Critical Thinking- Nursing Diagnosis

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Nursing diagnosis
Diagnosing is the second phase of the nursing process. In this phase, nurses use critical thinking skills to interpret assessment data and identify client strengths and problems.
The term diagnosing refers to the reasoning process, whereas the term diagnosis is a statement or conclusion regarding the nature of a phenomenon.
NANDA nursing diagnosis
North American nursing diagnosis association
The purpose of  NANDA is to define, refine and promote a taxonomy of nursing diagnostic terminology of general use to professional nurses.
A taxonomy is a classification system or set of categories arranged based on a single principle or set of principles.
The members of NANDA include staff nurses, clinical specialists, faculty, directors of nursing, deans , theorists and researchers.
Types of nursing diagnoses:
1.       Actual Diagnosis: client problem that is present at the time of the nursing assessment. Eg: ineffective breathing pattern, anxiety.
2.       Risk nursing diagnosis: is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. Eg: risk for infection, fall, injury
3.       Wellness diagnosis: describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement. Eg: readiness for enhanced family coping.
4.       Possible nursing diagnosis: is one in which evidence about a health problem is incomplete or unclear.
Eg: for an elderly widow who lives alone- possible social isolation related to unknown etiology
5.       Syndrome diagnosis: that is associate with cluster of other diagnoses. Eg: risk for disuse syndrome for a long term bedridden patients.
Clusters of diagnoses associated with this syndrome include
Impaired physical mobility
Risk for impaired tissue integrity
Risk for activity intolerance
Risk for constipation, Risk for infection
Risk for injury, Risk for powerlessness
Components of a NANDA diagnosis
A nursing diagnosis has three components
1.       The problem and its definition
2.       The etiology
3.       Defining characteristics
1.       Problem (diagnostic label) and definition
The problem statement or diagnostic label, describes the clients health problem or response for which nursing therapy is given.
The purpose of the diagnostic label is to direct the formation of client goals and described outcomes.
Eg: deficient knowledge (medications, dietary adjustments)
Qualifiers are words that have been added to some NANDA labels to give additional meaning. Eg:
Deficient (inadequate in amount, quality, or degree; not sufficient; incomplete)
Impaired (made worse, weakened, damaged, reduced, deteriorated)
Decreased (lesser in size, amount or degree)
2.  Etiology (related factors and risk factors)
Identifies one or more probable causes of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client's care. Eg:
Causes of activity intolerance include sedentary lifestyle, generalized weakness and so on
3.  Defining characteristics
Are the cluster of signs and symptoms that indicate the presence of a particular diagnostic label.
For actual nursing diagnoses, the defining characteristics are the client signs and symptoms
For risk nursing diagnoses no subjective signs are present.
Identification of client problems
Identifying client problems helps to individualize nursing diagnoses, by focusing on the more relevant data.
Formulation of nursing diagnosis involves recognizing the specific health problem. Eg.
General health problem - Problem with elimination.
Specific problem – Constipation
Nursing diagnosis statement
Most diagnosis are written as two part or three part statements, but there are variations of these.
1.       One part statements
2.       Basic two part statements
3.       Basic three part statements
One part statements
Some diagnostic statements, such as wellness diagnoses and syndrome nursing diagnoses, consist of a NANDA label only.
As the diagnostic labels are refined, they tend to become more specific, so that nursing interventions can be described from the label itself.
There fore, an etiology may not be needed. eg
Readiness for enhanced parenting
Rape trauma syndrome
Basic two part statements
It includes the following
1.  Problems (P): statement of the clients response (NANDA label)
2.  Etiology (E): factors contributing to or probable causes of the responses.
The two parts are joined by the words related to rather than due to.
Basic three part statements
The basic 3 part nursing diagnosis statement is called the PES format includes the following:
1. Problems (P): statement of the clients response (NANDA label)
2. Etiology (E): factors contributing to or probable causes of the responses.
3. Signs and symptoms (S): defining characteristics manifested by the client
Difference between medical and nursing diagnosis
A nursing diagnosis is a statement of nursing judgment and refers to a condition that nurse, by virtue of her education, experience and expertise are licensed to treat
A medical diagnosis is made by a physician and refers to a condition that only physician can treat.

Nursing Diagnosis
Medical Diagnosis
Example
Activity intolerance related to decreased cardiac output.
Myocardial infarction
Description
Describe human responses to disease   process of health problem, consist of one, two or three part statement, usually including problem and etiology.
Describe disease and pathology; physician responsible for diagnosing, diagnosis not within the scope of nursing practice.
Orientation and responsibility for diagnosing.
Oriented to the individual; nurses responsible for diagnosing.
Oriented to pathology; physician responsible for diagnosing; Diagnosing not with the scope of nursing practice.
Nursing focus
Treat and prevent
Implement medical orders for treatment and monitor status of condition.
Nursing action
Independent
Dependent (primarily)
Duration
Can change frequently
Remains the same while disease is present
Classification system
Classification system is developed   and being used but is not universally accepted
Well developed classification system accepted by the medical profession.


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notes.nursium.com: Critical Thinking- Nursing Diagnosis
Critical Thinking- Nursing Diagnosis
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https://notes.nursium.com/2017/10/critical-thinking-nursing-diagnosis.html
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