1) Nursing Diagnosis 2) Goals 3) Interventions 4) Collaborative problems

1) Nursing Diagnosis - Is the diagnosis still relevant to client care? - Is the high risk / risk diagnosis still existing? - Has the possible diagnosis been ruled out? - Is there a need to add a new diagnosis?

2) Goals - Have the goals been achieved? - Does the goal reflect the main focus of care? - Are the goals acceptable to the client? - Are there any specific modifiers to be added? 3) Interventions - Are the interventions specific, and acceptable to the client? 4) Collaborative problems - Is there a need to continue monitoring the collaborative problems?

After reviewing clients problems & nursing interventions, nurses will then DOCUMENT (RECORD) the evaluation in the nursing care plan + in clients progress notes (date / time of evaluation should be specified)

Categories: 1) Continue 2) Revised 3) Ruled out / confirmed 4) Achieved 5) Reinstate

Scott, has undergone a colostomy last week and is now transferred back to a post-operative unit under your care. He is sitting in bed for most of the day because of persistent abdominal pain. He seems to be restless at times and complains of pain on defecation.

Question: Discuss with fellow classmates to formulate a nursing care plan for Scott.

Hint: Remember the sequence of doing so. (Assessment: 1) Initial assessment Focus assessment 2) Planning 3) Goals 4) Interventions 5) Evaluation)

1) Initial assessment Gordons Functional Health Pattern 11 categories to conduct initial assessment 2) Focus assessment Obtain subjective & objective data

Assess Scotts elimination pattern e.g. How often do you have bowels open before colostomy? What about your stool? Soft, hard, or watery? Did you use any laxatives before? What kind of laxatives? How often? Do you have diarrhea? How often? Frequency? Duration? Precipitated by what?

(contd) Does Scott have any symptoms or complaints of ? Pain, lethargy, thirst, weakness, cramping, weight loss, anorexia, headache.. any awareness of bowel cues?

Assess for related (contributing factors) - Scotts level of activity at present - Occupation - Exercise pattern, how often? - Nutrition (e.g. usual 24- hr intake, any fiber?) - Amount / types of fluids taken /day

(contd) Assess Scotts medical surgical history (present and past) * Scott has just undergone colostomy surgical history. You then assess whether Scott had any other surgery prior to this current admission.

Assess for defining characteristics Stool colour / odor, any blood & mucus any parasites, pus, or undigested food Bowel sounds (by auscultation) ? High-pitched, gurgling, ? High-pitched, frequent, loud, pushing ? Weak and infrequent ? absent

Contd Assess for related factors Nutrition Types and amounts of food / fluid intake - Perianal / Rectal examination ? Any hemorrhoids, irritation, impaction, stool in rectum, fissures, control of rectal sphincter (? Presence of anal wink, bulbocavernosus reflex)

Nursing Diagnosis Constipation related to immobility and colostomy as evidenced by hard stool, pain on defecation, diminished bowel sounds and restlessness Planning Goal: 1) Scott will resume regular bowel movements by discharge (long term goal) 2) Scott will report bowel movements at least every two to three days (short term goal)

Nursing interventions: - regular time for elimination (e.g. 1 hr after meal) - adequate exercise (e.g. sit-ups) - balanced diet (e.g. fruits & vegetables, beans, fruit juices, increase fiber intake) - adequate fluid intake (~2 L /day) - optimal position (e.g. semisquatting; elevate legs on footstool whilst defecation)

(contd ) - health teaching - administer laxatives p.r.n. (e.g. glycerin suppository (per rectal) / metamucil (per orally) as medically prescribed Evaluation - Evaluate the effectiveness of the prescribed nursing interventions (Nursing goals Vs outcomes)
-

Documentation / Recording ? Continue the nursing care plan ? Revise the nursing care plan ? Any add-on to nursing interventions ? Any new nursing diagnosis

Defining characteristics: - Major (Must be present): ~hard, formed stool ~Defecation < 2 times / week ~Prolonged & difficult evacuation
- Minor (May be present): ~Decreased bowel sounds ~straining on defecation ~reported feeling of rectal fullness ~reported feeling of pressure in rectum ~palpable impaction ~feeling of inadequate emptying

References
Berman, A., & Snyder, S. (2012). Kozier and Erbs Fundamentals of Nursing: Concepts, process and practice (9th ed.). Pearson. Burton, M. (2011). Fundamentals of nursing care: concepts, connections, and skills. Philadelphia, PA: F. A. Davis. Carpento-Moyet, L. J. (2010). Nursing Diagnosis: application to clinical practice (13th ed.). Wolters Kluwer, Lippincott Williams & Wilkins. Gulanick, M., & Myers, J. L. (2011). Nursing care plans: diagnoses, interventions, and outcomes (7th ed.). St. Louis, Mo. : Elsevier Mosby.