Vous êtes sur la page 1sur 27

Care Mapping

Technologies in Nursing
Duquesne University

History of Nursing Diagnosis


First introduced in 1950.
In 1953 Fry proposed the formulation
of nursing diagnosis.
In 1973, the first national conference
was held.
In 1982, NANDA was founded.

Critical Thinking and the Nursing


Diagnostic Process

Diagnostic reasoning
A process of using assessment data to
create a nursing diagnosis

Defining characteristics
Clinical criteria or assessment findings

Clinical criteria
Objective or subjective signs and symptoms

Nursing Diagnosis (Match the


term to the definition)
1. Medical diagnosis

A. Clinical judgment
about the client in
response to an actual or
potential health problem

2. Nursing diagnosis

B. The identification of a
disease condition based
on specific evaluation of
signs and symptoms

3. Collaborative problem C. An actual or potential


complication that nurses
monitor to detect a
change in client status

Formulation of Nursing Diagnosis


(Match the term with the definition)
1. Actual Nursing
Diagnosis

A. Describe human

2. Risk Nursing
Diagnosis

B. Describes human

3. Wellness Nursing
Diagnosis

C. Describes human

responses to levels of
wellness that have a
readiness for enhancement
responses to health
conditions/life processes that
may develop
responses to health conditions
or life processes

Components of the nursing diagnosis:

Problem
Etiology
Signs and Symptoms

Nursing Diagnosis: Application


to Care Planning
By learning to make accurate nursing
diagnoses, your care plan will help
communicate the clients health care
problems to other professionals.
A nursing diagnosis will ensure that
you select relevant and appropriate
nursing interventions.

Problem

Problemthe name or diagnostic label


identified from the NANDA list. This may
be an actual problem, a risk (potential)
problem, or a wellness diagnosis.

Etiology
The

suspected cause or reason


for the response that has been
identified from the assessment

Signs and Symptoms


They

are stated as
evidenced by (A.E.B.) or as
manifested by, followed by a
list of subjective and
objective data.
Risk problems have no
evidence statement.

Correctly-Worded Nursing
Diagnoses
Ineffective Airway Clearance, related to
increased pulmonary secretions and
bronchospasm, evidenced by wheezing,
tachypnea, and ineffective cough.
Acute pain related to tissue distention and
edema as evidenced by reports of severe
colicky pain in right flank, elevated pulse
and respirations, and restlessness.

Correctly-Worded Nursing
Diagnoses
Hyperthermia related to increased
metabolic rate and dehydration as
evidenced by elevated temperature, flushed
skin, tachycardia, and tachypnea.
Risk for infection, related to broken skin,
traumatized tissues, decreased hemoglobin,
invasive procedures, increased
environmental exposure.

Right or Wrong?
Risk

for skin breakdown


related to immobility as
evidenced by stage III
sacral wound (7 X3 cm)

Right or Wrong?
Pain

related to myocardial
infarction as evidenced by
patients report of pain at 9
on the 1-10 pain scale

Right or Wrong?
Ineffective

airway clearance
related to pneumonia as
evidenced by adventitious
breath sounds, sputum
production, and abnormal chest
x-ray.

Right or Wrong?
Fluid

volume deficit related to


blood loss through wound as
evidenced by hemoglobin of
8 and hematocrit of 26%

Right or Wrong?
Fluid

volume deficit related to


NPO status as evidenced by
weight loss

Right or Wrong?
Diarrhea

related to C. Diff as
evidenced by 10 stool in one
day

Right or Wrong?
Risk

for infection related to


invasive procedure (surgery)

Right or Wrong?
Readiness

for enhanced
knowledge of disease process.

Potential Complications
Based

on a medical diagnosis
Examples:
Risk for pneumonia related to immobility
Risk for DVT related to immobility
Risk for myocardial infarction related to
inadequate tissue perfusion

Primary Goal or Objective


Written

in general terms
Not behavioral in nature
Patient centered
Example: To enhance airway
clearance and improve
oxygenation

Nursing Interventions
Actions

that the nurse carries out for


the client or encourages the client to
do for themselves.
Include interdisciplinary actions, but
identify them as such.
Includes assessment
Includes teaching the client
Include the rationale for the
intervention.

Desired behavioral outcomes/goals


should be SMART
Specific
Measurable
Attainable
Realistic
Time

oriented

Examples of SMART Goals


The patient will identify four
adaptive/protective measures for individual
situation by discharge.
The patient will maintain a patent airway,
ongoing. (This outcome is stated as ongoing
and does not include a specific timeframe
other than discharge from care. In this
example, this is appropriate because the
situation may not resolve until the patients
condition or status changes or discharge has
occurred.)

Examples of SMART Goals


The patient will be free of skin breakdown.
(This is another example of an ongoing
outcome).
The patient will demonstrate correct insulin
administration techniques within 48 hours.
The patient will attain pain relief identified as a
3 on the 0-10 pain scale 30 minutes after
being medicated with pain medication.
The patient will maintain an oxygen saturation
of 92 or higher.
The patient will not incur a fall.

Evaluation or Outcome

Should refer directly to the nursing


diagnosis and to the goal.