Week 1 NR 226 - Edapts
Fundamentals – Patient Care
(Chamberlain University)
,Introduction to Clinical Judgment
The nursing process is the profession’s universal, systematic decision-making approach to
organizing and providing care. Nurses around the world use the nursing process to deliver
personalized, evidence-based care as members of a multi-disciplinary healthcare team
every hour of every day.
Yet, for a non-nurse or novice nursing student, it is difficult
to “see” the nursing process by simply watching a nurse
at work. This is because the nursing process is the
foundation of what nurses
do and, like the foundation of a building set below
ground, the nursing process is not visible to the casual
observer. This lesson introduces the nursing process
through the creation of client care-centered concept
maps.
Clinical Judgment Model: Recognize Cues, Analyze Cues,
Prioritize Hyptheses, Generate Solutions, Take Action,
Evaluate Outcomes
The problem-based nursing diagnosis contains three elements:
• The diagnostic label is written with a focus on the
alteration in health, rather than the medical
diagnosis.
• The related to statement indicates that the
etiology contributes to, or is associated with, the
client’s medical diagnosis.
• The defining characteristics are the
objective cues, or symptoms, on which the
nursing diagnosis is based.
,Having collected data during the health assessment, the nurse utilizes clinical judgment to
analyze cues and determine the client’s highest priority care needs. This is the diagnosis
step of the nursing process. Nursing diagnoses can either be actual problems, potential
problems (risk for), or opportunities for enhanced wellness (health promotion). These types
of nursing diagnoses include different parts:
• actual problems = 3-part statement
• potential problems (risk for) = 2-part statement
• health promotion = 1-part statement
Select each tab to learn about the components of each type
of nursing diagnosis.
Problem-Based Diagnoses
•
An actual problem or problem-based nursing diagnosis has a
three-part statement: diagnostic label, related to
statement, and defining characteristics. This statement is
also called the PES format, which includes the problem,
etiology, and signs and symptoms.
Problem-Based Diagnosis
+
= +
Image Description
PES Format
When writing a three-part nursing diagnosis, remember
PES:
• P is the problem or North American Nursing
Diagnosis Association International (NANDA-I)
label
• E is the etiology or related to statement
• S is the symptoms or defining characteristics
, View these examples of problem-based nursing diagnoses:
Example 1
Problem-based nursing diagnosis: Impaired physical
mobility related to decreased muscle control as
evidenced by inability to control the lower extremities
• Diagnosis label: impaired physical mobility
• Related to statement: related to decreased muscle
control
• Defining characteristics: as evidenced by inability
to control the lower extremities
Example 2
Problem-based nursing diagnosis: Acute pain related
to tissue ischemia as evidenced by the client’s statement
of “I feel severe pain in my chest!”
• Diagnosis label: acute pain
• Related to statement: related to tissue ischemia
• Defining characteristics: as evidenced by
the client’s statement of “I feel severe pain in
my chest!”
Diagnosis label
The diagnosis label is written with a focus on the alteration in health, rather than the
medical diagnosis.
The diagnostic statement is placed first within the nursing diagnosis and represents
the alteration in health on which the client and caregivers will focus.
The North American Nursing Diagnosis Association International (NANDA-I) is
responsible for the list of accepted diagnoses, adding more as nursing research
provides the evidence.
Fundamentals – Patient Care
(Chamberlain University)
,Introduction to Clinical Judgment
The nursing process is the profession’s universal, systematic decision-making approach to
organizing and providing care. Nurses around the world use the nursing process to deliver
personalized, evidence-based care as members of a multi-disciplinary healthcare team
every hour of every day.
Yet, for a non-nurse or novice nursing student, it is difficult
to “see” the nursing process by simply watching a nurse
at work. This is because the nursing process is the
foundation of what nurses
do and, like the foundation of a building set below
ground, the nursing process is not visible to the casual
observer. This lesson introduces the nursing process
through the creation of client care-centered concept
maps.
Clinical Judgment Model: Recognize Cues, Analyze Cues,
Prioritize Hyptheses, Generate Solutions, Take Action,
Evaluate Outcomes
The problem-based nursing diagnosis contains three elements:
• The diagnostic label is written with a focus on the
alteration in health, rather than the medical
diagnosis.
• The related to statement indicates that the
etiology contributes to, or is associated with, the
client’s medical diagnosis.
• The defining characteristics are the
objective cues, or symptoms, on which the
nursing diagnosis is based.
,Having collected data during the health assessment, the nurse utilizes clinical judgment to
analyze cues and determine the client’s highest priority care needs. This is the diagnosis
step of the nursing process. Nursing diagnoses can either be actual problems, potential
problems (risk for), or opportunities for enhanced wellness (health promotion). These types
of nursing diagnoses include different parts:
• actual problems = 3-part statement
• potential problems (risk for) = 2-part statement
• health promotion = 1-part statement
Select each tab to learn about the components of each type
of nursing diagnosis.
Problem-Based Diagnoses
•
An actual problem or problem-based nursing diagnosis has a
three-part statement: diagnostic label, related to
statement, and defining characteristics. This statement is
also called the PES format, which includes the problem,
etiology, and signs and symptoms.
Problem-Based Diagnosis
+
= +
Image Description
PES Format
When writing a three-part nursing diagnosis, remember
PES:
• P is the problem or North American Nursing
Diagnosis Association International (NANDA-I)
label
• E is the etiology or related to statement
• S is the symptoms or defining characteristics
, View these examples of problem-based nursing diagnoses:
Example 1
Problem-based nursing diagnosis: Impaired physical
mobility related to decreased muscle control as
evidenced by inability to control the lower extremities
• Diagnosis label: impaired physical mobility
• Related to statement: related to decreased muscle
control
• Defining characteristics: as evidenced by inability
to control the lower extremities
Example 2
Problem-based nursing diagnosis: Acute pain related
to tissue ischemia as evidenced by the client’s statement
of “I feel severe pain in my chest!”
• Diagnosis label: acute pain
• Related to statement: related to tissue ischemia
• Defining characteristics: as evidenced by
the client’s statement of “I feel severe pain in
my chest!”
Diagnosis label
The diagnosis label is written with a focus on the alteration in health, rather than the
medical diagnosis.
The diagnostic statement is placed first within the nursing diagnosis and represents
the alteration in health on which the client and caregivers will focus.
The North American Nursing Diagnosis Association International (NANDA-I) is
responsible for the list of accepted diagnoses, adding more as nursing research
provides the evidence.
